Surgical Debridement In Combination Research Articles

PB2026 TRANSDIAPHRAGMATIC MUCORMYCOSIS

Background:Mucormycosis is a life‐threatening infection in immunocompromised patients and in haematological malignancy patients in particular.Aims:To report the phenomenon of transidaphragmatic mucormycosis and to raise concerns with regard to the extent of imaging studies in patients with mucormycosis.Methods:Retrospective chart review was performed on patients with Mucormycosis treated at the University Hospital of Cologne (UHC) between April 2012 and June 2017. Mucormycosis was confirmed either histologically or by culture. All cases were diagnosed pre‐mortem.Results:In a series of three patients we observed a previously unreported contiguous disease pattern, where the pulmonary type of disease contiguously spread through the diaphragm into abdominal organs, mostly liver or spleen.Patient 1, a 53‐year‐old women with history of B‐NHL, allogeneic stem cell transplantation and chronic renal disease developed mucormycosis of the lungs with continuous growth through the diaphragm into the liver. Fungal cultures and PCR of bronchoalveolar lavage and liver biopsy remained negative. Hepatic and diaphragm resection was performed and liposomal Amphotericin B (L‐AmB) >5 mg/kg once daily (QD) initiated. Histology showed invasive growth of fungal hyphae of the Mucorales order in liver and diaphragm. A planned lung resection was not possible due to progression of the disease and impossible one‐lung ventilation. The patient died seventeen days after the diagnosis was made.Patient 2, a 35‐year‐old man with history of acute myeloid leukemia and no further underlying conditions developed mucormycosis of the lungs with continuous growth through the diaphragm into the spleen. L‐AmB >5 mg/kg QD was initiated. Splenectomy was performed and histology showed invasive growth of fungal hyphae. Fungal cultures of the surgical sample remained negative, but panfungal PCR resulted in Rhizomucor spp. The patient died 976 days after the diagnosis was made, due to progression of the AML with neoplastic meningitis.Patient 3, a 42‐year‐old man with history of poorly controlled insulin‐dependent diabetes mellitus and injection drug use developed mucormycosis of the lungs with continuous growth through the diaphragm into the liver. Fungal culture of BAL fluid showed growth and PCR positivity of Rhizopus microsporus. Due to septic shock, high vasopressor support and extensive growth of mucormycosis, therapeutic goals were changed to palliative care. Therefore no surgery took place and no antifungal therapy was initiated. The patient died two days after the diagnosis was made.Summary/Conclusion:This is the first report of the clinical observation of transdiaphragmatic mucormycosis in 3 patients. We observed this phenomenon in 11% (3/27) of patients, raising concerns with regard to the extent of imaging studies in patients with mucormycosis. Clinicians should become aware of this new‐described entity. Upmost goal is to understand of the extent of the disease in order to personalize surgical debridement in combination with antifungal treatment. Therefore all patients with suspected mucormycosis should receive a complete staging with head, neck, chest and abdomen CT to find dissemination or contiguous rhinocerebral or transdiaphragmatic spread.

Cervical necrotizing fasciitis: an overlooked diagnosis of a fatal disease

Background: Necrotizing fasciitis of the neck is a rare potentially lethal condition if not early diagnosed and managed. We aimed to study the clinical presentation, radiological and microbiological diagnosis, management, and surgical outcome of patients having cervical necrotizing fasciitis (CNF).Materials and methods: We retrospectively studied patients having a final diagnosis of CNF who were treated at Al Ain Hospital during the period of January 2000 to December 2016.Results: Six patients with CNF were studied. Diabetes mellitus was the most common predisposing factor (83.3%). All patients presented with a painful neck swelling. The most common source of infection was odontogenic. Mixed microbiological flora was present in five patients. Five patients underwent CT scan of the head and neck with a positive finding of gas in all of them. Repeated aggressive surgical debridement in combination with antibiotic therapy was adopted. Four patients (66.7%) developed superior mediastinitis, two had septicemia, and one patient had a perforated duodenal ulcer. One patient died (overall mortality 16.7%).Conclusion: Maintaining a high index of suspicion is crucially important for diagnosing CNF. Early diagnosis, timely resuscitation, and aggressive surgical debridement are the key to a successful clinical outcome.

A case of diabetic foot ulcers complicated by severe infection and sepsis with Trueperella bernardiae

Introduction: Matrix‐assisted laser desorption/ionization time‐of‐flight mass spectrometry (MALDI‐TOF MS) allows us to identify bacteria directly from positive blood cultures with detailed taxonomy naming of the bacterial strains. Knowing the name of the infective bacteria makes it possible to adjust the antibiotic therapy early on. However, it also gives rise to detection of a number of unusual pathogens, which raises new questions on the pathogenicity and medical importance of a number of rarely isolated bacteria such as Trueperella bernardiae. Case presentation: We describe a case of diabetic foot ulcers in a 45‐year‐old male, which led to below‐the‐knee amputation due to widespread infection and sepsis with T. bernardiae and co‐infection with Peptoniphilus lacrimalis. The patient was treated initially with surgical debridement in combination with piperacillin/tazobactam and thereafter with amoxicillin for a total period of 1 month. Conclusion: Based on this case, as well as previous case reports in the literature, we conclude that T. bernardiae is a rarely isolated low‐pathogenic bacterium in patients with severe co‐morbidities. Often co‐infection with other low‐pathogenic bacteria is observed. T. bernardiae is susceptible to and readily treated with β‐lactam antibiotics.

Necrotizing Fasciitis: A Case Report of a Premature Infant With Necrotizing Enterocolitis

Necrotizing fasciitis (NF) is a severe infection involving the superficial fascia, subcutaneous tissue, and, occasionally, deeper tissue layers. Usual treatment is with surgical debridement in combination with antibiotics. In review of the literature there is one neonatal report of NF associated with necrotizing enterocolitis. We present a case report of a 25 week gestation infant with necrotizing fasciitis and the complexity of wound and pain management presented for the nursing staff in the neonatal intensive care unit.

Wound irrigation within the surgical treatment of osteomyelitis.

The basic treatment of osteomyelitis remains even today the surgical debridement in combination with a wound irrigation by lavage systems. Next to a comprehensive knowledge of the surgical techniques a profound knowledge of the lavage systems, the rinsing solutions used and the philosophies of revision programs are a must.In this article the typical hardware of modern lavage systems is analysed, their advantages and disadvantages are pointed out.In addition we investigate the value of common antiseptic wound irrigation solutions for their use in osteomyelitis therapy.Finally the two basic philosophies of wound revision and irrigation in the course of osteomyelitis therapy are presented and discussed.

Successful Treatment of Necrotizing Fasciitis in the Hind Limb of a Great Dane

A 5-month-old, intact female Great Dane was presented for an acute onset of rapidly progressive lameness, severe pain, and diffuse swelling of the right hind limb. Ultrasound evaluation revealed echogenic fluid pockets extending along fascial planes of the right hind limb, from the proximal femur to the hock. Necrotic soft tissues were debrided, and closed-suction drains were placed. No foreign material was identified at surgery. Fluid culture identified a beta-hemolytic Streptococcus sp., and affected fascial histopathology was consistent with necrotizing fasciitis. Postoperatively, the puppy was managed with intravenous broad-spectrum antibiotics, local infusions of amikacin, and daily physical rehabilitation. Oral pentoxifylline was administered to treat bronchopneumonia and streptococcal toxic shock syndrome that developed secondary to necrotizing fasciitis. To our knowledge, this is the first report of a successfully managed case of beta-hemolytic, streptococcal, necrotizing fasciitis successfully managed after a single surgical debridement in combination with systemic broad-spectrum antibiotics, local amikacin infusion, active closed-suction drainage, daily cytology, massage, and passive range-of-motion exercises to maintain limb function.

Rhinocerebral Mycosis: Combined Modality Protocol

AbstractRhinocerebral mycosis is an invasive fungal infection which occurs primarily in the paranasal sinuses and progresses to involve the brain and/or the orbit. It is commonly seen in immunocompromised individuals and can be most effectively treated if diagnosed early, when it is limited to the nasal cavity and the paranasal sinuses. Even though it is acceptable that surgical debridement in combination with antifungal therapy can lead to high rate of cure, the surgical approach for intracranial extension is still a subject of debate. Twenty-four cases of rhinocerebral mycosis managed at our institute are discussed, regarding presenting complaints and management.

Chronic Refractory Osteomyelitis of the Mandible and Maxilla Related to Dental Implant Placement

A 68-year-old diabetic woman with chronic refractory osteomyelitis involving the mandible and maxilla following dental implant placement is presented. The inflammatory lesion showed actinomycotic findings histopathologically and refractory responses to several surgical and medical treatments for over 2 years. A periapical lesion on an adjacent tooth was overlooked as a possible source of infection. The lesion was cured after complete surgical debridement in combination with long-term antibiotic therapy.

Ergebnisse bei der Behandlung von Gelenkinfektionen mit Vakuumversiegelung

At present the vacuum sealing technique is acknowledged as a therapy for acute and chronic wounds. An acceleration of the healing process, due to the vacuum suction with occlusive wound dressing, leads to the shortening of a cost-effective medical treatment. This can be applied to wound treatment and infections of soft tissues, but even today there is only sparse information in this context about joint infections. The results of therapy with the vacuum sealing technique in 68 patients with infections of the joints of an extremity or the trunk were analysed in a retrospective study without a control group. The importance of several patient-related factors for the medical treatment have been analysed. An adequate treatment of joint infections can be achieved even in the presence of endoprostheses or osteosynthetic material. The following factors have been found to be of significance for a prolonged medical treatment: diabetes mellitus (p=0.0052), obesity (BMI>25) (p=0.0458) and a preceding trauma (p=0.0457). The results confirm the value of the vacuum sealing technique following surgical debridement in combination with resistance tested antibiotic treatment, as a sufficient therapy for joint infections, even in patients with an endoprosthesis. This procedure leads to a safe treatment of the joint infection, combined with a good function of the treated joint, good patient comfort and a short duration of the therapy.