Purulent Drainage Research Articles

“Fishy” papule

A 60-year-old man and avid fisherman presented to Dermatology for a skin exam. He was noted to have a 6-mm pink papule on his hand that had developed 8 weeks earlier, after he’d gone fishing for striped sea bass. He had mild pain and scant purulent drainage but was otherwise healthy.What’s your diagnosis?

Pneumonia with empyema: rare complication after sea urchin injury

Staphylococcal pneumonias are rare, especially in immunocompetent children. They can represent a complication of tissue infection with hematogeneous dissemination. Sea urchin injuries can result in local reactions, granulomas and, unfrequently, systemic disease. We describe the case of a 16-year-old boy with a four-day fever and left-sided chest pain, with referral to a sea urchin injury five days before admission. Physical examination revealed diminished pulmonary sounds and crackles in the left lower hemithorax. The chest radiograph showed a pleural effusion. Blood tests showed leukocytosis, neutrophilia, and an elevated C-reactive protein. Empyema was diagnosed after performing a thoracentesis. Subsequently he initiated inflammatory signs with fluctuation on his right heel, with purulent drainage. Suspecting on a staphylococcal etiology, he was treated with flucloxacillin, a suspicion that was confirmed by the isolation of Staphylococcus aureus in pleural liquid and abscess material. After antibiotic treatment was established, there was a favorable clinical and radiological evolution. With this case report, we would like to draw attention to the possibility of hematogenous dissemination of a microorganism after local skin infection, even in immunocompetent individuals.

Karaciğer Apsesinin İlk ve Tek Bulgusu Olarak Klebsiella Endoftalmisi

This report aimed to present an endogenous endophthalmitis case occurred as an embolic complication of a liver abscess without any signs other than ocular symptoms. A 58-year-old man was admitted to ophthalmology clinic due to acute onset severe pain and loss of vision in the left eye. With no history of any ocular trauma or surgery, the patient underwent a thorough evaluation including blood sampling, cultures, and abdominal imaging as per the recommendations of the consultation to general surgery department. Computed tomography revealed a hepatic abscess, and an ultrasonography guided drainage was performed for treatment. The purulent drainage fluid culture was positive for Klebsiella pneumoniae. Ocular infection was managed by intravitreal antibiotic and steroid injections in addition to topical fortified and intravenous antibiotic therapy. After medical therapy, a vitrectomy was performed for the sequel such as fibrotic membranes but there was no improvement in the vision.

Vaginal Group B Streptococcal Colonization Not Associated With Chorioamnionitis In Laboring Patients

Multiple studies have reported increased rates of chorioamnionitis associated with group B streptococcal (GBS) colonization. We sought to estimate the risk of chorioamnionitis associated with GBS positive status in term laboring patients. This is a retrospective cohort study of term (≥37 weeks), singleton pregnancies who labored at our tertiary care center from 2005 to 2018. The primary outcome of chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38–38.9°C for 30 minutes) and one or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. The primary exposure was GBS colonization in the medical record. Cox proportional hazard regression was used to model the effect of GBS on the risk of chorioamnionitis while adjusting for number of cervical exams, epidural use, meconium, smoking, parity, BMI, duration of rupture, labor induction and cesarean section. 19,688 individuals met inclusion criteria and 981 (5%) patients met criteria for clinical chorioamnionitis. Of the subjects diagnosed with chorioamnionitis, 188 (19.2%) were GBS positive compared to 25.2% in those not diagnosed with infection (p < 0.001). GBS colonization was not associated with an increased rate of chorioamnionitis after adjusting for potential confounders (hazard ratio [HR] 0.6, 95% confidence interval [CI] 0.5-0.7; p= < 0.001). GBS colonization rates were higher among patients undergoing unplanned cesarean delivery (Vaginal: 12.0% vs Cesarean: 13.4%, p=0.01). Meconium rates were similar between the two groups (GBS positive: 19.0% vs GBS negative: 19.4%, p=0.06). In contrast to previous reports, GBS colonization in laboring patient did not increase the risk of chorioamnionitis. Individuals with positive GBS status should not be counseled on increased risk of chorioamnionitis.

Gluteal-sacrospinous-vaginal fistula as a complication of sacrospinous ligament fixation after a vault prolapse: A case report

Background: Vault prolapse has a negative impact on women’s quality life as a result of associated ano-rectal, urinary and coital dysfunctions. One of the most common surgical procedures for the treatment of vault prolapse is sacrospinous ligament fixation. In this report we present an uncommon case of a gluteal-sacrospinous-vaginal fistula complication after this procedure. Case presentation: A 63-year-old woman with a history of multiple procedures to repair vault prolapse and cystocele was referred to our institution with a nodule 5 X 4 cm in the left buttock. Magnetic Resonance Imaging and endoanal ultrasound confirmed an extrasphincteric gluteal-sacrospinous-vaginal fistula with purulent drainage in her vagina. A multidisciplinary approach was performed with Urogynecology, traumatology and colorectal surgeon. A fistulectomy was executed successfully. Posterior controls revealed an asymptomatic patient. Conclusions: This case report revealed an uncommon complication of sacrospinous fixation and the importance of a multidisciplinary approach and treatment with notable results. Keywords: complication; sacrospinous fixation; fistula; pelvic organ prolapsed; abscess; gynaecology; mesh. Abbreviations: POP: Pelvic Organ Prolapse; MRI: Magnetic Resonance Imaging; cm: centimetre.

Fever after Preterm Prelabor Rupture of Membranes.

Fever after Preterm Prelabor Rupture of Membranes.

Incremental risk of clinical chorioamnionitis associated with cervical examination

Clinical chorioamnionitis is associated with significant maternal and neonatal morbidity, yet there is no clear evidence on the association between cervical examinations and infection. We sought to assess the association between the number of cervical examinations performed during term labor management and the risk of clinical chorioamnionitis. This is a retrospective cohort study of term (≥37 weeks of gestation), singleton pregnancies who labored at our tertiary care center from 2014 to 2018. The primary outcome of clinical chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38°C-38.9°C for 30 minutes) and 1 or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. The primary exposure was the number of digital cervical exams documented in the medical record. Log-binomial regression was used to model the effect of cervical examinations on the risk of clinical chorioamnionitis while adjusting for potential confounders. A total of 20,029 individuals met the inclusion criteria and 1028 (5%) patients experienced clinical chorioamnionitis. The number of cervical exams was associated with increased risk of developing infection after adjusting for potential confounders. Individuals with ≥8 cervical exams had 1.7 times the risk of developing clinical chorioamnionitis compared with those with 1 to 3 exams. Prolonged rupture time, nulliparity, Black race, Medicaid insurance, higher gestational age, and higher body mass index were associated with increased risk of clinical chorioamnionitis, whereas smoking and group B Streptococcus colonization were associated with a lower risk. Our study found that the number of cervical exams performed during labor is an independent risk factor for developing clinical chorioamnionitis. Unnecessary cervical exams should be avoided during labor management at term.

Correlation between the Opacification Degree of Paranasal Sinuses on CT, Clinical Symptoms and Anatomical Variations of the Nose and Paranasal Sinuses in Patients with Chronic Rhinosinusitis.

Objectives: This study aimed to evaluate the correlation between the opacification degree of the paranasal sinuses on computed tomography (CT) with clinical symptoms, and anatomical variations of the nose and paranasal sinuses in patients with chronic rhinosinusitis (CRS). Materials and Methods: This descriptive prospective study evaluated 100 patients (60 males and 40 females), who were diagnosed with CRS by ENT specialists according to the clinical findings, and were scheduled for a CT scan. The patients were requested to express the severity of their symptoms using a visual analog scale. The CT scans of the paranasal sinuses were assessed for the presence of anatomical variations and scored using the modified Lund-Mackay scoring system for the opacification degree of each sinus. The correlations between the anatomical variations and sinusitis, and also between the severity of symptoms/disease severity and CT scores were statistically analyzed. P<0.05 was considered statistically significant. Results: The most common symptoms were purulent (discolored) nasal drainage and nasal obstruction. Septal deviation was the most common anatomical variation. The maxillary and anterior ethmoid sinuses were the most commonly involved areas. The Spearman’s correlation coefficient showed a significant correlation between the sinus involvement and some of the evaluated symptoms, as well as certain types of anatomical variations (P<0.05). Conclusion: Some specific anatomical variations of the paranasal sinuses may predispose them to sinusitis. The CT scan score can predict the severity of many symptoms such as purulent (discolored) nasal drainage, nasal obstruction, hyposmia/anosmia, halitosis, cough, and fatigue, among the other symptoms of CRS.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses.

Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery. This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery. Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%). MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

Deep Wound Infection in Pediatrics after Open Cardiac Surgery

Abstract Surgical site infection (SSI) is a serious complication requiring prolonged hospitalization, intravenous antibiotics, wound care and dressings resulting in increased cost and resistant bacteria. In pediatric cardiac surgery, Median sternotomy is the most frequently used incision for the correction of congenital anomalies. Sternal wound infections (SWIs) are well described complications of cardiac surgery and can occur in 3% to 8% of children. Furthermore, the mortality rate can increase 2-fold after SSIs. Also, SSIs are associated with an increased length of hospital stay, readmissions, and higher health care expenditures. Mediastinitis is a retrosternal wound infection frequently associated with a macroscopically sternal osteomyelitis. Mediastinitis is uncomfortable for patients, is poorly accepted by parents, leads to a prolonged hospital stay repeated surgery and prolonged antibiotic therapy. Mediastinitis are costly for patients, providers, and health-care institutions. In A recent survey among congenital heart programs, the incidence of mediastinitis has been reported to occur in 0.2–1.4%. Gram-positive cocci are the most common pathogen. Gram negative organisms are increasingly recognized, especially in neonates, and are related to delayed sternal closure. Fungal organisms are not infrequently found. Mediastinitis generally presents 2–3 weeks after cardiac surgery. Child often appear irritable, tired, and febrile. The incision is erythematous and painful. Wound separation and purulent drainage from the incision are frequent. Some but not all will also have sternal instability or dehiscence. Associated bacteremia is not uncommon, present in up to 40% of patients. Postoperative mediastinitis is a life-threatening infection and increase health expenditure. Young age, malnutrition, hypothermia, hyperglycemia, longer duration of surgery, long time of delayed sternal closure, postoperative low cardiac output and long ICU stay were a risk factor of mediastinitis. Stick to1999 CDC's Guideline for prevention of surgical site infection and their update in 2017 especially proper timing of antibiotic prophylaxis and post-operative blood glucose management is important in prevention of these life-threatening complication. procalcitonin can be useful biologic marker of infection. Management of mediastinitis consist of debridement and culture-based antibiotics. Primary closure over mediastinal drain or high vacuum drain gave good result, less time consuming, more economic and more cosmetic. Vacuum assisted closure gave excellent result, but more time consuming, less economic and delayed closure is necessary. Larger studies are needed to compare both techniques in effectiveness and coast benefit.

A PRIMARY EMPYEMA OF UNKNOWN DURATION DUE TO ANAEROBIC GRAM-NEGATIVE BACILLUS HAFNIA ALVEI

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Empyema is the presence of pus or bacteria in the pleural space. Incidence is increasing gradually with higher rates in the elderly with a greater prevalence in males [1]. Empyema is a fatal infection with a mortality rate of 20% [2]. Anaerobic Enterobacteriaceae accounting for less than 6% of empyema cases, are an infrequent cause [1]. CASE PRESENTATION: An 80-year-old male with a history of coronary disease, hypertension, hyperlipidemia, peripheral vascular disease, moderate aortic stenosis, a former smoker was seen at the pulmonary clinic for intermittent dyspnea with right-sided abdominal fullness of unknown duration and no symptoms of infection. He had significant asbestos exposure from his shipyard work. Around six months back, he underwent superior mesenteric artery (SMA) stenting for chronic abdominal angina. He was taking a super enzyme supplement to enhance his digestion. Chest x-ray review revealed right-sided effusion, which was also present before SMA stenting (Figure A1-2). A diagnostic thoracentesis showed brownish-green fluid with analysis indicative of empyema (Figure B). His blood work was normal. He was admitted, and a pigtail catheter was inserted into the right pleural space with purulent fluid drainage. He also underwent fibrinolysis. The pleural fluid culture grew Hafnia alvei sensitive to quinolones, aminoglycoside, and carbapenems (Amp C resistance pattern). At discharge, computed tomography and x-ray of the chest revealed empyema resolution, and the chest tube was removed (Figure C1-2). The initial antibiotic ertapenem was transitioned to levofloxacin for one month at discharge. At four weeks after discharge, his symptoms had entirely resolved DISCUSSION: H. alvei is a gram-negative facultative motile anaerobe of the Enterobacteriaceae family, a commensal in the gastrointestinal (GI) tract of humans and animals. It colonizes the oropharynx in humans [3]. It produces a cytolytic toxin, a virulent factor, causing acute gastroenteritis. It is a rare cause of nosocomial and community-acquired infection with a preference for biliary tree infection and has lower mortality [4-5]. In patients with multiple comorbidities and immunosuppressed, it causes extraintestinal diseases such as endophthalmitis, bronchopneumonia, gastroenteritis, and meningitis [5]. The infection source is the GI tract via gut translocation or oropharynx venous drainage draining into the heart and forced into the visceral pleura or alveolar capillary bed [5-6]. In our patient, another source could be the contaminated supplement (it contains Ox bile) CONCLUSIONS: In primary empyema of remote duration and an infrequent cause, a possible source could be the GI tract or the oropharynx. Clinicians should be aware of supplement contents that could be a source of infection REFERENCE #1: Godfrey MS, Bramley KT, Detterbeck F. Medical and Surgical Management of Empyema. Semin Respir Crit Care Med. 2019;40(3):361-74 REFERENCE #2: Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. Lancet Respir Med. 2015;3(7):563-77 REFERENCE #3: Fazal BA, Justman JE, Turett GS, Telzak EE. Community-acquired Hafnia alvei infection. Clin Infect Dis. 1997;24(3):527-8 DISCLOSURES: No relevant relationships by Phillip Beck, source=Web Response no disclosure on file for Wilson Grace; No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by AARON MILLER, source=Web Response No relevant relationships by Shakuntala Patil, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by ANTONY RAWINDRARAJ, source=Web Response

INFECTED MEDIASTINAL MATURE TERATOMA

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Mature teratoma, a benign germ-cell tumor, commonly presents in the ovaries. Extragonadal manifestation is uncommon and rarely occurs with superimposed infection. We present a unique case of extragonadal teratoma found in the mediastinum complicated by infection. CASE PRESENTATION: A 24-year-old male with a history of asthma presented with a 3-day history of dyspnea and right rib pain radiating into the center of his chest. He reported a 30-pound weight loss in the preceding 3 months. He denied tobacco, alcohol, or recreational drug use. He previously worked as a coal miner but is now working in coastal drilling. He was afebrile and normotensive but had an oxygen saturation of 93% on room air. On examination, he had right upper lobe rhonchi with absent breath sounds in the right basilar region. Chest imaging showed complete collapse of the right middle and lower lobes, large loculated right pleural effusion within the anterior right lung base, and heterogeneity with rim enhancing fluid collection, which was suggestive of empyema. The patient had leukocytosis of 16.6k with neutrophil predominance of 14.18k. The patient was started on empiric intravenous antibiotics with vancomycin, ceftriaxone, and metronidazole. He underwent video-assisted thoracoscopic surgery with cystic mass resection from the pericardial surface and anterior surface of right lower lobe, 1600 milliliters of purulent fluid drainage, and decortication of right middle and lower lobes. Frozen section showed squamous and glandular cells. Pathology showed keratinized skin with granulation tissue, acute and chronic inflammation, and giant cell reaction consistent with infected mature teratoma. Pleural fluid's gram stain revealed 2+ PMNs and no growth in aerobic, anerobic, fungus, or AFB cultures. The patient was de-escalated to amoxicillin-clavulanate for a 14-day course and clinically improved. DISCUSSION: This case demonstrates a rare presentation of extragonadal mature teratoma in the mediastinum. Mediastinal teratomas occur from 20 to 40 years old with clinical symptoms of cough, chest pain, trichoptysis, and fever. Possible complications are infection, rupture, malignant transformation, and paraneoplastic anti-N-methyl-D-aspartate receptor (anti-NMDA receptor) associated limbic encephalitis. Infected mature teratomas are uncommon. Reported infectious organisms include Salmonella enterica, Escherichia coli, Mycoplasma pneumonia, Staphylococcus aureus, Staphylococcus agalactiae, and Haemophilus influenza. Proposed pathogenesis is due to the release of proteolytic enzymes from pancreatic and/or intestinal mucosal tissues in the tumor leading to inflammation and eventual infection. CONCLUSIONS: Teratoma rarely presents with superimposed infection, which may be complicated by rupture. Definitive management is surgical excision of teratoma and antibiotic targeting the organism. REFERENCE #1: Lee WL, Yen MS, Tseng JY, Yu KW, Wang PH. Mature teratoma with secondary infection: case report. Changgeng Yi Xue Za Zhi. 1999 Jun;22(2):339-43. PMID: 10493045. REFERENCE #2: Li C, Lin F, Liu C, Hai Y, Liu L. Intrapulmonary teratoma misdiagnosed as aspergilloma. Thorac Cancer. 2018;9(2):328-329. doi:10.1111/1759-7714.12566 REFERENCE #3: Tian Z, Liu H, Li S, et al. Surgical treatment of benign mediastinal teratoma: summary of experience of 108 cases. J Cardiothorac Surg. 2020;15(1):36. Published 2020 Feb 17. doi:10.1186/s13019-020-1075- DISCLOSURES: No relevant relationships by Ashley Anselene, source=Web Response No relevant relationships by Asma Balobaid, source=Web Response No relevant relationships by Shu Xian Lee, source=Web Response No relevant relationships by Rebecca Reece, source=Web Response

WHEN THE WAY TO A MAN'S HEART IS THROUGH THE STOMACH: A RARE CASE OF GASTRO-PERICARDIAL FISTULA AFTER PERCUTANEOUS GASTRIC TUBE DISPLACEMENT

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gastro-pericardial fistula is an acquired abnormal communication between the stomach and the pericardium. We report one such case presenting as an unusual complication of percutaneous gastric tube (PEG) dislodgement. Early identification of this rare life-threatening condition can prevent fatal outcomes. CASE PRESENTATION: A 53-year-old male presented to our facility with acute substernal chest pain associated with dyspnea. He has a past medical history of chronic sclerosing peritonitis with a draining PEG tube. On presentation, his vital signs and physical examination were within normal limits. Laboratory investigation were unremarkable. Electrocardiogram (EKG) showed diffuse ST segment elevation concerning for pericarditis and he was started on steroids. During the course of his hospitalization his dyspnea worsened, and he subsequently underwent a Computerized Tomography(CT) scan of the chest which was significant for a pneumopericardium. An echocardiogram was performed which revealed a pericardial effusion which was free flowing without any stranding or loculations. There were no signs of tamponade. He consequently underwent an upper endoscopy which showed dislodgement of the PEG with the tip abutting the inferioapical region of the pericardium forming a fistulous tract. The PEG tube was therefore removed, and he was empirically treated with broad spectrum antibiotics. Endoscopic repair of the fistula was attempted, however it failed. Considering the clinical stability of the patient and absence of purulent drainage, the fistula was allowed to heal naturally while the patient remained on total parenteral nutrition in the Intensive Care Unit (ICU). DISCUSSION: Fistulous complications following PEG tube placement are extremely rare with an incidence of 0.3 to 6.7%. They have high mortality rate of 50%. Pneumopericardium can have a range of clinical presentations from being asymptomatic to presenting with chest pain, dyspnea, dyspepsia, epigastric pain, left shoulder due to diaphragmatic/pericardial irritation as well as sudden cardiac death due to cardiac tamponade. The diagnosis is challenging and is made using a combination of clinical suspicion, radiographic findings using small amount of methylene blue/contrast to visualize the fistula. An endoscopy may be helpful in establishing the diagnosis, but should be used with caution, because excessive air insufflation by the endoscope may exacerbate thecardiac tamponade. Treatment varies depending on the clinical stability and includes surgical closure of the fistula, pericardial drain placement or even conservative management. CONCLUSIONS: Gastro-pericardial fistula can be seen as a late complication of PEG tube and can present as an unusual cause of chest pain. Early detection of pneumo-pericardium and timely intervention while monitoring the patient in the ICU can prevent catastrophic outcomes. REFERENCE #1: Grandhi TM, Rawlings D, Morran CGGastropericardial fistula: a case report and review of literature Emergency Medicine Journal 2004;21:644-645. REFERENCE #2: Kato T, Mori T, Niibori K. A case of gastropericardial fistula of a gastric tube after esophagectomy: a case report and review. World J Emerg Surg. 2010 Jul 21;5:20. doi: 10.1186/1749-7922-5-20. PMID: 20663167; PMCID: PMC2917401. DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Sana Hyder, source=Web Response no disclosure on file for Jason Jacob; No relevant relationships by Heather Swales, source=Web Response

NOT FOR VETERINARIANS ONLY: A VERY RARE CASE OF PYOMETRA IN AN ELDERLY FEMALE

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Pyometra is a very rare but serious and potentially life threatening condition. It is defined as an accumulation of purulent material within the uterine cavity. It is a common presentation in the veterinary world however exceedingly rare in humans. CASE PRESENTATION: This is a 72-year-old female who presented to the emergency room with complaint of suprapubic abdominal pain and fullness. She reports having mild abdominal pain and fullness for 3 months however it progressively became worse over 2 weeks prior to presentation. She reported the pain to be very severe and sharp in nature. She denied any fever, chills, weight loss, dysuria, or vaginal discharge. In the ER CT of the abdomen and pelvis was obtained which revealed an intrauterine mass measuring 9.7x9.8x10.5 cm. Laboratory workup revealed leukocytosis with white blood cell count of 17.05x10^3. All other pertinent labs were within normal limits. She was transferred to our hospital and admitted to the medical floor. A pelvic ultrasound was then obtained which again revealed an enlarged uterus with a complex cystic appearing lesion. Ob/Gyn was consulted and she underwent a Pap smear and endometrial biopsy with culture. Pathology was negative for any malignancy however culture did grow streptococcus viridans. Patient was started on clindamycin and levofloxacin per infectious disease recommendations. She was then transferred to the intensive care unit as she became hypotensive and was then started on norepinephrine drip. Patient then underwent a dilatation and curettage which revealed copious amounts of purulent drainage in the uterus. Cultures again grew streptococcus viridans and she was continued on antibiotics. A repeat CT abdomen and pelvis was obtained which showed resolution of lesion. Patient remained in the ICU for monitoring and on postoperative day 4 went into cardiac arrest and subsequently deceased. DISCUSSION: Pyometra is reported to occur in 0.1-0.2% of all gynecologic patients [1]. The condition is commonly caused by malignant or benign tumors, radiation cervicitis, atrophic cervicitis or with the use of an intrauterine device. The classic triad of symptoms are vaginal discharge, postmenopausal bleeding and lower abdominal pain, however >50% of patients can be asymptomatic [2]. Pubmed literature review will reveal only a handful of such cases that have been reported. Most common microorganisms causing pyometra are E.coli and bactericides fragilis. A recent case report with literature review revealed a mortality rate of 22.2% [3]. Most suggest a CT scan and a pelvic ultrasound to obtain an accurate diagnosis and prompt initiation of antibiotics along with drainage of the pyometra. CONCLUSIONS: Pyometra is exceedingly rare however life threatening. This case illustrates the severity of the condition requiring prompt recognition and treatment. REFERENCE #1: Khan A, Prasad J. Perforated Pyometra Presenting As A Pelvic Abscess: A Case Report. International Journal of Case Reports and Images. 2012;3(2):10-14 REFERENCE #2: Schmiech K, Woods C, Hylton J, et al. Case Report: Recurrent Pyometra in an Adolescent. Journal of Pediatric and Adolescent Gynecology. 2020 October;33(5):574-576 REFERENCE #3: Uno K, Tano S, Yoshihara M, et al. A Case Report and Literature Review of Spontaneous Perforation of Pyometra. Journal of Emergency Medicine. 2016 May;50(5):231-236 DISCLOSURES: No relevant relationships by Mohammed Ali, source=Web Response No relevant relationships by Rahul Dadhwal, source=Web Response No relevant relationships by Jared Head, source=Web Response No relevant relationships by Aisha Mujahid, source=Web Response No relevant relationships by Salim Surani, source=Web Response

Role and Responsibility of Nurses in Central Line - Insertion and Maintenance

Introduction -A central venous catheter (CVC) is thin, a flexible tube (catheter) that is placed into a large vein above the Heart. It may be inserted through A vein in the Neck, (internal jugular) chest (subclavian vein. Axillary vein) groin (femoral vein), or through veins in the arms known as a PICC, or peripherally inserted central catheters. Site- Internal jugular vein, subclavian vein, axillary vein, femoral veins, the best approach or access point for Central line insertion. Indications - The indications for central venous access are broad and are often situational. Inability to obtain venous access in emergent situations, chemotherapy administration, medications administration (Vasopressors. inotropic administration Total Parental nutrition administration, Hemodynamic monitoring are common indications for CVC insertion. Contraindication- Local cellulitis, Low platelet count, Local infections, Thrombocytopenia, Congenital anomalies, Trauma are common contraindications of CVC insertion. Complications - Numerous potential complications can occur during the procedural placement of a central venous catheter, but also as a result of the indwelling equipment. Arrhythmias, Arterial puncture, Pulmonary puncture with or without resultant pneumothorax, Bleeding – hematoma formation, which can obstruct the airway, Tracheal injury, Air emboli during venous puncture or removal of the catheter, Pulmonary embolism, Local cellulitis, Catheter infection, Cardiac tamponade, Intravascular loss of guidewire, Hamo thorax, Phrenic nerve injury, Brachial plexus injury, Cerebral infarct from carotid artery cannulation, Bladder perforation, Bowel perforation, Sterile Thrombophlebitis. Post-procedural complications: Catheter-related bloodstream infections – bacterial or fungal, Central vein stenosis, Thrombosis, Delayed bleeding with multiple attempts in a coagulopathic patient Clinical Significance - Ensure that sterile products are not contaminated and that there is no evidence of damage to the packaging. Follow sterile procedures at all times. Central line infections can be a serious and life-threatening illness. Always ensure that the catheter is appropriately placed through one or several methods: radiographic evidence, measurement of CVP, or by analyzing a venous blood gas. Never use excessive force during any part of this procedure. It will lead to damage to local structures. Nursing Responsibility - After a CVC placement, nurses are responsible for maintaining, monitoring, and utilizing central venous catheters. The assigned nurse must check complications such as infections, hematoma, thrombosis of the catheter, and signs of pneumothorax and bleeding. Nurses are also responsible for ensuring that the site is maintained in a clean and sterile fashion. Daily inspection of the access site and device patency should be performed during nursing rounds. In particular, nursing officers must disinfect injection ports, catheter hubs, and needleless connectors with institutionally approved antiseptics. Intravenous administration sets should be changed regularly per hospital policy. The site should be checked for bleeding, hematoma formation, and signs of cellulitis, which include erythema, purulent drainage, and/or warmth. Dressings should be changed if visibly soiled. This must be performed with proper sterile technique. Keywords: CVC, Central Line, Central venous catheter.

Answer to October 2021 Photo Quiz.

We report an unusual pyomyositis with concomitant pulmonary lesions in an HIV-positive patient. Due to the difficulty of collecting sputum, gastric lavage was performed. The abscess in the leg was drained (Fig. 1B in photo quiz case presentation). The gastric lavage and the abscess drainage were analyzed using an acid-fast bacilli smear (Fig. 1C in photo quiz case presentation) and Xpert MTB/RIF assay. Gastric lavage, purulent drainage, and blood culture were positive for Mycobacterium tuberculosis. The typical formation of serpentine cords was demonstrated upon culture of abscess drainage (Fig. 1D in photo quiz case presentation). Gastric lavage was M. tuberculosis nucleic acid positive by Xpert MTB/RIF assay. The diagnosis of tuberculosis (TB) pyomyositis was confirmed. Anti-TB therapy (rifampin) was started. Pyomyositis is the accumulation of purulent material within individual muscle groups, and the most common organisms implicated in pyomyositis include Staphylococcus aureus (1). Typical cases of pyomyositis involve fever and pain, which are specific to a muscle group, generally the lower extremities (1, 2). TB pyomyositis, defined as M. tuberculosis infection of skeletal muscle, is more common in immunocompromised patients, but even in these patients, it is considered to be a rare extrapulmonary manifestation of TB. The clinical manifestations may be insidious, with nonspecific symptoms, such as fever, night sweats, malaise, and weight loss (3). Ohnishi et al. reported three cases of TB pyomyositis in women coinfected with TB/HIV with a CD4 below 200 cells/mm3 (4). Pathogenesis for TB pyomyositis can include contiguous spread, lymphatic or hematogenous spread, and direct inoculation (3, 5). We hypothesize that in this case it was a hematogenous spread because of the absence of trauma or infection, with no evidence of osteomyelitis. TB pyomyositis is very difficult to clinically diagnose and distinguish from other soft tissue diseases. Diagnosis depends on a high clinical suspicion of infection in a susceptible population. TB should be considered in patients who present with soft tissue swelling and pain, particularly if they have an abnormal chest X-ray (6). Drainage through surgery and aggressive anti-TB therapy is normally required (7). The case presented here is noteworthy given the rarity of this manifestation of TB and highlights the need for early diagnosis. With timely diagnosis and adequate clinical and surgical treatment, the prognosis is good. Prompt diagnosis requires a high index of suspicion, especially in immunocompromised patients. Fluid cultures should be sent for acid-fast bacilli staining (Fig. 1C in photo quiz case presentation) and culture (8). In laboratories serving areas of high M. tuberculosis incidence with limited economic resources, cord factor detection (Fig. 1D in photo quiz case presentation) is a fast and valid criterion for identifying these mycobacteria using liquid or solid medium (9).

Staphylococcal Scalded Skin Syndrome in a Breastfed Newborn: A Case Report

The authors reveal a clinical report of a 9-day-old newborn girl admitted to the emergency department with generalized erythematous blisters and desquamation without systemic symptoms. A purulent drainage was observed in the left groin area. Staphylococcal scalded skin syndrome (SSSS) was suspected and the newborn was transferred to a pediatric intensive care unit where she started intravenous antibiotics and supportive care. During her stay in the intensive care unit, Staphylococcus aureus (SA) was isolated from the culture obtained from the left groin lesion. A culture from the mother’s milk, that did not show any signs of mastitis, was performed which yielded a pure growth of SA. The child improved after empirical treatment with antibiotic. SSSS is potentially life-threatening and thus its early recognition and prompt treatment are crucial to improve patients’ outcomes. Further studies are required to better understand the role of breast milk in the transmission of SA. Int J Clin Pediatr. 2021;10(2-3):53-56 doi: https://doi.org/10.14740/ijcp438

Locally advanced squamous cell carcinoma with extensive destruction of face

A 58-year-old male with a past medical history of squamous cell carcinoma and basal cell carcinoma presented to the emergency department with complaints of right facial mass, loss of vision, and frequent falls due to visual disturbances. The mass was also associated with pain and purulent drainage. On examination, the patient had a large necrotizing and ulcerative mass occupying the entire right hemiface with complete destruction of facial anatomy including the right eye and nose as shown (Figure 1). On further inquiry, the patient stated that he noticed a “Little Bubble” on his face 3 years ago, which has been progressively worsening since then. He was estranged from his family and had been living alone. The patient did not seek medical care earlier for reasons he did not want to share with the medical team despite our multiple attempts at patient-centered interviewing. He recently established contact with his daughter who ultimately convinced him to seek medical attention. The patient was diagnosed with squamous cell carcinoma and basal cell carcinoma over his face and scalp several years ago, which was successfully treated with surgery at that time. However, he did not follow up and had not seen a physician in several years.

Çocuklarda Ampiyem Tedavisinde Tüp Torakostomi ile Torakoskopik Debridmanın Karşılaştırılması

Objective: Empyema is an important problem that develops after pneumonia in children. Antibiotherapy and drainage of purulent fluid form the basis of treatment. Various methods are used for drainage. Thoracoscopic debridement is widely used today with the development of minimally invasive methods. In this study, patients who were treated for empyema in the period before the use of thoracoscopic debridement in our clinic were compared with the patients who were treated in the period after the use of thoracoscopic debridement. Materials and methods: For this purpose, cases before thoracoscopic debridement (Group 1, n = 25) and patients after thoracoscopic debridement (Group 2, n = 28) were compared in various aspects. While tube thoracostomy was applied to all cases in the first group, thoracoscopic debridement was applied to the cases in the second group whether or not tube thoracostomy was applied. Results: Fever, leukocytosis, respiratory distress and purulent drainage lasted shorter in the group in which thoracoscopic debridement was applied, in other words, clinical improvement was faster. In the group in which thoracoscopic debridement was applied, the duration of tube thoracostomy was shorter and the need for thoracotomy was less than in the group not applied. Conclusion: Thoracoscopic debridement accelerates the recovery of empyema in children. In this, it is effective to debride fibrin and septations in the pleural space more effectively and quickly under the camera view. Therefore, thoracoscopic debridement should be the first option in the treatment of empyema without delay.

Single-Cell RNA Sequencing Reveals Cellular and Transcriptional Changes Associated With M1 Macrophage Polarization in Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent abscesses, nodules, and sinus tracts in areas of high hair follicle and sweat gland density. These sinus tracts can present with purulent drainage and scar formation. Dysregulation of multiple immune pathways drives the complexity of HS pathogenesis and may account for the heterogeneity of treatment response in HS patients. Using transcriptomic approaches, including single-cell sequencing and protein analysis, we here characterize the innate inflammatory landscape of HS lesions. We identified a shared upregulation of genes involved in interferon (IFN) and antimicrobial defense signaling through transcriptomic overlap analysis of differentially expressed genes (DEGs) in datasets from HS skin, diabetic foot ulcers (DFUs), and the inflammatory stage of normal healing wounds. Overlap analysis between HS- and DFU-specific DEGs revealed an enrichment of gene signatures associated with monocyte/macrophage functions. Single-cell RNA sequencing further revealed monocytes/macrophages with polarization toward a pro-inflammatory M1-like phenotype and increased effector function, including antiviral immunity, phagocytosis, respiratory burst, and antibody-dependent cellular cytotoxicity. Specifically, we identified the STAT1/IFN-signaling axis and the associated IFN-stimulated genes as central players in monocyte/macrophage dysregulation. Our data indicate that monocytes/macrophages are a potential pivotal player in HS pathogenesis and their pathways may serve as therapeutic targets and biomarkers in HS treatment.