Skin Cellulitis Research Articles

Reprint-Necrotizing Fasciitis: A Case Report and A Review of the Literature

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. Diagnosis may be delayed because of the initial minimal skin cellulitis, even as the subcutaneous tissue suffers extensive necrosis and pronounced systemic toxicity develops. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) might be useful in cases where signs are equivocal or diagnosis is in doubt. Computed tomography scans are estimated to have a sensitivity of 80% for detecting necrotizing soft tissue infections. We present a case of limb salvage in a 52-year-old patient with misunderstood type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome. Necrotizing fasciitis is a soft tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures and fascia. Background: the characteristic of this case was aggression and rapid extension. Case presentation: a 59-year-old woman was observed in a very serious condition, with fever and a large necrotic area that smelled of the right inguinal-femoral region in extension to the thigh. No history of illness. Obesity. Diagnosis may be delayed due to minimal initial cutaneous cellulite. A delay in diagnosis can lead to the progression of the disease shown by shock, multiple organ failure and, ultimately, death. Computed tomography and Magnetic Resonance Imaging could be useful in cases where the signs are equivocal or the diagnosis is in doubt. A detailed review of the literature is presented and the current treatment modalities are described. In this case, the aggressive surgical debridement, the complete medical management of sepsis and comorbidities and the timely closure of the wound by dermo-epidermal grafting were essential for a positive result. Conclusions: necrotizing fasciitis is an uncommon life-threatening soft tissue infection, which spreads rapidly and progressively along the deep fascia. The prognosis depends on accurate diagnosis and immediate treatment.

Hand infections

The integument provides only a limited barrier to protect the multiple functional structures of the hand from infection by common bacteria and other rare organisms. If infection is limited to just skin cellulitis, then antibiotics and careful monitoring may be all that is needed. Once bacteria become trapped in a deeper soft-tissue space and form an abscess then debridement must be performed to evacuate the purulence and necrotic tissue. Specialized compartments in the hand such as the pulp space, nail folds, joint cavities, and tendon sheaths facilitate bacterial containment and abscess formation, rendering immune response less effective. Osteomyelitis can originate from direct penetration or spread from an adjacent soft-tissue infection. Orthopaedic devices foster the development of a biofilm that can harbor bacteria, making resolution more difficult. The surgeon should obtain tissue for laboratory analysis at the deep infection site and subsequently administer empiric antibiotics while awaiting culture results. Greater duration of antibiotics is needed for infections of synovial tissues and bone. Unique infections caused by rare organisms may affect the hand, requiring recognition based on specific clinical features and confirmation by specialized laboratory testing.

Skin infection caused by Burkholderia thailandensis: Case report with review

Burkholderia thailandensis is genetically closed to Burkholderia pseudomallei , which causes melioidosis. The bacterium inhabits the environments of tropical regions including those in Southeast Asia and the Northern part of Australia. B. thailandensis is considered avirulent and extremely uncommon to cause disease. We report the first case of foot abscess with skin cellulitis and ankle swelling caused by B. thailandensis in Malaysia. J Microbiol Infect Dis 2016;6(2): 92-95

Skin infection caused by Burkholderia thailandensis: Case report with review

Burkholderia thailandensis is genetically closed to Burkholderia pseudomallei, which causes melioidosis. The bacterium inhabits the environments of tropical regions including those in Southeast Asia and the Northern part of Australia. B. thailandensis is considered avirulent and extremely uncommon to cause disease. We report the first case of foot abscess with skin cellulitis and ankle swelling caused by B. thailandensis in Malaysia. J Microbiol Infect Dis 2016;6(2): 92-95

Reduction Mammaplasty in Patients with a Medialized Nipple-Areola Complex

Sir:FigureWhen using traditional skin and dermoglandular markings for a breast reduction, a medialized nipple-areola complex can contribute to excessively short vertical limbs and tension on the closure/pedicle. This increased tension can predispose to abnormal nipple transposition with poor projection, wound dehiscence, or nipple-areola complex necrosis and/or diminished sensation.1,2 We propose a novel approach to preoperative marking of the keyhole skin pattern and superomedial breast reduction pedicle to compensate for a medially based nipple-areola complex. After institutional review board approval, a retrospective review was performed on all consecutive patients who presented for reduction mammaplasty from January of 2003 through January of 2009. The meridians of the breasts are marked based on the point of greatest projection or ptosis of the breast. The anticipated position of the nipple is then marked 2 cm above the inframammary fold along the breast meridian. Patients are recognized to have a “medialized” nipple-areola complex if the transposed nipple-areola skin is completely off the breast meridian. If so, the medial vertical limb of the Wise reduction skin pattern is increased in centimeters using a 1:1 ratio based on the lateral margin of the nipple-areola complex and the breast meridian, up to a total vertical limb of 10 cm. Beyond this length, medial pole distortion is increased, and the patient may be better suited for an inferior dermoglandular breast reduction. At the time of closure, the pedicle is also given a small backcut along the horizontal limb. This allows the dermoglandular pedicle to rotate into position superiorly, and augments the T-junction closure by bolstering vascularized tissue. A total of 32 patients were noted to have a medialized nipple-areola complex and underwent this technique. Two (6 percent) minor complications were recorded at follow-up, including one seroma that resolved following aspiration in the office, and one superficial skin cellulitis that responded to oral antibiotics. Twenty-five patients (78 percent) rated their results as excellent, and seven patients (22 percent) rated their results as fair. No partial or complete nipple-areola loss was noted in any patient. No patients described their outcome/satisfaction as poor. This is the first report to address the anatomical issue of a medialized nipple-areola complex while using the Wise pattern skin incision and superomedial dermoglandular pedicle for reduction mammaplasty. We have used this technique on 32 consecutive patients and consider it a superior method of managing a medially based nipple-areola complex, by decreasing the tension introduced on the pedicle and final closure, and improving the pedicle arc of rotation. The most common complications following classic skin patterns are based on either increased tension or decreased vascularity at the T-junction closure, as demonstrated by incisional dehiscence, partial skin loss, and inframammary scarring.3,4 Also, in the setting of small reductions or a medialized nipple-areola complex, the pedicle may be difficult to rotate for proper inset. The short medial vertical limb unfortunately prevents this rotation and instead displaces tension across the pedicle base and the T-junction skin closure.2 By instead planning ahead for this problem by lengthening the medial limb of the reduction pattern, this problem can be easily obviated. This modification to the superomedial reduction mammaplasty allows for a tension-free transposition of the nipple-areola complex to an ideal position on the breast mound for aesthetically pleasing results. By increasing the length of the medial vertical limb of the pattern, a reduction on the tension of the nipple/pedicle and final suture line is created without added glandular resection (Fig. 1 and Table 1).Fig. 1: (Left) Preoperative views demonstrating marked breast ptosis with a medialized nipple-areola complex. (Right) Postoperative views with excellent breast mound projection and a centralization of the nipple-areola complex along the breast central meridian.Table 1: Patient Demographics and Operative MeasurementsMatthew L. Iorio, M.D. Matthew Endara, M.D. Ivica Ducic, M.D., Ph.D. Department of Plastic Surgery, Georgetown University Hospital, Washington, D.C. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Clinical outcomes of open heart surgery in patients with atopic dermatitis

Atopic dermatitis is a skin condition often complicated by colonization with Staphylococcus aureus, which increases the risk of infective endocarditis, skin cellulitis and osteomyelitis. Positive cultures for Staphylococcus aureus are obtained from 70% to 80% of wounds in patients with mediastinitis. Thus sternotomy carries increased risk of mediastinitis in patients with atopic dermatitis. We retrospectively reviewed 25 patients with atopic dermatitis who underwent cardiac surgery via a median sternotomy or thoracotomy from January 1997 to September 2010 at our institution. Postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus was found in 3 patients who had a median sternotomy. They were ultimately discharged in good condition. No mediastinitis occurred in patients undergoing thoracotomy. Mediastinitis may occur due to direct exposure of the bone marrow to methicillin-resistant Staphylococcus aureus in patients with atopic dermatitis whose skin is colonized with such bacteria. Thoracotomy may be a better surgical approach in patients with atopic dermatitis who require thoracic surgery.

Regarding extremely large inguinal hernias with a contribution of two cases

We report two men of ages 62 and 80 years, respectively, with giant inguinoscrotal hernias. They were operated with a single-stage repair by two approaches, extended preperitoneal of Nyhus and an inguinal method. After hernia content reduction, a policaproamide antimicrobial mesh Ampoxen (MEDICA SA, Sandanski, Bulgaria) with dimensions 20 x 30 cm was inserted by using Stoppa's technique. An additional inguinal reinforcement with other mesh patch was done on the external aponeurosis hernial defect. Synchronous orchiectomy and transscrotal drainage of both patients was performed. The first patient suffering from umbilical hernia was also operated at the same stage. He was prepared by preoperative pneumoperitoneum. The second patient, due to scrotal skin cellulitis with ulceration, was operated without pneumoperitoneum preparation. The latter created easier mobilization and reduction of the hernial content. The sizable mesh dimensions allowed, to some degree, an acceptable level of intra-abdominal pressure after the repair. These hernias demand interdisciplinary teamwork and their treatment has to be adapted to the individual condition of the patient using all therapeutic options.

Phase II study of gefitinib in metastatic or locoregionally recurrent nasopharyngeal carcinoma (NPC)

15509 Background: Our preclinical work has shown that epidermal growth factor receptor (EGFR) is expressed in ∼ 80% of undifferentiated NPC & gefitinib is a small molecule inhibitor against EGFR with anti-proliferative activity in NPC in vitro. Methods: We report the preliminary result of a phase II study of gefitinib in patients (pts) who progressed after 1–2 lines of chemotherapy (at least 1 line had to contain platinum) for metastatic or locoregionally recurrent NPC. Fourteen Chinese pts were accrued, of whom the median age was 48 years (range 34–64 years), 12 were males, 9 had metastatic & 5 had locoregionally recurrent NPC. All received gefitinib at 500mg/day orally, every 28 days with radiological assessment performed every 2 cycles for a maximum of 8 cycles. Ten pts had 1 line & 5 pts had 2 lines of prior chemotherapy. Results: The median number of administered cycles was 2 (range 1–8). Of the 14 pts evaluable for toxicity, the most commonly reported were acneiform rash (86%, grade 1–2, n = 10; grade 3, n = 4), dry skin (86%, grade 1–2), diarrhea (71%, grade 1–2), fatigue (64%, grade 1–2), anorexia (64%, grade 1–2) & nausea (20%, grade 2). Other grade 3–4 toxicities included fever (n = 2, skin cellulitis, infective pneumonia), hyponatremia (n = 2), near-syncope (n = 2), anemia (n = 1). Dose reduction to 250mg/day was required in 4 pts who encountered grade 3 skin rash. Of the 11 pts evaluable for response, 2 had stable disease (SD) for ≥ 6 months (m) (mean 6.8 m) 9 progressed and no partial responders. Five pts have died mostly of progressive disease & there were no treatment-related deaths. Conclusions: Gefitinib is well tolerated in pts with advanced NPC with some pts experiencing disease stabilization for over 6 months & study accrual is ongoing. No significant financial relationships to disclose.

Prophylactic antibiotics and post laryngectomy pharyngocutaneous fistulae

Pharyngo-cutaneous fistula following laryngectomy is a serious complication. The incidence worldwide varies from 7.6 to 50 per cent. The value of prophylactic antibiotics in preventing fistulae is well recognized but the type of antibiotics and the length of administration of the antibiotics is variable depending on the individual surgeon. Below we present the Plymouth Head and Neck Unit experience where, in the last five years, 33 patients underwent laryngectomy (30 total, three vertical hemi-laryngectomies). The prophylactic antibiotics used in all patients was parenteral cefotaxime 1G or cefuroxime 750 mg, given at eight hours pre-operatively, with the premedication and at eight, 16 and 24 hours post-operatively. Only two patients developed pharyngo-cutaneous fistulae, both after total laryngectomy (six per cent of total). Three patients developed skin cellulitis and five patients developed chest infection which required further treatment with antibiotics.