Small Abscesses Research Articles

Index C-reactive protein predicts increased severity in acute sigmoid diverticulitis.

PurposeConservative management is successful in unperforated (Hinchey Ia) acute diverticulitis (AD) and also generally in local perforation or small abscesses (Hinchey Ib). A higher degree of radiological severity (Hinchey >Ib), ie, a larger abscess (>3–4 cm) or peritonitis, commonly requires percutaneous drainage or surgery. Retrospective studies show that high levels of C-reactive protein (CRP) distinguish Hinchey Ia from all cases of minor and major perforations (Hinchey >Ia). The current study aims to evaluate the usefulness of CRP in distinguishing AD with a higher degree of severity (Hinchey >Ib) from cases that can be treated noninvasively (Hinchey Ia/Ib).MethodsData from consecutive patients with AD were collected prospectively. All underwent computed tomography (CT). Index parameters obtained at the initial evaluation at the emergency unit were analyzed to assess the association with the outcome. The exclusion criteria comprised concomitant conditions that affected CRP baseline levels.ResultsNinety-nine patients were analyzed. Eighty-eight had mild radiological grading (Hinchey Ia/Ib), and 11 had severe radiological grading (Hinchey >Ib) (median index CRP 80 mg/L vs 236 mg/L [P<0.001]). White blood cells, neutrophils/lymphocytes, serum creatinine, serum glucose, generalized peritonitis, generalized abdominal tenderness, urinary symptoms, and index CRP were related to severe disease. Index CRP was the only independent predictor for Hinchey >Ib (P=0.038). The optimal cutoff value calculated by receiver operating characteristic curve analysis was found to be 173 mg/L (sensitivity 90.9%, specificity 90.9%, P<0.001). All patients who underwent radiological drainage or surgery had an index CRP >173 mg/L and Hinchey >Ib.ConclusionCRP levels >173 mg/L obtained at the initial evaluation at the emergency unit predict major acute complications in AD. These patients commonly require urgent percutaneous drainage or surgical management.

POTT'S DISEASE: A RARE BUT CRITICAL DIAGNOSIS

SESSION TITLE: Chest Infections 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pott’s disease is the most common form of skeletal tuberculosis (TB) which often affects the thoracic and lumbar spines. In 2013, it represented only 2.3% of all United States TB cases. However, it is important for clinicians to include this differential diagnosis to prevent delays of diagnosis and treatment. CASE PRESENTATION: An 82-year-old male with a history of non-compliance to Mycobacterium Avium-Intracellulare (MAI) treatment and atrial fibrillation presented after notification of “bone biopsy positive for TB”. Previously, he presented to another hospital for worsening lower back and bilateral hip pain for the past three months associated with unintentional twenty-pound weight loss within the last six months and night sweats for the past two to three years. Chest X-Ray showed a right lower lobe opacity. Magnetic Resonance Imaging (MRI) revealed abnormal signal intensities/ enhancements and discitis/ osteomyelitis at the thoracic and lumbar vertebrae. It also showed a small epidural abscess/ phelgmon causing moderate to severe spinal canal stenosis at the L2/L3 level and bilateral psoas muscle abscesses. Following a Computed Tomography (CT) guided biopsy of the paraspinal collection and L2- L3 disc space, he received empiric osteomyelitis treatment with Vancomycin and Meropenem. Despite being Quantiferon positive, he was deemed as having latent TB after three negative Acid-Fast Bacillus (AFB) by sputum. Three weeks later, he presented to our hospital after notification of the biopsy results. AFB smear was negative, but culture revealed growth of AFB detected in broth and Mycobacterium tuberculosis complex by DNA probe. Further history revealed he had emigrated from China ten years ago and recently visited China for one month a year ago. Subsequently, Pott’s disease treatment was initiated with Isoniazid, Rifampin, Pyrazinamide, Ethambutol and Pyridoxine. DISCUSSION: Pott’s disease presents as back pain with muscle spasms and rigidity, but rarely constitutional symptoms. Diagnosing skeletal TB presents with challenges such as not including it as a differential diagnosis due to the subtle presentation, lack of active pulmonary disease, and slow disease progression. It is diagnosed by clinical presentation, radiologic imaging with MRI as the most sensitive diagnostic modality, and biopsy. Biopsy limitations include slow culture growth of 6 to 8 weeks, needing 10 – 100 bacilli for culture recovery, and sometimes inconclusive histopathology. Delays in diagnosis lead to complications including vertebral collapse, cord compression, and paraplegia. CONCLUSIONS: It raises the importance of a proper and thorough history in order to include an appropriate differential diagnosis. Since extra-pulmonary tuberculosis is more common in immigrants from endemic areas, our patient who was from China with complaints of back pain should have elicited a higher suspicion of Pott’s disease. Reference #1: McDonald M and Sexton D. Skeletal tuberculosis. UpToDate. July 2017. Available at https://www.uptodate.com/contents/skeletal-tuberculosis?source=search_result&search=potts%20disease&selectedTitle=1∼13#H6 . Accessed August 15, 2017 Reference #2: Ansari S, Amanullah F, Ahmad K, Rauniyar R. Pott’s Spine: Diagnostic Imaging Modalities and Technology Advancements. N Am J Med Sci. 2013 Jul; 5 (7): 404-411. Reference #3: Kumar M, Kumar R, Srivastva AK, et al. The efficiency of diagnostic battery in Pott’s disease: A prospective study. Indian Journal of Orthopedics. 2014; 48 (1) : 60-66 DISCLOSURES: No relevant relationships by Adam Hines, source=Web Response No relevant relationships by Roxana Lazarescu, source=Web Response No relevant relationships by Jennifer Tom, source=Web Response

Successful Closure of Upper GI Leaks by Endoscopic Vacuum Therapy

Endoscopic Vacuum Therapy (EVT) is a novel approach in the management of GI perforations and leaks. We report 3 cases of post-surgical leaks that failed previous endoscopic therapy but were closed by EVT. In all cases, a wound vacuum sponge (KCI-V.A.C. GranuFoam) was affixed to the distal end of a 12 or 16Fr NG tube (Covidien) with 2-0 sutures and endoscopically guided to the defect. The sponge was then placed either intracavitarilly or intraluminally. In case 1, a 58 year old man developed a 15mm duodenal leak after surgical resection of a 20cm retroperitoneal hemangiopericytoma. The sponge/NG tube was inserted nasally over a guidewire, endoscopically guided into the duodenal perforation using a snare, and secured with hemoclips. The NG tube was kept at low continuous suction (30 mm Hg) and was replaced once over a 28-day period, ultimately resulting in leak closure. Patient was discharged tolerating oral diet with CT showing resolution of fluid collections. In case 2, a 62 year old woman with gastric adenocarcinoma developed a persistent 0.6cm anastomotic leak after total gastrectomy and esophago-jejunal anastomosis. EVT was employed intracavitarilly with NG tube kept at low continuous suction (30mm Hg) for 7 days, leading to leak closure. After sponge removal, the patient was discharged tolerating full liquid diet with imaging confirming leak resolution. In case 3, a 48 year old woman with history of lap band placement underwent gastric bypass surgery with development of a small abscess and esophageal leak. EGD showed a leak 2cm above the GE junction. An OTSC, one partially covered and, later, one fully covered esophageal metal stent were placed. Repeat EGD showed a persistent 4mm opening near the OTSC with radiographic evidence of leak. The EVT sponge/NG tube was placed intraluminally over the leak. The NG tube was kept on low continuous suction (30mmHg) and replaced once over a 17-day period. After removal of the sponge, the patient was discharged on full liquid diet. Follow-up CT demonstrated resolution of the leak and the abscess. EVT is a promising approach to the management of upper GI luminal defects. The appeal of the technique lies in its minimally invasive nature, ease of use, and cost effectiveness. Our cases support EVT's reported efficacy and provides evidence for its role as a viable alternative to surgical closure, OTSC, or metal stent placement in the repair of upper GI perforations/leaks2123_A Figure 1. The vacuum sponge affixed to the distal end of a NG tube2123_B Figure 2. The sponge/NG tube placed intracavitarilly within the defect

Risk factor analysis of incisional infection in Crohn's disease patients after bowel resection.

Objective To analyze the risk factors affecting postoperative incisional infection in Crohn′s disease (CD) patients after bowel resection. Methods The retrospective case-control study was conducted. The clinicopathological data of 239 CD patients who underwent bowel resection in the Sixth Affiliated Hospital of Sun Yat-sen University between January 2007 and December 2016 were collected. All patients underwent bowel resection. Observation indicators: (1) surgical situations; (2) follow-up; (3) risk factors analysis affecting postoperative incisional infection; (4) clinical factors affecting preoperative anemia. The follow-up using outpatient examination or ward diagnosis was performed to detect incisional infection within 30 days postoperatively up to January 2017. The normality test was done by Shapiro-Wilk. Measurement data with normal distribution were represented as ±s, and comparison between groups was evaluated with the t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the Wilcoxon rank-sum test. The univariate analysis and multivariate analysis were done using the Logistic regression model. The P<0.05 in univariate analysis was incorporated into multivariate analysis for analysis in the forward wald. Results (1) Surgical situations: of 239 patients, 11 underwent emergency surgery and 228 underwent elective surgery; 65 and 174 underwent respectively laparoscopic surgery and open surgery; 179 received digestive tract reconstruction and anastomosis and 81 received enterostomy (21 combined with anastomosis and enterostomy). Among 239 patients, 137, 113, 101, 58, 54 and 11 were complicated respectively with fiber stenosis, intestinal fistula, obstruction of small intestine, abscess, cellulitis and enterobrosis (some patients combined with multiple signs). (2) Follow-up: 239 patients were followed up at 30 days postoperatively. During the follow-up, 48 with incisional infection were improved by symptomatic treatment. (3) Risk factors analysis affecting postoperative incisional infection: ① Results of univariate analysis showed that illness behavior, sedimentation rate of RBC > 20 mm/h, preoperative anemia, preoperative chronic intestinal fistula, open surgery, intraoperative fiber stenosis and intraoperative intestinal fistula were risk factors affecting occurrence of postoperative incisional infection [odds ratio (OR)=2.530, 2.579, 4.233, 2.988, 2.554, 0.503, 3.052, 95% confidence interval (CI): 1.218-2.259, 1.141-5.833, 1.598-11.210, 1.522-5.864, 1.082-6.029, 0.265-0.954, 1.555-5.993, P 20 mm/h, platelet (PLT) > 300×109/L, elevated C-reactive protein, albumin (Alb) <35 g/L were respectively 120, (17.4±2.9)kg/m2, 130, 75, 139, 65 in patients with preoperative anemia and 65, (18.3±2.9)kg/m2, 36, 12, 39, 10 in patients without preoperative anemia, with statistically significant differences (χ2=17.966, t=2.210, χ2=12.219, 14.440, 14.661, 12.272, P<0.05). Conclusion The preoperative anemia and intraoperative intestinal fistula are independent risk factors affecting occurrence of postoperative incisional infection, and preoperative anemia is associated with perioperative inflammatory conditions. Key words: Crohn′s disease; Bowel resection; Incisional infection; Anemia; Risk factors

Adult parapharyngeal and retropharyngeal abscesses:clinical features and their implications for treatment strategy

Objective:To identify the clinical risk factors related to the increased likelihood of surgical drainage and medical therapy failure in parapharyngeal and retropharyngeal abscess. Method:The charts of 93 consecutive patients from January 2006 to April 2017 with parapharyngeal and retropharyngeal abscess were reviewed retrospectively. Logistic regression analysis was used to study the clinical risk factors.Result:A total of 97 adult patients, there were 34 cases in the immediate surgical drainage group and 32 cases in the delayed surgical drainage group and 31 cases treated with medical therapy alone. The rate of operation therapy was 68%,and the success rate of the medical therapy alone was 32%. All patients had successful resolution of their abscesses by medical therapy and(or) surgical drainage. The average length of stay(17.26d) in the surgical drainage group was longer than the medical therapy group(10.26 d), and the difference was statistically significant(P<0.001).The maximum dimension of abscess＞2.37cm is not only the risk factor of increasing likelihood of surgical drainage, but also that of medical therapy failure(P<0.001, P<=0.002).The factors affecting the hospitalization day were whether or not the operation was performed. There was no significant difference in operative rate between diabetic group and nondiabetic group(χ2=0.523,P>0.05).There were no correlation between diabetes mellitus and the multiple space abscesses(r=-0.032,P<=0.760).Conclusion:Although a majority of adult parapharyngeal and retropharyngeal abscesses were treated with surgical drainage and sufficient effective intravenous antibiotics,but not all patients need surgical treatment. The diameter of the abscess is a risk factor affecting the operation or not.For those with larger abscesses,the preoperative preparation should be actively prepared and the operation should be intervened as early as possible;for those with smaller abscess,the treatment can be cured alone, and the surgical incision and drainage should be avoided in order to reduce the complications and shorten the hospital days.

Classification of Acute Diverticulitis for Stage-directed Therapy

In recent years, there has been a significant change in the treatment recommendations for acute diverticulitis. In order to provide the right treatment to the individual patient, it is therefore important to classify the stage of the disease accurately, after taking various aspects into consideration. Patients treated for acute diverticulitis in Würzburg University Hospital during 2010 to 2014 were included. Inclusion criteria were the presence of a computer tomography for disease classification. More than half of the patients examined (n = 135, 52.9%) had acute uncomplicated diverticulitis on admission; 112 (43.2%) had a covered perforation (small paracolic abscess n = 63, 24,3%; large abscess n = 49, 18,9%) and 12 (4.6%) a free perforation. In a total of 150 (57.9%) patients, this was the first episode of diverticulitis, with a covered (66.1%) or a free perforation (75.0%) occurring at a higher than average rate as the first manifestation. Nearly two-thirds (66.4%, n = 168) of patients underwent sigmoid resection during follow-up. Despite current trends towards more conservative therapy of acute diverticulitis, sigmoid resection remains a corner stone of successful therapy throughout all types of acute diverticulitis. The indication of sigmoid resection nowadays requires profound knowledge of the individual prognosis for recurrent diverticulitis and quality of life.

Abstract 1767: Synergy between intratumoral immunotoxin and systemic anti-CTLA-4 promotes massive inflammation and leads to complete regression of tumors in mice

Abstract Background: The immunotoxin SS1P consists of an anti-mesothelin Fv attached to Pseudomonas exotoxin A and kills tumor cells by inhibiting protein synthesis. Because of its unique mechanism of cell killing and unlike other anti-cancer drugs, SS1P does not suppress the immune system. Here we determined if SS1P can cooperate with anti-CTLA-4 to induce anti-tumor immunity and cause tumor regression. Methods: A BALB/c breast cancer cell line was transfected with human mesothelin (66C14-M) and implanted in two different locations. SS1P was injected directly into one tumor and anti-CTLA-4 given IP. Twelve days after treatment initiation, the tumors were harvested and evaluated for immune related gene expression by Nanostring Technologies. A portion of each tumor was sent to pathology and stained for CD8. Results: In mice treated with anti-CTLA-4 and SS1P, complete tumor regressions occurred in 25/30 (86%) SS1P injected tumors and in 16/30 (53%) tumors at the un-injected location. No complete regressions occurred with either drug given separately. This indicates that the combination therapy has a synergistic and systemic anti-tumor effect. Pathological evaluation of injected tumors from combination-treated mice revealed large central abscesses surrounded by a collar of inflammation, containing a mixture of lymphocytes and mononuclear cells. The collar of inflammation was unique to the combination treated mice. Only very small abscesses were observed in tumors from control mice. Immunohistochemistry of tumors from mice treated with SS1P and anti-CTLA-4 showed an increase in CD8+ cells located mainly in the inflammation collar. Analysis of gene expression in tumors from combination-treated mice, compared to PBS-treated tumors, showed that 341/747 (45%) immune transcripts were elevated by 2-fold or more including CD8a, PDL2 and CD56 (8, 15 and 24-fold, respectively). In mice treated with anti-CTLA-4 and PBS, the increase of transcripts was lower: 127/747 (17%) genes. Only 18 out of 747 transcripts (2%) were elevated in the SS1P-treated tumors. This suggests that SS1P by itself does not initiate an inflammatory process. However, SS1P greatly potentiates the inflammatory process initiated by anti-CTLA-4. Conclusions: Combining local SS1P with anti-CTLA-4 promotes massive inflammation that cures injected and un-injected tumors and provides a strong rational to explore this combination therapy in patients. Citation Format: Yasmin Leshem, James O'Brien, Yoram Reiter, Ira Pastan. Synergy between intratumoral immunotoxin and systemic anti-CTLA-4 promotes massive inflammation and leads to complete regression of tumors in mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1767.

Evaluation of Rhomboidal Flap in Recurrent Pilonidal Sinus

Background: A pilonidal sinus (PNS) is a small cyst or abscess that occurs in the cleft at the top of the buttocks. A PNS usually contains hair, dirt, and debris. It can cause severe pain and can often become infected. If it becomes infected, it may ooze pus and blood and have a foul odor. The exact cause of pilonidal sinuses is unclear. It is generally thought they are caused by loose hairs pushing into the skin. They could also be caused by deep layers of skin being stretched and moved, leading to a hair follicle rupturing. Aim of the Work: The prospective study aimed at evaluating the outcomes of management of recurrent pilonidal sinuses by rhomboid flap. Patients and Methods: A prospective study of cases with recurrent pilonidal sinus, was done at the department of general surgery at In Al-Azhar University hospitals over the period from July 2017 with medium follow up period of three months. Results: Age: ranged between 17 to 36 years with mean = 24.7±5.57. Sex: included 12 male and 8 female. Conclusion: Based on this study, it seems to us that the rhomboid flap is a good alternative for recurrent sacrococcygeal pilonidal sinus, especially for complex sinuses, and it could be appropriate for cases where simpler techniques have failed. It permits early return to complete activity, does not require prolonged postoperative attention, and has very low recurrence rate and postoperative morbidity which may compensate the inconveniences related to an unfavorable cosmetic look.

Video-mediastinoscopy assisted fish bone extraction and superior Medistinal abscess debridement

BackgroundMediastinum abscess caused by sharp esophageal foreign body perforation usually needs surgical treatment, and the surgical procedures vary according to size of perforation and scope of abscess, etc. For special case with small esophageal mucosal crevasse and focal abscess confined to mediastinum, minimally invasive surgery with guidance of video-mediastinoscopy would be an alternative method, however, application of video-mediastinoscopy in this life-threatening situation was rarely reported.Case presentationOne patient with detention of fish bone stuck in the esophagus developed systemic inflammatory response syndrome. Computed tomography results revealed that two high-density foreign bodies migrated extraluminally and caused abscess confined in the mediastinum. Multidisplinary collaborative efforts of anesthesiology, gastroenterology and thoracic surgery were made to optimize the therapeutic process. By taking advantages of wide working channel and better exposure of video-mediastinoscopy, two sharp fish bones were removed with minimal risk of injuring adjacent important tissues, furthermore, complete debridement of the abscess and precise drainage tube indwelling was achieved simultaneously. Postoperative comprehensive therapy including anti-infection and nutrition support guaranteed a smooth transition of perioperative period.ConclusionThis is the first report on application of video-mediastinoscopy in removing two fish bones that migrated extraluminally and debridement of the abscess caused by esophagus perforation with minimal injury risk, which offer a safe and effective minimal invasive method for specific cases.

A study of clinical presentation, diagnostic difficulties and various treatment modalities of liver abscess

Background: Liver abscess is an uncommon entity and over past 100 years dramatic changes in demographics, etiology, diagnosis and treatment occurred. The purpose of this study was to determine the clinico-etiological demographic profile of liver abscess by using radiological studies and to evaluate the outcome associated with different treatment strategies.Methods: A prospective study was conducted over a cohort of 50 patients presenting with liver abscess. Patients diagnosed with malaria, enteric fever, pyrexia of unknown origin, acute viral hepatitis, chronic liver diseases, or hepatomegaly due to any cause, were excluded from study. Results: The amebic liver abscess was found in 32 patients and pyogenic abscess in 18 patients. The age group ranges from 16 to 78 years with mean age of 38 years and the peak incidence is found in the 31-40 years age group for both types. The M: F ratio is 7:2 in pyogenic liver abscess and 13:3 in amebic. In the present study, the most common symptoms in both types of liver abscess were pain abdomen, loss of weight, anorexia, chills and rigor, vomiting and cough. The most common signs seen in both type liver abscess were tenderness, hepatomegaly and jaundice. In both types liver abscess, right lobe was affected more commonly, and single abscess was more common. Hb &lt;10 gm % is present in more than 50 % cases in both liver abscesses. The right dome of diaphragm elevation present in 75%-89% in both types of liver abscess. In pyogenic liver abscess group, patient had associated intra-abdominal infections. In amebic liver abscess group associated illness was not seen. Antibiotics alone used for small multiple abscesses and antibiotics with needle aspiration done for large abscess, are the main line of treatment in this series. Mortality was nil in present series.Conclusions: Liver abscesses are more common in males, alcoholics and immune-compromised patients. Percutaneous drainage with antibiotics treat majority of cases. The mortality from liver abscess has decreased but incidence appears to be increasing.

A critical role of ultrasonography in management of liver abscesses

Aims and objectives: to see the efficacy of ultrasonography in the management of amoebic liver abscess. We assessed whether patient required surgery or can be managed with drainage procedure on ultrasonography basis.Materials and Methods: This is a prospective study done from July 2014 to May 2015, in a medical college in remote area. A total of 88 patients diagnosed with liver abscess were included in the study for ultrasound-guided percutaneous aspiration or pigtail drainage management. All patients had been treated with antibiotics or antimicrobials for at least 2 weeks if treated conservatively and were still being continued for another 6 weeks.Results: A total of 88 patients with liver abscess were successfully treated, consisting 79 males and 9 female. The age ranged from 18 to 82 years with a mean of 43.6 years. A total number of 76 (86.36%) cases undergone percutaneous catheter drainage and 12 (13.6%) underwent needle aspiration. A total of 73 (82.95%) patients had single large abscess, while 8 (9%) had two and 7 (7.9%) had multiple abscesses. The abscesses were commonly located on the right lobe of liver. The Pigtail catheters of sizes 10 F to 18 F was introduced either directly under the guidance of the guide wire with safety precautions. The volume of pus aspirated averaged from 70 - 1200 ml, while the period of catheter drainage ranged from 7 to 24 days with the follow up on ultrasonography.Conclusion: This study shows a success rate of ultrasonography almost 98 % by avoiding unnecessary surgical intervention. It was confirmed that needle aspiration in small abscesses and catheter drainage in large abscesses offers the safest and best modality.Bangladesh Journal of Medical Science Vol.17(2) 2018 p.258-262

Concurrent methicillin-resistant Staphylococcus aureus septicemia and pyomyositis in a patient with dengue hemorrhagic fever: a case report

BackgroundConcurrent presence of dengue hemorrhagic fever (DHF), tropical pyomyositis and septicemia due to methicillin-resistant Staphylococcus aureus (MRSA) in a previously healthy person has never been reported. These three conditions even individually are potentially fatal. “Here we describe a case of a patient contracting dengue and developing DHF along with concurrent pyomyositis likely to be due to MRSA, leading to MRSA septicemia with abscesses formed by MRSA”.Case presentationA 44-year old previously healthy Sinhalese man presented on day 3 of the illness with fever, headache, arthralgia and myalgia and watery loose stools. His pulse rate was 76/min, blood pressure was 110/80 mmHg, while cardiovascular, respiratory and abdomen examination findings were unremarkable. The test for the dengue NS1 antigen was positive on the same day. We have diagnosed dengue and started managing him symptomatically as per the current national guidelines. The patient developed DHF with bilateral pleural effusion and ascitis. On the day 5 he developed severe myalgia, tenderness and non pitting edema of lower limbs especially in the thighs. His creatine kinase levels were high and an ultrasound scan confirmed myositis of both thighs. We suspected myositis due to dengue but investigated for possible simultaneous sepsis as well. On day 9 his blood culture became positive for MRSA. Considering the sensitivity of the bacteria intravenous vancomycin and ciprofloxacin was administered for 21 days. He developed a small abscess at the site of the first intravenous access and a large one above the ankle on the left. On day 12 the latter was drained and the pus culture yielded MRSA sensitive to the same antibiotics. The rapid test for dengue IgM was negative initially but later a positive MAC-ELISA test entrenched dengue infection. After improvement he was sent home on day 33 of the illness. He has developed two other abscesses in the proximity of the drained one and they were drained on day 57. The patient recovered.ConclusionsWhen dengue patients develop symptoms and signs of myositis, prompt investigations for pyomyositis and the treatment can save lives.

Evidence-Based Management of Orbital Complications of Rhinosinusitis in Children

The purpose of this review is to assess recent evidence regarding orbital complications of rhinosinusitis in children and discuss the implications of these findings on current management protocols and clinical practice. The evidence base for this topic is level 4 and 5, based on case series and expert opinion. There are some cohort studies investigating the public health aspects and microbiology of the disease which guides empirical antibiotic prescribing. The management of periorbital complications of rhinosinusitis in children is based on low levels of evidence. Expert consensus recommends expeditious cross-sectional imaging with appropriate intravenous antibiotic usage penetrating the blood brain barrier and selective surgical drainage which can be sight saving. There is some evidence to support conservative management of small subperiosteal abscesses. Surgical drainage via endoscopic, open or hybrid technique depends on individual patient circumstances and skill set of the available surgical team. However, the key tenet of all treatment options remains that clinicians should manage expeditiously to avoid visual loss.

Splenic Abscess: An Uncommon Entity with Potentially Life-Threatening Evolution.

Background/Purpose Splenic abscess is rare with potentially life-threatening evolution. The aim of this study is to review the clinical features, microbiological etiologies, treatment, and outcomes of patients with splenic abscess. Methods We reviewed the admitted patients with suspected splenic abscess and made the diagnosis of splenic abscess. The clinical characteristics, underlying diseases, treatment course, organism spectra, abscess number and size, therapeutic methods, and clinical outcome at a tertiary medical center in Taiwan over a period of 5 years were analyzed. Results Of 16 patients with splenic abscess, the male to female ratio was 1 : 1. Common presentations were fever (11 patients, 68.7%), diffuse abdominal pain (6 patients, 37.5%), left upper quadrant pain or tenderness (6 patients, 37.5%), and left-sided pleural effusions (8 patients, 50%). Antimicrobial therapy was administered in all patients. Fourteen (87.5%) patients recovered under medical treatment. One (6.2%) patient underwent splenectomy, four (25%) patients performed percutaneous drainage of their splenic abscess, and 11 (68.7%) patients received antimicrobial therapy alone. Conclusion We noted that mortality may be more related to patients with underlying immunodeficiency. Patients with splenic abscesses receiving antimicrobial therapy alone were in a relatively high proportion and got a good prognosis especially in patients with small and multiple abscesses.

The diagnostic value of 18F\u2013FDG-PET/CT and MRI in suspected vertebral osteomyelitis \u2013 a prospective study

PurposeThe aim of this study was to determine the diagnostic value of 18F–fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) and magnetic resonance imaging (MRI) in diagnosing vertebral osteomyelitis.MethodsFrom November 2015 until December 2016, 32 patients with suspected vertebral osteomyelitis were prospectively included. All patients underwent both 18F–FDG-PET/CT and MRI within 48 h. All images were independently reevaluated by two radiologists and two nuclear medicine physicians who were blinded to each others’ image interpretation. 18F–FDG-PET/CT and MRI were compared to the clinical diagnosis according to international guidelines.ResultsFor 18F–FDG-PET/CT, sensitivity, specificity, PPV, and NPV in diagnosing vertebral osteomyelitis were 100%, 83.3%, 90.9%, and 100%, respectively. For MRI, sensitivity, specificity, PPV, and NPV were 100%, 91.7%, 95.2%, and 100%, respectively. MRI detected more epidural/spinal abscesses. An important advantage of 18F–FDG-PET/CT is the detection of metastatic infection (16 patients, 50.0%).Conclusion18F–FDG-PET/CT and MRI are both necessary techniques in diagnosing vertebral osteomyelitis. An important advantage of 18F–FDG-PET/CT is the visualization of metastatic infection, especially in patients with bacteremia. MRI is more sensitive in detection of small epidural abscesses.

In small skin abscesses, clindamycin or trimethoprim-sulfamethoxazole after incision and drainage increased cures.

Source Citation Daum RS, Miller LG, Immergluck L, et al; DMID 07-0051 Team. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017;376:2545-55. 28657870

Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Infective Endocarditis (IE) is one of the most life threatening diseases. Echocardiography is a key tool used in diagnosing IE. There are times however when clinical suspicion outweighs diagnostic tests. CASE PRESENTATION: 35-year-old female presented with fever, joint pains, vomiting and a rash. Patient's medical history is significant for a bicuspid aortic valve and an ascending aortic aneurysm with a graft repair. Blood pressure was 93/66 and other vitals were within normal limits. Her physical exam was significant for generalized pustules (palms, soles, face), 2x2 cm ulcerated lesion on the tip of the 3rd right digit, and asymmetric joint tenderness. Cardiovascular exam was significant for Grade II Aortic, Crescendo murmur. Initial labs showed white blood cells count of 20.1 K/uL, Creatinine 2.11 mg/dL, CRP 275 mg/L, ESR 67 MM/HR. Blood cultures were positive for Staphylococcus Aureus. A transesophageal echocardiogram (TEE) showed a bicuspid aortic valve, and no evidence of valvular vegetation. Despite the lack of evidence on TEE, patient treated with Nafcillin for 6 weeks. She was discharged and over the next few weeks she followed up with her primary care doctor. A repeat echocardiogram in 6 weeks did not reveal any vegetations. DISCUSSION: TEE is recommended in patients with high clinical suspicion of IE and a negative or nondiagnostic TTE (transthoracic echocardiogram). The sensitivity of TEE for vegetation is approximately 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is approximately 90 percent. Therefore the question arises whether we should continue treatment for IE if TEE is negative? As in this case, clinical suspicion of IE may persist after a negative TEE. Potential sources of false-negative TEE studies include vegetation’s that are smaller than the limits of resolution, previous embolization of vegetation, or inadequate views to detect small abscesses. Accurate differentiation between true vegetation’s and other IE-related changes, such as ruptured chordae, is frequently difficult. It is also important to emphasize that there are blind spots with TEE. CONCLUSIONS: When clinical suspicion of IE is high and the TEE results are negative, a repeat TEE study is warranted within 7 to 10 days, which may demonstrate previously undetected vegetations or abscesses. Even if a TEE is negative, treatment is warranted if clinical suspicion is high. Reference #1: Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:3075. Reference #2: Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol. 1991;18:391-397. DISCLOSURE: The following authors have nothing to disclose: Mouzamjha Faroqui, Amal Shariff No Product/Research Disclosure Information

Effects of liver abscess severity and quality grade on meat tenderness and sensory attributes in commercially finished beef cattle fed without tylosin phosphate.

Strip loin steaks (n = 119) were used to evaluate the association between liver abscess severity and USDA quality grade and meat tenderness and sensory attributes of steaks from finished feedlot cattle. Steaks were used in a 3 × 2 factorial treatment structure using a completely randomized design and were collected at a commercial abattoir located in northwest Texas. All cattle were sourced from a single feedlot and fed a common diet that did not include tylosin phosphate. Treatments were USDA quality grades of Select (SEL) and Low Choice (LC) and liver abscess scores of normal (NORM; healthy liver, no abscesses), mild (M; 1 abscess less than 2 cm in diameter to 4 abscesses less than 4 cm in diameter), and severe (SV; 1 abscess greater than 4 cm in diameter or greater than 4 small abscesses). All steak samples were collected on the same day, approximately 36-h post-mortem and were cut from the left side of the carcass at the 13th rib by a trained abattoir employee. Steaks were vacuum-packaged, and aged at 3 ± 1°C for 14-d post-mortem. Warner-Bratzler Shear Force (WBSF) and Slice Shear Force (SSF) analyses were conducted and cook-loss percentage was measured. A trained sensory panel analyzed samples for juiciness, tenderness, and flavor attributes. There were no differences among liver abscess scores for WBSF or SSF (P > 0.52). Warner-Bratzler Shear Force was lower for LC-SV than SEL-SV (P = 0.04). Sensory attributes of initial and sustained juiciness, and overall tenderness were all greater for LC than for SEL steaks (P < 0.04) and connective tissue amount was less for LC steaks when compared to SEL (P = 0.03). Liver abscess score had no effect on any sensory attributes (P > 0.70); however, there was an interaction between quality grade and liver score for myofibillar tenderness (P = 0.03). Within LC steaks, liver abscess score had no effect on myofibrillar tenderness (P > 0.05), however, in SEL steaks, M steaks were more tender than SV steaks (P < 0.03). These results indicate that within quality grades, meat tenderness or sensory attributes were not influenced by liver abscess score but that mild liver abscesses may affect the myofibrillar tenderness of SEL steaks.

Use of 2-Octyl Cyanoacrylate Adhesive and Polyester Mesh for Wound Closure in Primary Knee Arthroplasty.

Wound closure in primary knee arthroplasty is important both for surgical success, by minimizing the risk of wound complications and infection, and for patient satisfaction with wound care and cosmesis. This article reports the use of a topical self-adhering, pressure-sensitive polyester mesh combined with 2-octyl cyanoacrylate adhesive for final skin closure of primary knee arthroplasty without external staples or sutures. During a 2.5-year period, 360 consecutive primary knee arthroplasty procedures (321 total knee arthroplasty procedures and 39 partial knee arthroplasty procedures) performed by 1 surgeon at 1 institution were reviewed. For all primary arthroplasty procedures, closure was performed with a standardized method. Final skin closure was performed with 2-octyl cyanoacrylate adhesive and polyester mesh. Patients returned at 6 weeks and 1 year postoperatively. The study found a 0.8% rate of superficial wound complications, no cases of dehiscence, no wound complications requiring operative irrigation and debridement, and no prosthetic joint infections. One patient had a reaction consistent with previously reported localized contact dermatitis that was believed to be related to the 2-octyl cyanoacrylate adhesive. In 2 cases, treatment with cephalexin was required, in 1 case for 2 small suture abscesses and in the other case for periincisional cellulitis. All wound complications resolved by 6 weeks. The results showed that 2-octyl cyanoacrylate adhesive and polyester mesh can be used successfully in the setting of primary knee arthroplasty for closure of high-tension knee arthroplasty wounds. This series found a 0.8% rate of superficial wound complications, no cases of dehiscence, and no infections. [Orthopedics. 2017; 40(5):e784-e787.].

Antimicrobial Treatment of Small Skin Abscesses

Uncomplicated soft-tissue abscesses are seen commonly in U.S. emergency rooms and urgent care centers, particularly since emergence of