Thick Pus Research Articles

Infected Infradiaphragmatic Retroperitoneal Extralobar Pulmonary Sequestration: A Case Report

Infradiaphragmatic extralobar pulmonary sequestration is an extremely rare congenital malformation. It is more frequently diagnosed in the antenatal period due to routine ultrasonic examination of the fetus or in the first 6 months of life, though on rare occasions it is discovered incidentally in adults. A 32-yr-old man presenting with epigastric discomfort and fever was referred. Computed tomographic scanning showed that a 16-cm, multiseptated, dumbbell-shaped, huge cystic tumor was located beneath the diaphragm. On the next day, 850 mL of thick yellowish pus was drained by sonography-guided fine needle aspiration for the purpose of infection control and diagnosis, but no microscopic organisms were found in repeated culture studies. Surgical removal of the cyst was performed through thoracoabdominal incision and most of these pathologic lesions were removed but we could not find the feeding arteries or any fistulous tract to surrounding structures. Histopathologic study revealed that it was extralobar pulmonary sequestration and culture study showed that many WBC and necrotic materials were found but there were no microorganisms in the cystic contents. We report the first case of an infected infradiaphragmatic retroperitoneal extralobar sequestration which was administered a staged management and achieved an excellent clinical course.

The Inaccessible or Undrainable Abscess: How to Drain It

Percutaneous abscess drainage is a safe, effective, and widely used technique for the treatment of patients with abdominal or pelvic sepsis. The majority of abdominal and pelvic abscesses afford reasonably straightforward access and are amenable to percutaneous drainage. However, requests are occasionally received for drainage of abscesses or fluid collections that initially appear unsuitable for percutaneous drainage. Factors that render collections seemingly unsuitable for imaging-guided drainage include inaccessibility due to surrounding organs, difficult location, and thickened contents (eg, clotted blood, thick pus). Well-established alternative approaches (eg, transgluteal, transvaginal, transrectal) can be used to facilitate drainage of deep-seated collections that are inaccessible via more traditional routes. Other factors that may improve the accessibility of collections include modifications in patient positioning or in the use of imaging hardware (eg, angling of the computed tomography scanner gantry). Use of these techniques and modifications can allow percutaneous drainage of less accessible intraabdominal abscesses, thus eliminating the need for laparotomy.

Paravesical Abscess as an Unusual Late Complication of Inguinal Hernia Repair in Children

We analyzed pitfalls in the etiology, diagnosis and treatment of pediatric patients who had a paravesical abscess (PVA) resulting from previous inguinal hernia repair. We retrospectively reviewed the records of 6 children undergoing operation for PVA related to previous inguinal hernia repair between 1994 and 2002. All patients were male and 1.5 to 8 years old. The location of PVA was the right side of the bladder in 4 patients and the left side in 2. History showed that only 2 cases were complicated by early postoperative wound infection. Four patients were hospitalized with a relapse of symptoms following antibiotic treatment for possible urinary tract infection. The interval between initial inguinal hernia repair and the diagnosis of PVA was 6 to 48 months. Five patients had from recurrent lower urinary tract symptoms, 2 had ipsilateral groin discomfort and 1 had lower abdominal discomfort. There were swelling and tenderness at palpation of the ipsilateral groin in 5 patients not present at previous examinations. Only 1 patient had fever and leukocytosis. Urinalysis showed microscopic hematuria in all patients, of whom 2 had also leukocyturia. All patients had negative urine cultures. Ultrasound and computerized tomography findings suggested features of abscess formation at the paravesical space with concomitant focal thickening of the adjacent bladder wall. At surgery when entering the abscess cavity, thick pus and granulation tissues were débrided. Transfixing silk sutures were found to be secured to the adjacent bladder wall in 2 patients and in the area of the internal ring in 4. They were removed. The adjacent bladder walls needed no additional intervention. Biopsy specimens revealed only chronic inflammatory components. Antibiotics were continued for a mean of 7 days. Weekly ultrasound was performed to evaluate bladder wall thickening, which resolved completely within 3 to 5 weeks. Followup was 5 months to 6 years and no recurrence was noted. In children presenting with lower urinary tract symptoms (early period) plus findings of soft tissue infection at the ipsilateral inguinal region (late period) after inguinal hernia repair clinicians should be aware of the possibility of PVA as a primary problem to avoid insufficient treatment because its definitive treatment is removal of the infected suture material.

A CASE OF BRAIN ABSCESS.

A CASE OF BRAIN ABSCESS.

Definitive treatment of pancreatic abscess by endoscopic transmural drainage

Background: Experience with endoscopic transmural drainage of pancreatic pseudocysts prompted the use of a similar technique for the primary treatment of pancreatic abscess. The aim of this study was to assess the feasibility, safety, and effectiveness of endoscopic transmural drainage for the treatment of pancreatic abscesses compressing the gut lumen. Methods: In 9 patients, a total of 11 pancreatic abscesses compressing the stomach, duodenum, or both organs were drained endoscopically by means of endoscopic fistulization followed by saline solution irrigation and subsequent stent(s) placement. Complete resolution of the pancreatic abscess was defined as the absence of symptoms and no residual collection on follow-up CT. Observations: Endoscopic transmural drainage was technically successful in all cases. Ten abscess cavities (91%) resolved completely after stent placement for a mean duration of 32 days. In 2 patients, insertion of a nasopancreatic catheter was required to irrigate thick pus or necrotic debris. Bleeding occurred in 1 case (11%) but there was no mortality. The relapse rate was 13% over a mean follow-up of 18 months. Conclusion: Endoscopic transmural drainage is an effective therapy with minimal morbidity for pancreatic abscess compressing the gut lumen and is a valuable alternative to surgical drainage.

Laryngite révélatrice d’une trachéite bactérienne chez un enfant âgé de cinq ans

Case report. – We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. Comments. – We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. Conclusion. – Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.

3396 Endoscopic drainage of pancreatic abscess with endoscopic fistulization and transgastro-duodenal stenting.

Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen. Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen.

Ilio-psoas abscesses: Percutaneous drainage under image guidance

Over a 5-year period, 56 psoas abscesses occurring in 51 patients were managed by image-guided percutaneous drainage, either by needle aspiration (n = 10) or by catheter drainage (n = 46) in conjunction with medical therapy. Twenty-seven patients had tuberculous abscesses (bilateral in five) while 24 patients had pyogenic abscesses. Percutaneous treatment was successful in 16 of the 24 patients (66.7%) with pyogenic abscesses. The reasons for failure were co-existent bowel lesions, phlegmonous involvement of muscle without liquefaction, multiloculated abscess cavity and thick tenacious pus not amenable to percutaneous drainage. Surgery was required in seven patients, either for failed percutaneous drainage or for the management of co-existent disease. Percutaneous drainage was initially successful in all 27 patients of tuberculous psoas abscesses. However, eight patients presented with recurrence requiring repeat intervention. The average duration of catheter drainage was longer in patients with tuberculous abscess (11 days) than in patients with pyogenic abscess (6 days). Percutaneous drainage under image guidance provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses.

Mesenchymal hamartoma of the liver—report of an unusual case

An 8 year old girl presented with gross hepatomegaly, anaemia and pyrexia unresponsive to antibiotics. At laparotomy a cystic mass 19 cm in diameter was found arising from the liver. The cyst contained 2.4 litres of changed blood and an abscess cavity filled with thick pus was present in the cyst wall. Histological examination showed the appearances of a mesenchymal hamartoma of the liver, a rare diagnosis at this age. This case is unusual as mesenchymal hamartoma has not been previously reported presenting with pyrexia and anaemia as well as hepatomegaly.

An experimental model for pyogenic liver abscess

We have developed a reproducible small-animal model for pyogenic liver abscess, suitable for investigating diagnostic and therapeutic modalities. Male New Zealand white rabbits weighing 2-3 kg were anaesthetized and the liver exposed. Gentle pressure was applied with forceps to the right hepatic lobe. A suspension of 10(5) colony forming units (cfu) Escherichia coli plus Fusobacterium necrophorum (10(6) cfu) plus Bacteroides fragilis (10(6) cfu) was immediately injected into a mesenteric vein. Two weeks later a palpable mass (mean diameter 4 cm) had developed. Thick pus could be aspirated percutaneously. Necropsy revealed a single, but often multiloculated, abscess at the site of the previous trauma. Injection of E. coli alone did not produce any abscesses and B. fragilis alone only small abscesses, with low and variable frequency. Inoculation with F. necrophorum alone produced large abscesses, and a dose-response relationship was established. This is a simple and reliable small-animal model useful in studies of imaging techniques, antibiotic regimens and invasive treatments for pyogenic liver abscess.

Accuracy of Ultrasound in the Diagnosis of Nonfunctioning Kidneys

The accuracy and reliability of ultrasound were assessed in 246 patients with 338 radiologically nonfunctioning renal units. The causes of nonfunction included hydronephrosis, pyonephrosis, renal parenchymal disease, renal agenesis, renal neoplasm and polycystic disease. Obstruction was proved in 158 patients, with an accuracy of 98.1 per cent. Retrograde pyelography was avoided.The diagnosis of a small end stage kidney was correct in 42 patients. In 9 patients with a unilateral nonfunctioning kidney less than 9cm. long a thin coarsely textured cortex with dilatation of 1 or more calices was found. To our knowledge the presence of dilated calices in a small kidney, suggestive of chronic pyelonephritic changes, has not been described previously by ultrasound. Nonvisualization occurred in 16 cases (4.7 per cent) despite the anatomical presence of a kidney. An advanced degree of pyonephrosis with thick inspissated pus sometimes may mimic the ultrasonic appearance of a renal neoplasm.

192 PURULENT PERICARDITIS (PP)–CHANGING ETIOLOGY AND TREATMENT

All cases of bacterial pericarditis admitted to Children's Hospital from 1961-1980 were reviewed. To exclude patients with sympathetic pericardial effusion, only cases with pericardial fluid that was culture or CIE positive were analyzed. The organisms that caused PP with median age for each were:The most common bacterial cause of PP may be shifting from SA to HIB. All children presented with fever and ST-T wave EKG abnormalities. Associated findings for children with SA and HIB were:All children received antimicrobials. Four children recovered without surgical drainage and 2 recovered after pericardiectomy. Eight children were treated with pericardiotomy with tube drainage. Two of these 8, both of whom had thick pericardial pus, developed constrictive pericarditis requiring total pericardiectomy. One of the two died. The other children have not had evidence of cardiac abnormalities on follow-up evaluations. Patients with thick pericardial pus should undergo pericardiectomy not pericardiotomy.

Human actinomycosis: A study of 181 subjects

The clinical and pathologic features of 181 cases of human actinomycosis are reviewed. Actinomycosis is a chronic, sometimes fatal infection caused by species of Actinomyces and involves any part of the body. The abscesses produced contain soft tiny granules in thick pus. These granules contain gram-positive branching bacilli and a radiating eosinophilic fringe. Actinomycosis is not characterized by draining sinuses or hard yellow grains, and the organism is seldom identified by culture. The clinical diagnosis of actinomycosis is seldom made. The infection responds best to a combination of surgical and antibiotic treatment.

UNUSUAL COMPLICATION OF A CHALAZION.

Case Report A labourer, aged 21 years, came to the Casualty Department on May 16, 1962, with an infected chalazion which had troubled him for approximately a week. It involved the medial third of the right lower eyelid. At this first attendance there was some injection of the adjoining bulbar conjunctiva, that is, over the insertion of the medial rectus. He was treated with chloramphenicol ointment and hot bathing four times a day and systemic Broxil 250 mg. four times a day. He was supervised as an out-patient for 3 days, during which time the chalazion pointed on to the tarsal surface, but the eye became more painful and the bulbar conjunctiva became grossly injected and chemosed, more particularly over the insertion of the medial rectus. On May 19, 1962, the eye was slightly proptosed, and showed some reduction in ocular movements, chiefly medially. The patient was pale and sweating and in considerable pain and with a fever of 100°F. A diagnosis of purulent tenonitis was made and he was admitted to hospital. The systemic antibiotic was changed to tetracycline 250 mg. sixhrly and the local treatment to tetracycline ointment and hot bathing. The following morning he felt something burst in the right eye and the pain abated. The dressing was found to be soaked with thick yellow pus which was seen to be coming from a site on the bulbar conjunctiva over the insertion of the superior rectus. This was obviously the site of pointing of an abscess in Tenon's capsule. A pure growth of Staphylococcus was cultured. During the following week the condition very quickly improved. The patient left hospital, and was finally seen 10 days later in the out-patients' Department and discharged as symptom-free. The visual acuity on first attending was 6/18 in the right eye and 6/5 in the left. This could be corrected on the day of admission to 6/6 in the right eye with + 1 D sph. This did not change while he was under supervision and at no point did any abnormality of the anterior segment or fundus appear. The progress of disease in this case accords well with the description given by DukeElder (1952), particularly in that the site of entry of infection and of maximal chemosis did not correspond with the site of eventual pointing, which was close to the insertion of the superior rectus. It is interesting also, in that there was no involvement of the globe or deterioration of the visual acuity which are reported as being frequent complications.

Treatment of antro-oral fistula with particular reference to use of streptokinase and streptodornase.

STREPTOKINASE and streptodornase offer the surgeon a new biologic approach to the therapy of infections. Fibrin and desoxyribose nucleoprotein form substantial parts of the solid increment of thick pus. If thick viscid purulent material could be successfully removed from infected areas, the formation of healthy granulation tissue and consequently healing could be facilitated. Through their catalytic and enzymatic properties, streptokinase and streptodornase produce the hydrolysis of fibrin and desoxyribose nucleoprotein if direct contact can be effected for a sufficient period of time. Thick purulent material is thus made less viscid and therefore more easily aspirated, with the result that infected areas can be cleaned up preparatory to plastic surgery. Clinical experience with these compounds in the treatment of infections has been uniformly good. Streptokinase and streptodornase have wide clinical applications. They will prove useful wherever the surgeon wishes to cleanse the wound of fibrin and desoxyribose nucleoprotein. Their usefulness is

Treatment of tuberculous empyema by aspiration followed by instillation of promanide with phemeride

Four cases of tuberculous empyema were treated by aspiration followed by instillation at intervals varying from one to three weeks of 1 c.c. of Promanide with Phemeride dilluted with 7 c.c. of sterile distille water to make a preparation containing 5 per cent Promanide with I: 1,000 Phemeride. No reactions of any consequence followed the injection of the Promanide with Phemeride. In every case the character of the empyema fluid changed fairly rapidly following the commencement of treatment from that of a thick pus difficult to aspirate to a fluid which became progressively thinner and finally serous in character. All four cases terminated in complete re-expansion of the lung and pleural obliteration. Re-expansion of the lung occurred in two of the cases despite the presence of a greatly thickened pleura, and this may be attributable to the effect of the Promanide. The parenchymal lesions in the cases reported appeared to be well controlled at the time of their discharge from hospital.

RECOVERY FROM THROMBOSIS OF THE CAVERNOUS SINUS

The extreme rarity of a recovery from thrombosis of the cavernous sinus, in addition to the administration of an unusually large amount of sulfanilamide seems sufficient reason for this case report. <h3>REPORT OF A CASE</h3> Mrs. S., aged 19, white, had a history of intermittent suppurative otitis media in the left ear which had followed an attack of scarlet fever during early childhood. I was asked to examine her in her home on Dec. 14, 1938. She was complaining of severe pain in and around her left ear and the left side of her head and neck. According to the patient's mother, her present illness had begun about two weeks previously with an attack of influenza and tonsillitis. During the first days she had had a chill and intermittent chilly sensations followed by fever. On examination I found copious discharge of thick yellow pus from the left ear. There was

TREATMENT OF LYMPHOGRANULOMA INGUINALE WITH BOUILLON FILTRATE

In view of the chronicity of course and the various forms of treatment advised in lymphogranuloma inguinale, we feel justified in reporting a single case because of the unusual rapidity and completeness of healing that followed treatment with autogenous filtrate. A man, aged 31, seen at the office in October, 1932, had a tender swelling in the right groin draining since an incision had been made seven weeks previously. This had begun nine weeks before, with a small firm lump in the right groin aching somewhat. During the subsequent two weeks it became larger and softer, turned red and was incised, draining thick yellow pus. Fever persisted for ten days, the patient feeling ill; it then improved for a time, but both local and general conditions became worse with increased activity. From five to six weeks preceding the onset, the patient noticed several small red pimples on the penis, which

METASTATIC PANOPHTHALMITIS FOLLOWING PNEUMOCOCCIC OTITIS MEDIA

A boy, aged 4 years, who was anemic, was seen in consultation because of difficulty in maintaining drainage from a suppurative right otitis media of four weeks' duration. The drum had been incised at the end of the second week and again at the end of the third week. At the time that the child was examined, the temperature was 102; the patient was lethargic and irritable. When the drum membrane incision was enlarged there appeared a quantity of thick pus under pressure. At this time it was noted that the left eye was sensitive to light and that the pupil was contracted. No surface lesion could be detected even after staining with fluorescein. A culture taken from the ear revealed the pneumococcus as the offending organism. On the succeeding five days the eye became progressively worse, the cornea became clouded, the globe became inflamed, pus appeared in the anterior

Nasal Accessory Sinus Diseases Clinically and Roentgenographically Correlated

NOT long ago we passed through what may be described as the Surgical Age of nasal sinus disease. Numerous unnecessary operations, many of them detrimental to the patient, were performed, at least a part of them due to the fact that a proper relationship did not exist between the otolaryngologist and the roentgenologist. From the surgical standpoint too much stress was laid on the x-ray picture: signs and symptoms were not correlated with the x-ray plate. This was not the fault of the roentgenologist; perhaps it was due in part to the tendency to teach surgical procedure without stressing physiology, pathology, and diagnosis. Otolaryngology does not differ from any other branch of medicine in its relation to the x-ray service. The primary factor in the proper examination of the patient is the history, a statement which may be illustrated by the following case: A boy, 12 years of age, developed in August what seemed to be a terrific infectious pansinusitis. What appeared to be thick white pus poured from each nostril. The x-ray examination was made early in the study of the case. All the sinuses were seen to be cloudy. An immediate radical operation was advised. For some reason or other it seemed advisable to go over the patient again. In the second examination, considerable attention was directed to the securing of a meticulously exact history. Certain outstanding facts were elicited: First, the onset of the acute condition occurred on a dry hot day in July; the patient had had two previous attacks, both in hot weather; he was practically free of trouble during midwinter. A cytological study was made of his nasal discharge, which was found to contain 50 per cent eosinophils and only an occasional polymorphonuclear neutrophil. In spite of the fact that the nasal discharge was typical of macroscopic pus, a different recommendation was made, namely, that the patient leave the laryngologic service and enter the allergic service. As the result of withholding milk from the diet the clinical condition of the patient rapidly improved and in four months' time the roentgenologist expressed the opinion that the x-ray plates showed almost perfect healing. This is not an unusual result: it occurs often when one devotes at least twenty minutes to the securing of the history. A good history may bring to light a correlation of facts and takes precedence over either clinical or laboratory examination. To me it seems obvious that a cytologic examination of the nasal and otologic discharges should be made in every case in which these conditions are present. The chest man would not think of neglecting a cytologic examination of the sputum: the genito-urinary man always makes a careful microscopic study of the urine: the cytologic examination of the nasal discharge is just as important. The presence of polymorphonuclear neutrophils in the discharge taken from the neighborhood of the ostium of a sinus means one thing; the absence of cells means another.