Leg Cellulitis Research Articles

Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary?

Percutaneous nephrolithotomy for staghorn calculi is reported to have a residual stone rate of 28%, while shockwave lithotripsy alone results in residual stones in approximately 50% of cases. Combination therapy, sandwich therapy, and multiple percutaneous accesses have also been advocated for staghorn stones. We believe these stones can often be removed with a staged procedure via a single upper-pole percutaneous access using flexible nephroscopy and the holmium:YAG laser. Our experience is reviewed. The hospital records of patients having a cumulative stone burden > or =5 cm who underwent percutaneous nephrolithotripsy (PCNL) for a single complex staghorn calculus were reviewed. There were 15 male and 34 female patients having 45 complete and 7 partial staghorn calculi constituting a mean stone burden of 6.7 cm (range 5.0-10.0 cm). A calix was punctured that would provide access to the majority of the involved calices. Thirty-five renal units were approached through a single upper-pole percutaneous access, and four and six renal units were accessed through single middle or lower-pole calices, respectively. The remaining seven renal units were treated with multiple percutaneous accesses. In the renal units having only a single access, a mean of 1.6 (range 1-3) procedures were required to achieve stone-free status. The mean operating room time was 2.9 hours (range 2.0-3.5 hours). For the second PCNL, the mean operating room time was 63 minutes (range 30-90 minutes). Two patients (two renal units) had residual stones <1 cm in diameter. One refused additional surgery, and the other is awaiting further treatment. The mean estimated blood loss was 238 mL (range 50-800 mL), with only one procedure (2.2%) necessitating a blood transfusion. One (2.8%) hydrothorax developed among the 35 upper-pole puncture cases. Six patients had transient oral temperature readings >101 degrees F with negative blood cultures. Other early complications included single cases of leg cellulitis, atrial fibrillation, and noncardiac chest pain. There were no delayed surgical complications. Patients were discharged from the hospital a mean 2 days (range 1-10 days) after the first PCNL. Use of flexible nephroscopy with holmium:YAG laser lithotripsy and Nitinol basket stone extraction has allowed us to render staghorn-containing renal units stone free in a mean of 1.6 procedures. Of the 45 renal units treated through a single percutaneous access, 43 (95%) were rendered stone free. The holmium:YAG laser appears to be a safe lithotrite for the kidney, as no complications occurred from its use.

Pierre Paul Broca.

Pierre Paul Broca. Illustration by Venita Jay, MD, FRCPC. T 19th century French surgeon Pierre Paul Broca left an indelible mark in medicine with his observations on aphasia, language dominance, and cerebral localization. Broca is also remembered for his contributions to anthropology, which include valuable studies of human skulls and the founding of the Societe d’Anthropologie. Broca (1824–1880) was born at Sainte-Foy-la-Grande near Bordeaux, France, on July 28, 1824. He was educated in Bordeaux and Paris, and received his medical degree in 1848. Broca’s remarkable career would revolve around 2 lasting interests—medicine and anthropology. He excelled in both, as a professor of surgery at the Bicetre in Paris and as a noted anthropologist dealing with a plethora of subjects, including the Cro-Magnon man and Neolithic trephination. Broca also founded the world’s first anthropological society and his own school and institute of anthropology. The first cortical localization that became widely accepted linked fluent, articulate speech to the frontal lobes. Cortical localization of speech was a much-debated issue in the early and mid-19th century, and many scientists had presented data for and against this theory before Broca’s epoch presentation in 1861. In the early part of the 19th century, Franz Joseph Gall addressed the issue of localization of speech to a specific area of the brain. Gall placed the faculty of memory of words in the frontal lobes, based primarily on his observation of skull shape. Jean Baptiste Bouillaud also believed in the localization of speech to the frontal region. In 1836, Marc Dax suggested that speech disturbances were due to lesions of the left hemisphere, but his hypothesis remained unknown for 30 years until his son, Gustave Dax, presented his father’s work in 1863 and published it in 1865. Broca’s concepts on speech localization were initially based on the study of a single patient, Monsieur Leborgne, who was affected by epilepsy and who had lost the ability to speak. Leborgne was able to comprehend and communicate by gestures, but his speech was limited to the monosyllable ‘‘tan,’’ and he thus came to be nicknamed ‘‘Tan.’’ Tan also had right hemiparesis. On April 11, 1861, Tan was admitted to Broca’s surgical service for cellulitis of the right leg. He was examined also by Ernest Auburtin,

Management of lower leg cellulitis

Management of lower leg cellulitis

Risk factors for erysipelas of the leg (cellulitis): case-control study

Objective: To assess risk factors for erysipelas of the leg (cellulitis).Design: Case-control study.Setting: 7 hospital centres in France.Subjects: 167 patients admitted to hospital for erysipelas of the leg and 294...

Postoperative Radiotherapy in Early Stage Carcinoma of the Uterine Cervix: Treatment Results and Prognostic Factors

Purpose.The objective was to investigate the effect of pathologic parameters and other variables on treatment outcome for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB, IIA cervical carcinoma, as well as to assess the morbidities attributable to radical surgery combined with postoperative radiotherapy.Materials and methods.Between January 1980 and June 1994, 179 women with FIGO stage IB, IIA carcinoma of the uterine cervix were treated with radical hysterectomy and postoperative irradiation. The median follow-up of alive patients was 6.8 years. All patients received 44–60 Gy external irradiation. One hundred fifty-nine patients received 3–10 Gy intracavitary brachytherapy. The data were analyzed for overall survival, disease-free survival, pelvic control, and treatment-related complications.Results.The 5-year overall survival rate, disease-free survival rate, and pelvic control rate for the 179 patients were 72, 74, and 90%, respectively. The 5-year overall survival rate was 81% for patients without pelvic lymphadenopathy and 53% for those with pelvic lymphadenopathy (P= 0.0000). Other independent prognostic factors for overall survival included tumor differentiation and the interval between operation and initiation of radiotherapy. For the endpoint of disease-free survival, pelvic lymph node status, tumor differentiation, the duration of interruption of radiotherapy, and the interval between operation and radiotherapy were of independent prognostic significance. As pelvic control was concerned, the 5-year pelvic control rate was 90% and only the duration of interruption of radiotherapy was noted as an independent predictor of pelvic control. Distant metastases were noted in 43 patients (24%); the most common sites were lung (10%), liver (6%), and bone (6%). The overall 5-year intestinal and urinary complication-free rate was 66 and 82%, respectively. The overall incidence of grade 3 or above late rectal and urinary sequelae was 10%. For patients sustaining leg lymphedema after radiotherapy, there was higher incidence of severe leg cellulitis which warranted antibiotics treatment.Conclusion.These prognostic factors should be considered in patient counseling and treatment planning. Based on these factors, a more aggressive treatment to improve survival in these subsets of high-risk patients might be justified. New therapeutic regimens and modalities aimed to overcome treatment failure should be investigated.

Cutaneous Paecilomyces lilacinus infection: Report of two novel cases

A 56-year-old white man had painful skin lesions on his left leg 10 months after a liver transplant. His medications included prednisone, tacrolimus, azathioprine, trimethoprim-sulfamethoxazole, acyclovir, and granulocyte-macrophage colony-stimulating factor. Examination revealed multiple crusted and violaceous papules, plaques and nodules extending from the dorsal aspect of the left foot to the left knee (Fig. 1). He had a leukocyte count of 2.8 xl03/g 1 and a hematocrit of 27.6%. A biopsy specimen revealed findings consistent with a deep fungal infection. Fungal cultures of bone marrow and blood were negative. The patient received a 2-week course of intravenous amphotericin B with subsequent oral itraconazole, 400 mg daily. About a year later, he was readmitted because of a cellulitis and persistent deep fungal infection of the left leg. The patient was treated with oral itraconazole, but the infection persisted. Lesions extended from the dorsal aspect of the left foot to the left upper thigh. A culture grew P. lilacinus. A biopsy specimen demonstrated granulomatous and suppurative dermatitis. A periodic acid-Schiff stain demonstrated fungal spores and hyphae within the dermal granuloma. Oral itraconazole was stopped and the patient was again given intravenous amphotericin B but experienced no improvement. With

Interdigital Tinea Pedis and Cellulitis

The bacteria that cause cellulitis of the leg are usually beta-hemolytic streptococci, but often the site where they enter the skin is not apparent. Furthermore, the source from which these organisms originate is puzzling, because they are not part of the resident cutaneous flora and do not survive long on intact skin. Clinicians have observed an association between cellulitis and interdigital tinea pedis, particularly in patients who have undergone saphenous-vein …

Cellulitis and the Prevalence of Deep Vein Thrombnosis

From February, 1994, to August, 1995, we reviewed the venous duplex ultrasound findings of 207 consecutive patients who presented with clinically evident lower leg cellulitis to determine if thrombophlebitis plaued a role in this entity. All patients had a recent onset of intense erythema of the lower leg with associated pitting edema and diffuse painful cutaneous or subcutaneous tenderness. One hundred ninety-one patients (92%) had normal venous duplex ultrasound examinations, with no evidence of any acute or chronic disease. Four patients (2%) had superficial thrombophlebitis involving the greater saphenous vein in the lower leg only, and 10 patients (5%) had evidence of chronic obstructive disease with recanalizattion and post-thrombotic popliteal venous insufficiency. In a subset of 73 patients aged more than 60 years, arterial evaluation with Doppler spectral waveform analysis showed significant obstructive disease in 41 (56%); 17 of the 19 patients with diabetes in this subset (89%) were noted to have positive arterial examinations. Theae data indicate that when the clinical diagnosis of cellulitis can be made, there is no associated significant acute deep venous thrombosis, and venous duplex ultrasound testing is not indicated. In oldet patients, particularly patients with diabetes, arterial testing for obstructive disease appears to be most appropriate.

Possible Nafcillin-Warfarin Interaction

There are multiple reports of drug interactions with warfarin in the literature. Many of these result in resistance to warfarin therapy due to enzyme inducers such as barbiturates, carbamazepine, and rifampin, with resulting decreased warfarin effect and prothrombin time (PT). 1-3 Nafcillin is not well documented as an inducer of drug metabolizing enzymes, yet it appears to have this effect on warfarin. 4 We recently observed a possible interaction between nafcillin and warfarin. Report of a Case. A 71-year-old woman was admitted with a 3-month history of left lower extremity swelling and a 3-week history of pain, tenderness, and edema. On admission, an attempted left lower leg ultrasound was unsuccessful due to swelling of the lower leg. Therefore, her admitting diagnosis was rule-out deep vein thrombosis vs cellulitis of the lower leg. Her medicines prior to admission included levothyroxine (0.125 μg daily), extended-release nifedipine (60 mg twice daily), extended-release potassium

The erection sign

Dear Sir, An erect penis is an unexpected finding for a resuscitation team. I believe this to be the first description of the ‘erection sign‘, which in this case helped to explain the cause of a patient's syncope. A hospital resuscitation team called to a 63-year-old man found him unconscious and pulseless but with an erect penis. Basic cardiopulmonary resuscitation was instituted and he quickly regained a palpable femoral pulse and a low systolic blood pressure, which responded well to intravenous fluid challenge. The medical notes were studied. Five days previously the patient had been admitted and treated for an acute cellulitis of the right leg with signs of chronic venous insufficiency. His past history included an admission 25 years previously, following prolapse of a lumbar intervertebral disc. This had been complicated by right deep vein thrombosis and a subsequent pulmonary embolism, at which time an inferior vena cava filter was fashioned at laparotomy. The patient had then remained well until the present admission. This time he made a rapid recovery following the arrest call, and was discharged home on warfarin therapy. Despite the absence of venographic proof, it is likely that this patient suffered syncope caused by venous thromboembolism to the inferior vena cava filter. He was already relatively fluid-depleted due to the acute cellulitis of the leg, and the acute obstruction of the inferior vena cava was sufficient extra insult to produce syncope. It is interesting and significant that the patient remembers being puzzled by the developing erection before the onset of syncope. In physiological erection the smooth muscle of the penis corpora trabeculae and the helicine arteries relaxes due to parasympathetic stimulation. As a result the arteries straighten and their lumina enlarge, allowing blood to flow freely in the cavernous spaces. The blood engorges and dilates the cavernous spaces, compressing the venous plexuses at the periphery of the corpora cavernosa and preventing the return of blood. The corpora then become rigid and enlarged and the penis erects.1 The pathological penis erection described here — occurring secondarily to acute inferior vena caval obstruction —contrasts with physiological erection, in which increased arterial flow is of primary importance and increased venous resistance occurs as a secondary phenomenon. The presence of an erection in this ‘arrested’ patient gave useful diagnostic information. Complete penile erection has not been described as an agonal event before. This first description of the ‘erection sign‘, however unusual, might be of value to a future resuscitation team.

Surgical management of refractory venous stasis ulceration.

A 15-year experience with 27 patients, 20 to 75 years of age, with refractory venous stasis ulcers is presented. All patients had been managed with support hose, elevation, elastic wraps, Unna's paste boots, and graduated compression stockings. Because of multiple recurrences of their ulcers, the patients were offered surgical treatment to reduce the venous hypertension in the areas of ulceration. The 27 patients had 32 modified Linton procedures. Five had bilateral procedures. At the time of operation, 18 limbs had medial malleolar ulcers, five had bimalleolar ulcers, four had lateral ulcers, three had posterior ulcers, and two patients were free of ulcer. Medial incisions were used in 20 limbs, lateral incisions in six, medial and lateral incisions in three, and midposterior incisions in three. Split-thickness skin grafts were placed on six limbs the day of surgery and on 22 limbs 4 to 7 days later. Postoperative complications included deep venous thrombosis in two, partial flap necrosis in three, and cellulitis of the lower leg in three patients. Follow-up has ranged from 6 months to 10 years. During the most recent clinic visits, 21 limbs were completely healed, whereas six limbs had a recurrence of the ulcer. Five patients have been lost to follow-up. The good long-term results in 78% of the cases indicate that patients with recurrent venous stasis ulcers may receive lasting benefit from modified Linton procedures.

Surgical management of refractory venous stasis ulceration

A 15-year experience with 27 patients, 20 to 75 years of age, with refractory venous stasis ulcers is presented. All patients had been managed with support hose, elevation, elastic wraps, Unna's paste boots, and graduated compression stockings. Because of multiple recurrences of their ulcers, the patients were offered surgical treatment to reduce the venous hypertension in the areas of ulceration.The 27 patients had 32 modified Linton procedures. Five had bilateral procedures. At the time of operation, 18 limbs had medial malleolar ulcers, five had bimalleolar ulcers, four had lateral ulcers, three had posterior ulcers, and two patients were free of ulcer. Medial incisions were used in 20 limbs, lateral incisions in six, medial and lateral incisions in three, and midposterior incisions in three. Split-thickness skin grafts were placed on six limbs the day of surgery and on 22 limbs 4 to 7 days later.Postoperative complications included deep venous thrombosis in two, partial flap necrosis in three, and cellulitis of the lower leg in three patients. Follow-up has ranged from 6 months to 10 years. During the most recent clinic visits, 21 limbs were completely healed, whereas six limbs had a recurrence of the ulcer. Five patients have been lost to follow-up.The good long-term results in 78% of the cases indicate that patients with recurrent venous stasis ulcers may receive lasting benefit from modified Linton procedures.

Recurrent acute leg cellulitis in patients after radical vulvectomy

Recurrent acute leg cellulitis (ALC) known to occur in patients with impaired venous or lymphatic circulation was studied in 126 patients after radical vulvectomy with lymphadenectomy through the years 1973 to 1985. Among these patients surveyed for a total period of 6153 patient months, 33 (26%) experienced 75 episodes of ALC. Recurrent attacks were frequently observed. Although antimicrobial treatment was often started, clinical signs resolved also in 9 patients without antimicrobial treatment. To prevent recurrencies penicillin prophylaxis was given to 23 patients. Only 1 of them had once a mild attack of ALC, whereas recurrent attacks occurred frequently in those patients not receiving penicillin prophylaxis. Although penicillin prophylaxis was successful in preventing the recurrence of ALC the risk-benefit ratio of this approach has not been ascertained. The etiology and pathogenesis of recurrent ALC is discussed. Analysis of a number of assumed risk factors for ALC showed that the frequency of ALC was significantly higher in patients colonized with β-hemolytic streptococci, mainly group B, than in patients not colonized with these microorganisms just prior to surgery. This suggests that non-group A β-hemolytic streptococci are involved in the onset of ALC in patients after radical vulvectomy. However, portals of entry for microorganisms were not apparent in any of our patients.

Recurrent acute leg cellulitis after hysterectomy with pelvic lymphadenectomy.

Recurrent acute leg cellulitis known to occur in patients with impaired venous or lymphatic circulation was surveyed prospectively in 270 patients after radical hysterectomy with pelvic lymphadenectomy and in 66 patients after hysterectomy with pelvic lymphadenectomy from 1977 to 1985. Among them, six (2%) and three (4%) patients experienced a total of 17 episodes of acute leg cellulitis, respectively. Analysis showed that postoperative percutaneous radiation therapy of the pelvic area was a highly significant risk factor. Penicillin prophylaxis is recommended for patients experiencing recurrent attacks.

Congenital Hemihypertrophy

A 41-year-old man presented with congenital hemihypertrophy. At 15 years of age, the patient developed bilateral varicose veins and lymphedema of the right leg. At age 20 years, he developed streptococcal cellulitis of the right leg and has had numerous similar episodes since, which frequently progress to septicemia. The long-term management of congenital hemihypertrophy must be concerned with the possible occurrence of childhood neoplasms, mental retardation, abnormal sexual development, and the complications of associated vascular anomalies.

CHOLESTATIC HEPATITIS FOLLOWING THE ADMINISTRATION OF SODIUM OXACILLIN.

HEPATIC injury in the form of intrahepatic cholestasis due to allergic drug sensitivity has been reported for many drugs.1The prototype most extensively studied is that of cholestatic jaundice caused by chlorpromazine. This report describes a case of cholestatic hepatitis due to sodium oxacillin (Prostaphlin) and documented by liver biopsy. As far as we know, no such case has been reported so far due to this agent or to other natural or semisynthetic penicillins. The antibiotics erythromycin estolate2,3and triacetyloleandomycin,4however, have caused this reaction. Report of a Case A 65-year-old white woman presented herself in the emergency room of Henry Ford Hospital on Feb 3, 1964, with cellulitis of the right leg. She was started on a regimen of sodium oxacillin, 2 gm daily, administered orally. She returned to the clinic on Feb 6; no improvement was found, and she was admitted to the hospital. The

Recurrent, fixed erysipelas-like dermatophytid; ineffectiveness of antibiotics reported in a case.

Recurrent erysipelas-like manifestations of the legs and their relationship to fungus infections have been thoroughly discussed and investigated. 1 McGlasson's la article focused attention on the phenomenon and its bacterial etiology. Sulzberger and associates, 1b Traub and Tolmach, 1c Waisman, 1f and Reiss 1g advanced the concept that some of the cases represent dermatophytids. The purpose of this paper is to focus attention on the ineffectiveness of antibiotics and to reemphasize the importance of fungicidal measures when the cause is mycotic. Reference to the use of antibiotics in active or prophylactic therapy of this condition has not been found. REPORT OF CASE Present Illness .—W. S., a 24-year-old white man, was admitted to Osaka Army Hospital on Feb. 1, 1952, with a diagnosis of recurrent cellulitis of the right leg. Approximately two hours before admission, the patient, who was well and at work, suddenly experienced a sharp chill followed by

A CASE OF RAYNAUD'S DISEASE INVOLVING THE FEET, THE LEFT RETINA AND THE HEART WALL

This case is reported because of the distribution of the involved parts and the opportunity of direct observation of the process during life. REPORT OF CASE Mrs. J. E. Q., white, aged 44, referred to me, Aug. 21, 1923, by Dr. Clarence J. Broeman, complained of extreme pain in the feet and ankles. The family history was irrelevant. She had had ordinary childhood ailments. At 16 she was married, and at 18 was left a widow with two children, by the murder of her husband. At this time, she had attacks of pain in the left chest, radiating down the left arm. This could be relieved only by morphin, which she took occasionally for a year. She lived well on inherited money. At 24, she had malaria, at which time what may have been a cellulitis of the right lower leg occurred. At 40, she married a man who had