Surgical Debridement Of Necrotic Tissue Research Articles

A retrospective analysis of eleven cases of invasive rhino-orbito-cerebral mucormycosis presented with orbital apex syndrome initially.

BackgroundRhino-orbito-cerebral mucormycosis(ROCM) is an invasive fungal infection that usually occurs in immunocompromised patients and sometimes presents as orbital apex syndrome(OAS) initially. It is rapidly fatal without an early diagnosis and treatment. We report the cases of invasive ROCM presenting with OAS initially in order to raise the attention of clinicians.MethodsWe retrospectively investigated eleven cases of invasive ROCM presenting initially with OAS admitted between January 2006 and December 2013. We analyzed clinical features, results of laboratory and radiological examinations, nasal endoscopy, aggressive surgical excision and debridement, and medical management outcomes of each case.ResultsA total of eleven cases of invasive ROCM with OAS as an initial sign were presented. Mucormycosis was accompanied by type II diabetes mellitus in nine cases, renal transplant in one case, and injury caused by traffic accident in one case. Anterior rhinoscopy revealed palatine or nasal necrotic lesions in all patients, and transethmoidal optic nerve decompression was carried out in three patients at the same time. CT scan revealed rhino-orbital-cerebral involvement in every patient. All patients were given intravenous amphotericin B. Nine patients underwent surgical debridement of necrotic tissue. Three patients survived.ConclusionsROCM is a severe, emergent and fatal infection requiring multidisciplinary management. It may often present with OAS initially. For ophthalmologist, mucormycosis must be considered in immunocompromised patients presenting with OAS initially, and anterior rhinoscopy is imperative before hormonotherapy, even in the cases absent of ketoacidosis induced by diabetes mellitus.

Acute necrotizing fasciitis developed due to Staphylococcal infection during neonatal varicella

Although varicella acquired during childhood normally has a benign course, complications may occur during the course of the disease. Cellulitis sometimes occurs as a result of bacterial superinfection. When caused by A-group Streptococci cellulitis may evolve into necrotizing fasciitis leading to necrosis of deep tissues. We have found treatment using parenteral antibiotics, intensive supplementary therapy and surgical debridement of necrotic tissues to be effective. A case of Staphylococcal necrotizing fasciitis in a neonate is reported.

Necrotizing fasciitis associated with systemic lupus erythematosus in a child.

Sir, Necrotizing fasciitis (NF) is a rapidly progressive, potentially fatal necrotizing infection of skin and subcutaneous tissues.[1] It is rarely seen in children and its association with systemic lupus erythematosus (SLE) is even rarer. We report a 11-year-old female child who developed NF of the lower leg and was incidentally diagnosed to have SLE. Patients with SLE are predisposed to develop fatal infections. Early recognition of this condition and its association is important to prevent mortality. A 11-year-old female child was referred from the pediatric intensive care unit for evaluation of painful skin lesions on her left lower limb since two weeks. There was a history of local trauma following which the child developed swelling and pain of her left lower limb associated with fever. She was diagnosed to have cellulitis and treated with intravenous antibiotics ceftriaxone, amikacin, and metrogyl with not much improvement. Past history was noncontributory. Cutaneous examination revealed ill-defined ecchymotic plaque with overlying bullae on the medial aspect of left lower leg [Figure 1]. The entire limb was edematous and tender with local increase in temperature. Over one day, the lesions blackened with areas of necrosis and yellowish slough involving the entire lower limb. In few days, there was necrosis extending into deeper planes of skin. Laboratory investigations showed anemia (hemoglobin: 6.2 mg%), leukopenia (2500 cells/mm3), thrombocytopenia (32,500 cells/mm3), increased liver enzymes, and hyponatremia. Urine routine test showed hematuria and proteinuria. Erythrocyte sedimentation rate (ESR) and C-reactive protein were highly elevated. Chest radiography and ultrasonogram abdomen were normal. Serology for Human immunodeficiency virus (HIV) and blood culture was negative. Culture from the tissue and pus grew group A Streptococcus, Klebsiella, and Escherichia coli. A diagnosis of NF was considered. In view of the above clinical features and investigations, antinuclear antibody and anti-double-stranded DNA tests were done, which were strongly positive. A final diagnosis of systemic lupus erythematosus with NF was made. Surgical debridement of necrotic tissue was done [Figure 2]. As the necrosis had reached the bony tissues, amputation was done. However, the child died due to sepsis.Figure 1: Ecchymotic plaque with overlying bullae and necrotic areas on the medial aspect of left lower legFigure 2: Surgical debridement showing necrotic tissue extending into deeper planesNF is a life-threatening infection with a high mortality rate ranging from 20% to 80% despite the use of appropriate treatment modalities. The etiology of NF is polymicrobial in nature. Most patients with NF have associated comorbidities such as diabetes, HIV infection, renal failure that predispose them to infections.[2] Clinically the patient presents with ecchymosis, bullae, necrosis, and gangrene. The inflammation rapidly progress to involve deep fascial planes thus making the importance of early diagnosis and exploration. Infections are the major cause of mortality in SLE. Even though SLE patients are prone to develop infections, NF is rarely reported. There is an increased risk of infections in SLE due to impaired cell-mediated immunity, immunoglobulin deficiencies, complement factor deficiency, and various defects in other immune effector cells, including neutrophils, macrophages, and natural killer cell.[3] Genetic predisposition and presence of R131variant of FCrRIIA on Fc receptor are believed to contribute to the risk of infection.[4] NF has been associated with other rheumatic disorders that include dermatomyositis, polymyositis, systemic sclerosis, rheumatoid arthritis, and ankylosing spondylitis.[5] Clinically, NF may not be diagnosed early and only when necrosis occurs diagnosis may become evident. In our case, the child had been diagnosed as having soft tissue infection before presenting to us and treated with antibiotics, which were unresponsive. This indicated deeper infection that required aggressive approach and exploration. Even though appropriate interventions and surgical debridement was done, as the child had presented to us late, there was a delay in diagnosis; the child had to undergo amputation and eventually succumbed to sepsis. There is partly increased risk of infections due to use of oral steroids and immunosuppressants in SLE cases but our case was treatment naïve and it was SLE-associated immunosuppression that must have contributed to the infection. Impaired immune response in SLE is a primary risk factor for developing NF which is an emergency condition requiring early detection and quick debridement. Increased awareness of this condition and its association is necessary to prevent mortality.

Actinomycotic Osteomyelitis of Maxilla Presenting as Oroantral Fistula: A Rare Case Report.

Actinomycosis is a chronic granulomatous infection caused by Actinomyces species which may involve only soft tissue or bone or the two together. Actinomycotic osteomyelitis of maxilla is relatively rare when compared to mandible. These are normal commensals and become pathogens when they gain entry into tissue layers and bone where they establish and maintain an anaerobic environment with extensive sclerosis and fibrosis. This infection spreads contiguously, frequently ignoring tissue planes and surrounding tissues or organ. The portal of entry may be pulpal, periodontal infection, and so forth which may lead to involvement of adjacent structures as pharynx, larynx, tonsils, and paranasal sinuses and has the propensity to damage extensively. Diagnosis is often delayed and is usually based on histopathology as they are cultured in fewer cases. The chronic clinical course without regional lymphadenopathy may be essential in diagnosis. The management of actinomycotic osteomyelitis is surgical debridement of necrotic tissue combined with antibiotics for 3–6 months. The primary actinomycosis arising within the maxilla with contiguous involvement of paranasal sinus with formation of oroantral fistula is rare. Hence, we present a 50-year-old female patient with chronic sclerosing osteomyelitis of maxilla which presented as oroantral fistula with suppurative and sclerotic features.

Anesthetic considerations in the management of mucormycosis

Mucormycosis or zygomycosis is a well described but a complex disease which appears unseemingly benign but is fatally malignant in its behaviour. Mucormycosis causes severe tissue destruction by endothelial invasion. Our pateint was 65 year old lady with palatal mucormycosis with uncotrolled diabetes who was treated successfully with systemic amphotericin B and surgical debridement which is the main stay of treatment of mucormycosis. Systemic amphotericin B has a lots of side effects like fever, shivering, hypotension, hypoxia, arrhythmia and mainly nephrotoxicity. Our aim is to highlight the need for early diagnosis and surgical debridement of necrotic tissues while keeping in mind the toxic effects of systemic amphotericin B and its interaction with anaesthetic agents.

Nanostructured platforms for the sustained and local delivery of antibiotics in the treatment of osteomyelitis.

This article provides a critical view of the current state of the development of nanoparticulate and other solid-state carriers for the local delivery of antibiotics in the treatment of osteomyelitis. Mentioned are the downsides of traditional means for treating bone infection, which involve systemic administration of antibiotics and surgical debridement, along with the rather imperfect local delivery options currently available in the clinic. Envisaged are more sophisticated carriers for the local and sustained delivery of antimicrobials, including bioresorbable polymeric, collagenous, liquid crystalline, and bioglass- and nanotube-based carriers, as well as those composed of calcium phosphate, the mineral component of bone and teeth. A special emphasis is placed on composite multifunctional antibiotic carriers of a nanoparticulate nature and on their ability to induce osteogenesis of hard tissues demineralized due to disease. An ideal carrier of this type would prevent the long-term, repetitive, and systemic administration of antibiotics and either minimize or completely eliminate the need for surgical debridement of necrotic tissue. Potential problems faced by even hypothetically "perfect" antibiotic delivery vehicles are mentioned too, including (i) intracellular bacterial colonies involved in recurrent, chronic osteomyelitis; (ii) the need for mechanical and release properties to be adjusted to the area of surgical placement; (iii) different environments in which in vitro and in vivo testings are carried out; (iv) unpredictable synergies between drug delivery system components; and (v) experimental sensitivity issues entailing the increasing subtlety of the design of nanoplatforms for the controlled delivery of therapeutics.

The Case Files

A 63-year-old woman presented to the ED via ambulance with complaint of a draining abscess from her groin that had worsened over the past day. She also reported subjective fever and chills. The patient said she first noticed the abscess two days earlier. The patient had had an appendectomy in 1994 and a hysterectomy in 2000, and she had type II diabetes, hypercholesterolemia, and hypertension. The patient was not compliant with her medications, and was not sure what they were. Her body mass index was 33.2, respiration rate was 18 bpm, oral temperature was 100.5°F, pulse was 108 bpm, blood pressure was 173/94 mm Hg, and pulse oximetry was 97% on room air. Physical examination was significant for a foul-smelling draining abscess in the perineal region that was tender, erythematous, and edematous with crepitus surrounding the site of drainage and copious amounts of pus that were expressed with light pressure during palpation. Laboratory results were significant for a blood glucose level of 395 mg/dL and a white blood count of 20.3 cells/ml. A CT scan of the abdomen and pelvis with contrast showed multiple foci of air in the right lower anterior pubic region that was suspicious for a gas producing infection. (Photo.) The diagnosis of Fournier's gangrene was confirmed, and the patient was immediately started on broad-spectrum IV antibiotics, insulin, and IV fluids.Figure: CT of the abdomen and pelvis.The patient was transferred to surgery where, after consulting with urology, a decision was made to perform a radical debridement of necrotic tissue and to drain the area surgically. The patient was stabilized after debridement and released from the ICU. The patient underwent reconstructive surgery, and was released three weeks after admission. The patient also received education on managing her chronic conditions. Because of immediate identification and intervention, the patient recovered. Fournier's gangrene is a rare form of necrotizing fasciitis with rapid onset and progression. Venereologist Jean Alfred Fournier was the first to describe a rapidly progressing case of necrotizing fasciitis in 1883. (AJR Am J Roentgenol 1998;170[1]:163.) This form of necrotizing fasciitis is caused by anaerobic and aerobic microorganisms. The infection often begins as a simple cellulitis from a defect or break in the skin of the perineal or genital region, providing entry for bacteria. Because of the aggressive nature of the bacteria, even with early intervention, mortality rates remain high. Multiple organisms can be present in the infection and may act synergistically, encouraging growth. The most common bacteria present are Escherichia coli, Bacteroides, Proteus, Staphylococcus, Enterococcus, Streptococcus, Pseudomonas, Klebsiella, and Clostridium species. (EMN 2005;27[5]:24.) The byproducts of an anaerobic metabolism lead to soft tissue gas formation that is composed of hydrogen, hydrogen sulfide, and nitrous oxide. (AJR Am J Roentgenol 1998;170[1]:163.) It is important that surgical debridement be performed as soon as possible once Fournier's gangrene is identified. Diagnosis can be made through physical examination, blood tests such as a CBC, imaging such as sonograms and CT scans that can provide evidence of the extent of subcutaneous infection, and a thorough history to help establish comorbidities such as diabetes, alcohol abuse, or immunodeficiency. Treatment consists of broad-spectrum antibiotics, surgical debridement of necrotic tissue, and surgical drainage. Hyperbaric oxygen therapy is not a mainstay of treatment, but it can be beneficial and reduce mortality. (J Urol 1997;158[3 Pt 1]:837.) Primary closure of the skin is done once granulation tissue begins to form after surgical debridement. Depending on the amount of debridement, local skin flap coverage or skin grafts can be used for closure of surgical site. Differential diagnosis of Fournier's gangrene includes cellulitis, abscess, hernia, hydrocele, orchitis, testicular torsion, balanitis, fungal infections, and vulvovaginitis. Patients should have appropriate surgical and urological follow-up.

Neonatal necrotising fasciitis managed conservatively: an experience from a tertiary centre.

Conventional therapy for neonatal necrotising fasciitis (NF) involves resuscitation and aggressive surgical debridement of necrotic tissue. This approach adds surgical stress in septicaemic neonates with low reserves. The present study reports a more conservative approach to the management of neonatal NF. A prospective study was conducted between July 2010 and June 2013 and included 11 cases of neonatal NF. Demographic characteristics of patients were noted. No debridement was performed. Dressings were applied after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. A record was made of type and duration of supportive modalities and complications. The primary outcome was recorded as final recovery, need of surgical intervention or need of grafting. Out of 11 neonates, 6 were males and 5 were females. Age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). In all cases, the wound was cleaned with normal saline, dressed, necrotic slough was allowed to separate spontaneously and granulation tissue was allowed to develop; this took approximately 14 to 28 days (mean 20.45±5.78 days). As opposed to the conventional approach of aggressive debridement in neonatal NF, these cases can be managed conservatively without increase in morbidity or mortality. This approach also minimises the surgical risk and requirement of blood transfusion. Antifungal drugs have a definitive role in management of these immunologically deficient babies.

Necrotizing fasciitis complicating pregnancy: a case report and literature review.

Necrotizing fasciitis is a rare, life-threatening surgical infection in pregnancy with high rates of morbidity and mortality. A 15-year-old primigravid woman, at 28 weeks of gestation with no significant previous medical history, was admitted to our hospital complaining of severe left lower extremity pain and high fever the last 72 hours. During clinical examination, she had a swollen, erythematous and tender to palpation inflamed skin over the medial aspect of the upper thigh without any evidence of injury. Incision drainage was performed immediately and she received broad spectrum antibiotics. During initial laboratory examinations, diabetes mellitus was diagnosed. There was no clinical improvement over the following days. Magnetic resonance imaging (MRI) revealed subcutaneous tissue inflammation and edema of infected tissues confirming the disease entity. Multidisciplinary therapy with immediate aggressive surgical debridement of necrotic tissues, multiple antibiotics, and intensive care monitoring was performed successfully. The patient's postoperative course was uncomplicated and skin defect was closed with split thickness skin grafting. Our case emphasized the potential immunosuppressive role of pregnancy state in conjunction with diabetes mellitus in the development of severe necrotizing soft tissue infections.

Role of Muscle Free Flap in the Salvage of Complicated Scalp Wounds and Infected Prosthetic Dura

BackgroundThe prosthetic dura is an essential element in the protection of the cranial parenchyma and prevention of cerebrospinal fluid leakage. Although prosthetic dura are widely used in neurosurgery, they occasionally provoke infection, which can be a major concern after neurosurgical treatment. However, removal of the prosthetic dura carries a risk of brain parenchyma injury and cerebrospinal fluid leakage. The salvage of infected prosthetic dural material has not been adequately addressed in the literature. In this study, we demonstrate the value of the combination of a meticulous surgical debridement of necrotic tissue and simultaneous muscle free flap for intractable postoperative epidural abscess without removal of the infected prosthetic dura.MethodsBetween 2010 and 2012, we reviewed the data of 11 patients with persistent infection on the prosthetic dura. The epidural infections each occurred after a neurosurgical procedure, and there was soft tissue necrosis with the disclosure of the underlying prosthetic dura and dead bone around the scalp wound. To salvage the infected prosthetic dura, meticulous debridement and a muscle free flap were performed.ResultsAll 11 patients experienced complete recovery from the complicated wound problem without the need for further surgical intervention. No signs of prosthetic dural infection were observed during the mean follow-up period of 11 months.ConclusionsThe combination of a meticulous surgical debridement and coverage with a muscle free flap is an effective treatment for salvage of infected prosthetic dura.

Mucormycosis is a rare etiology of ophthalmoplegia: How to diagnose and to manage it, about one exceptional case

AbstractPurpose Mucormycosis is a rare opportunist infection,characterized by a high mortality rate occurring in immunodeficient patient population.Its rhino‐cerebral form may be complicated by neuro‐ophthalmological and orbital symptomatology.Methods We report a case of a 57 years old woman, referring because of diplopia associated with a diabetic ketoacidosis .Ocular examination revealed a complete left ophthalmoplegia. Magnetic resonance imaging highlighted a cavernous sinus thrombosis associated with ipsilateral pansinusitis. In this context, mucormycosis diagnosis is discussed and confirmed by anatomopathology analysis after sinusal biopsy.The follow‐up is exceptional in its ophthalmological complications despite antifungal agents and anticoagulant therapy.We observed consecutively a left central retinal artery occlusion (CRAO) then a contralateral central retinal veinous occlusion,and finally a left neovascular glaucoma.Results Mucormycosis is a fungal opportunist infection that must be very early diagnosed.This pathology is caracterized by sinusal infiltration, necrosis, and bony walls damage. Medical treatment by anti‐fungal agents alone, can not contain it. It must be associated with a wide and repeated surgical debridement of necrotic tissue. Symptomatic ocular treatment (anti‐VEGF, Laser) is needed in order to preserve visual function and anatomical prognosis.Indeed, the extension along blood vessels walls leads to thrombosis and necrosis, that is resistant to systemic therapy. Our patient is still alive after a follow‐up of 24 months.Conclusion This case illustrates a serious multidisciplinary pathology,that is very difficult to control.The ocular signs were predominant but revealed a large rhino‐cerebral infiltration.

Mucormycoses

Mucormycosis is a life-threatening invasive fungal infection that arises among immunocompromised patients (haematological malignancies, solid organ transplantation, diabetes mellitus). The most frequent sites of infection are pulmonary, rhinocerebral, cutaneous and disseminated. Reversal of the underlying conditions is mandatory for controlling mucormycosis. Another cornerstone of mucormycosis treatment is prompt and aggressive surgery. It is achieved by extensive surgical debridement of necrotic tissues. Finally an antifungal therapy is needed. The first-line chemotherapy of mucormycosis includes high-dose liposomal amphotericin B (≥ 5mg/kg/day). The duration of antifungal chemotherapy is not defined but guided by the resolution of all associated symptoms and findings (usually 6-8 weeks). Maintenance therapy/secondary prophylaxis by posaconazole has to be considered in persistently immuno compromised patients.

Recognition and Treatment of Freezing and Nonfreezing Cold Injuries

This article reviews recent medical literature to provide an overview of the recognition and treatment of the two broad categories of cold injuries, freezing and nonfreezing. Frostbite, a freezing cold injury, is treated traditionally with rapid rewarming followed by tissue care and surgical debridement of necrotic tissue. Recently, newer therapies aimed at prevention of tissue necrosis have shown improved outcomes compared with more traditional therapies. These newer treatment regimens for frostbite include the use of various drugs such as ibuprofen, aspirin, warfarin, tissue plasminogen activator, and prostacyclin. The use of Tc bone scans, magnetic resonance imaging arthrogram, or angiography may have prognostic value for early determination of the extent of tissue loss. The more common nonfreezing cold injuries, though less severe than frostbite, may lead to short- and long-term complications requiring treatment and are discussed also.

Rhino-orbito-cerebral mucormycosis: Five cases

Introduction and objectiveMucormycosis is an invasive fungal infection usually observed in immunocompromised patients. Mucormycosis is rapidly fatal without an early diagnosis and treatment. We report five patients of rhino-orbital-cerebral mucormycosis and a literature review. DesignThe medical records of five patients presenting with rhino-orbital-cerebral mucormycosis, admitted between January 1995 and December 2007, were analyzed. All patients underwent tissue biopsy. The histologic sections revealed the presence of non-septate hyphae of the order Mucorales. ResultsThe five patients, three men and two women, between 27 and 61 years of age, were all diabetic. The main symptoms were exophthalmia (five patients), facial swelling (four patients), periorbital cellulitis (four patients), and cranial nerve palsy (four patients). Anterior rhinoscopy revealed palatine or nasal necrotic lesions in four patients. All presented with diabetic ketoacidosis and CT scan revealed rhino-orbital-cerebral involvement in every patient. All patients were given intravenous amphotericin B. Four patients underwent surgical debridement of necrotic tissue. Two patients survived. ConclusionsMucormycosis is usually a fatal infection in diabetic patients. Early diagnosis should be based on imaging data and histology. Amphotericin B must be rapidly initiated and associated with aggressive surgical debridement to reduce mortality.

Invasive Group A Streptococcal Disease

Invasive group A streptococcal infections are uncommon, although serious, infections with high case fatality rates. Periodic resurgences in invasive group A streptococcal infections in industrialized countries have been reported from the 1980s onwards, with current estimates of incidence in these countries of approximately 3–4 per 100000 population. Infants, pregnant women and the elderly are at increased risk of invasive group A streptococcal infection. The group A streptococcus has an array of virulence factors that underpin its invasive capacity and, in approximately 10% of cases, super-antigen toxins produced by the bacteria stimulate a large proportion of T cells, leading to streptococcal toxic shock syndrome. Given the rapid clinical progression, effective management of invasive group A streptococcal infections hinges on early recognition of the disease and prompt initiation of supportive care (often intensive care) together with antibacterial therapy. In cases of toxic shock syndrome, it is often difficult to distinguish between streptococcal and staphylococcal infection before cultures become available and so antibacterial choice must include coverage of both of these organisms. In addition, clindamycin is an important adjunctive antibacterial because of its anti-toxin effects and excellent tissue penetration. Early institution of intravenous immunoglobulin therapy should be considered in cases of toxic shock syndrome and severe invasive infection, including necrotizing fasciitis. Early surgical debridement of necrotic tissue is also an important part of management in cases of necrotizing fasciitis.

Prognostic factors in Fournier gangrene

Fournier gangrene is a necrotizing fasciitis, arising in the genital and perineal area. This entity is still associated with a high mortality rate despite improvements in antibiotic and surgical treatment. This is a retrospective study of all the patients diagnosed and surgically treated for Fournier gangrene at General University Hospital Ramon y Cajal between 1988 and 2008. Possible prognostic factors that could have any influence on the evolution of Fournier gangrene were analyzed. Seventy patients were analyzed, 62 males (88.6%) and 8 females (11.4%) with a mean age of 57.9 ± 13.5 years. Most frequent clinical manifestations were perineal pain (82.9%) and fever (60%). Physical examination revealed edema (91.4%), erythema (88.6%) and perineal skin necrosis (60%). All the patients underwent surgical debridement of necrotic tissue. In 54.3% reoperations were necessary for new surgical debridements. Medical complications rate was 27.1% and mortality one 22.9%. Ethylism, coexistence of neoplasms, presence of skin necrosis, myonecrosis, abdominal wall affection, number of debrided areas, reoperations, concentration of creatinine in serum>1.4 mg/dL, and hemoglobin <10 g/dL, and platelet count <150 × 10(9)/L in whole blood are associated with higher mortality rates. Identification of prognostic factors may help to determine high-risk patients in order to establish an optimal treatment, according to severity of the infection and general status.

Covering the Cover

Covering the Cover

Successful Treatment of Deep Cutaneous Zygomycosis Developing Early after Renal Transplantation

A 25-year-old male patient with end-stage renal disease due to chronic pyelonephritis who had undergone renal transplantation was admitted 20 days after the operation with complaints of nausea, vomiting and darkening in the skin of the transplantation site. A 30x30 cm area of skin at the transplantation site in the left inguinal area was dark colored and of necrotic appearance. Gram-negative and gram-positive bacilli were observed in the gram stain of the material taken from the lesion through thin needle aspiration. Surgical debridement of necrotic tissues at the lesion site was performed. There were fungi with bacterial groups and branched rough hyphae infiltrating the necrotic lipid and connective tissue. The venous wall was under the invasion of these fungi hyphae in the histopathological examination of the debridement material and a diagnosis of subcutaneous zygomycosis was established. Amphotericin B was administered for 14 days at a cumulative dose of 625 mg. The skin defect at the left lower quadrant was closed by placing a graft. The patient no longer required dialysis after two weeks of hospitalization. He was discharged 48 days later with total recovery of the lesion site and a serum creatinin level of 2 mg/dL, under treatment with cyclosporine 400 mg/day and prednisolone 20 mg/day.

Fasciite nécrosante de la face après un traumatisme palpébral mineur : rôle des anti-inflammatoires

Facial necrotizing fasciitis is a rare but potentially serious and fatal infection, especially in children. We report the case of a five-year-old girl who developed rapidly progressive necrotizing fasciitis of the face secondary to a mild trauma, with a small wound in the upper eyelid. She had received nonsteroidal anti-inflammatory treatment before she was referred to our hospital. Despite surgical debridement of necrotic tissues and intravenous antibiotic therapy, recurrence occurred. Final progression was satisfactory without sequelae. We discuss here the role of nonsteroidal anti-inflammatory drugs in the development of necrotizing fasciitis in cutaneous lesions, whether traumatic or not.

New therapies for fungal pneumonia

This review summarizes recent developments in the diagnosis and treatment of fungal pneumonia, with an emphasis on invasive pulmonary aspergillosis. Improvements in nonculture-based fungal diagnostics, early implementation of pulmonary high resolution, or spiral computed tomography scanning and a recent expansion of the antifungal armamentarium have greatly improved the outcome of immunocompromised patients with invasive aspergillosis. However, the field is changing: new pathogens (such as Zygomycetes) are emerging, and novel risk groups (ICU patients in particular) are being identified. Galactomannan antigen detection is a valuable tool for evaluating patients at risk for invasive aspergillosis (as a screening assay on serum samples from neutropenic patients or as a confirmatory assay on bronchoalveolar lavage fluid samples, in general), but should be used in conjunction with modern imaging techniques. beta-D-Glucan and PCR assays are still investigational. Voriconazole is the drug of choice for invasive aspergillosis, whereas liposomal amphotericin B at 3 mg/kg per day is the preferred alternative in case of contraindication, drug-related side-effects, or intolerance. Whenever possible, optimal antifungal therapy should be complemented by surgical debridement of necrotic tissue. The added value of combination therapy is still unproven. Therapeutic drug monitoring of mold-active azoles should be implemented in order to minimize toxicity and maximize efficacy. Lipid-based formulations of amphotericin B, and to a lesser extent voriconazole, are the drugs of choice for non-Aspergillus related fungal pneumonia. Although active in prophylaxis, the efficacy of posaconazole in confirmed infections remains controversial.