1/59. Staged operative treatment in a septic patient with an infected, unstable pelvis, and a missed bladder rupture.This case demonstrates once again the potential and serious complications of pelvic fractures, especially when associated urogenital injuries are missed. Missing the bladder rupture proved almost fatal to our patient. Second, it was confirmed that in very unstable pelvic fractures, external fixation alone does not provide enough stability. Local stability is the cornerstone in the treatment of (bone) infection, and in these cases, maximal stability is only obtainable with internal fixation. The advantages of metal implants in infected areas outweigh the disadvantages by far. For the bladder-rupture, we chose a two-stage approach. First, we performed a urinary diversion, to avoid surgical closure of the infiltrated bladder wall. All cavities, including the open bladder, were packed with omentum to fill the dead space with highly vital tissue to offer stout resistance to infection. Two years later, with the patient in excellent physical condition, urinary undiversion was carried out. Ultimately physical and social recovery was complete.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/59. Primary iliac muscle abscess due to staphylococcus aureus.A 55-year-old man presented with a 3-day history of lower back pain and right thigh pain. A diagnosis of discogenic pain had been made at two other hospitals. He had been admitted to a medical center for acute hepatitis 5 months prior to this admission. Large doses of parenteral hydrocortisone were used for 13 days to treat acute hepatitis. At the present admission, he was unable to stand and refused to move his right leg. There was mild tenderness in the right lower abdomen on deep palpation. Passive flexion and rotation of the right hip produced mild pain, while passive extension of the right hip produced severe pain and resistance. The Patrick test was positive and the psoas sign was present on the right side. The erythrocyte sedimentation rate (ESR) was 66/hr. The c-reactive protein (CRP) level was 0.161 g/L. Abdominal sonography showed a lobulated mass in the right iliac fossa. magnetic resonance imaging showed severe swelling of the right iliac muscle with a central heterogeneous mass. debridement, drainage of the abscess, and application of a septopal chain were performed via an anterior retroperitoneal approach, and parenteral cephazolin and gentamicin were administered. A culture of the abscess grew staphylococcus aureus. The ESR and CRP concentrations decreased to within the normal ranges 3 weeks later. awareness of this disease entity, careful physical examination, and appropriate imaging studies such as ultrasonography and magnetic resonance imaging are key to making a correct diagnosis.- - - - - - - - - - ranking = 6.1039117633053keywords = physical examination, physical (Clic here for more details about this article) |
3/59. Disseminated BCG infection following bone marrow transplantation for X-linked severe combined immunodeficiency.An 8-month-old boy with X-linked severe combined immunodeficiency (XSCID) developed disseminated bacille Calmette-Guerin (BCG) infection following BCG vaccination at birth. He initially presented with an abscess at the site of BCG vaccination and was begun on three-drug antituberculous treatment (rifampicin, isoniazid, and pyrazinimide). Dissemination was subclinical prior to a human leukocyte antigen (HLA)-identical bone marrow transplant (BMT) from his sister, following which he presented with an acute erythroderma. A skin biopsy specimen revealed granulomas with epithelial histiocytes and giant cells in the reticular dermis, and numerous acid-fast bacilli (AFB) were present on Ziehl-Nielsen stain. A diagnosis of disseminated BCG disease was made. Despite the addition of a fourth antituberculous agent, ethambutol, he did not recover and developed numerous skin abscesses over the following weeks. Examination of pus from these lesions demonstrated numerous AFB. clarithromycin was added as a fifth antituberculous agent. Despite five-drug antituberculous therapy and monthly intravenous immunoglobulin infusions, recurrent abscesses containing AFB developed intermittently until 7 months posttransplant. At follow-up 1 year post-BMT he showed good general physical improvement. All abscesses had healed with scarring, and no further skin lesions had occurred.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
4/59. Bacterial subretinal abscess: a case report and review of the literature.PURPOSE: To report a case of klebsiella subretinal abscess with a successful visual outcome with treatment and to review the literature pertaining to focal intraocular infection in bacterial endophthalmitis. methods: Clinical data including medical history, findings on physical examination, blood cultures, and an abdominal computed tomographic scan were collected in a 32-year-old man with klebsiella sepsis, liver abscesses, and a focal subretinal abscess. Ocular data including visual acuity, fundus photographs, fluorescein angiography, and ultrasound were evaluated, as were results of culture and histopathologic studies. RESULTS: Despite immediate intervention, including vitreous tap and intravitreal antibiotics, the eye deteriorated, with enlargement of the abscess. A pars plana vitrectomy was performed in which the subretinal abscess material was removed after an extensive retinectomy of the involved area in association with an endophotocoagulative barrier and intravitreal amikacin without gas or oil tamponade. culture confirmed klebsiella subretinal infection. A retinal detachment occurred 1 month postoperatively and was successfully repaired. visual acuity was 20/30 and has remained stable for 14 months. CONCLUSION: klebsiella endophthalmitis with subretinal abscess formation is a rare but devastating ocular condition. In the present case, prompt intervention with extensive retinectomy, complete abscess excision, and intravitreal antibiotic therapy resulted in unprecedented visual recovery.- - - - - - - - - - ranking = 6.1039117633053keywords = physical examination, physical (Clic here for more details about this article) |
5/59. Chronic paronychia, osteomyelitis, and paravertebral abscess in a child with blastomycosis.blastomycosis is an unusual fungal infection in children. It is often a chronic infection characterized by granulomatous and suppurative lesions. Clinical manifestations include either pulmonary findings or disseminated disease. Disseminated blastomycosis usually begins with a lung infection that spreads to the skin, bones, and central nervous system. This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin b. He was discharged in good condition on oral therapy with ketoconazole. The literature on blastomycosis, with particular emphasis on clinical presentations and management, is reviewed. When the history and physical examination suggest a chronic granulomatous or disseminated disease, such as tuberculosis, the physician must include blastomycosis in the differential.- - - - - - - - - - ranking = 6.1039117633053keywords = physical examination, physical (Clic here for more details about this article) |
6/59. A rare case of Salmonella soft-tissue abscess.A healthy 6-year-old boy had complained of fever and chest pain for 3 days. On admission, he had a mass on the sternum, 3.7 x 2.5 cm in size. Abnormal laboratory findings included a white blood cell count of 12,900/microl, erythrocyte sedimentation rate (ESR), 74 mm/h, and c-reactive protein (CRP), 9.7 mg/dl. Ultrasound examination of the chest revealed a hypoechoic lesion on the sternum that was 30 x 15 mm in size. Chest computed tomography (CT) scan showed no bone fracture or bone erosion. The patient received cefpirome, given intravenously at 60 mg/kg per day for 10 days. Incision and drainage was performed on the seventh day in the hospital, and we collected 0.5 ml of pus. salmonella enteritidis was detected from the drainage. However, the patient had no gastrointestinal symptoms. He was discharged on the fourteenth hospital day, as he was asymptomatic. Results of all physical and laboratory examinations including blood and stool cultures and ultrasound examinations, were within the normal limits upon discharge.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
7/59. Solitary pancreatic tuberculous abscess mimicking prancreatic cystadenocarcinoma: a case report.BACKGROUND: The incidence of pancreatic tuberculosis is extremely rare, and it frequently misdiagnosed as pancreatic neoplasms. The nonsurgical diagnosis of this entity continues to be a challenge. CASE PRESENTATION: A 33 year old male with six-month history of intermittent right epigastric vague pain and weight lost had found a solitary pancreatic cystic mass and diagnosed as pancreatic cystadenocarcinoma. The chest x-ray film and physical examination revealed no abnormalities. Abdominal ultrasound (US) examination showed an irregular hypoechoic lesion of 6.6 cm x 4.4 cm in the head of pancreas, and color Doppler flow imaging did not demonstrate blood stream in the mass. The attempts to obtain pathological evidence of the lesion by US-guided percutaneous fine needle aspiration failed, an exploratory laparotomy and incisional biopsy revealed a caseous abscess of the head of pancreas without typical changes of tuberculous granuloma, but acid-fast stain was positive. CONCLUSIONS: Pancreatic tuberculosis should be considered in the differential diagnosis of focal pancreatic lesions, especially for young people in developing countries.- - - - - - - - - - ranking = 6.1039117633053keywords = physical examination, physical (Clic here for more details about this article) |
8/59. Management of complex multi-space odontogenic infections.The successful management of multi-space orofacial odontogenic infections involves identification of the source of the infection, the anatomical spaces encountered, the predominant microorganisms that are found during the various stages of odontogenic fascial space infection, the impact of the infectious process on defense systems, the ability to use and interpret laboratory data and imaging studies, and a thorough understanding of contemporary antibiotic and supportive care. The therapeutic goals, when managing multi-space odontogenic infections, are to restore form and/or function while limiting patient disability and preventing recurrence. Odontogenic infections are commonly the result of pericoronitis, carious teeth with pulpal exposure, periodontitis, or complications of dental procedures. The second and third molars are frequently the etiology of these multi-space odontogenic infections. Of the two teeth, the third molar is the more frequent source of infection. diagnostic imaging modalities are selected based on the patient's history, clinical presentation, physical findings and laboratory results. Periapical and panoramic x-rays are reliable initial screening instruments used in determining etiology. magnetic resonance imaging and computed tomography are ideal imaging studies that permit assessment of the soft tissue involvement to include determining fluid collections, distinguishing abscess from cellulitis, and offering insight as to airway patency. Antibiotics are administered to assist the host immune system's effort to control and eliminate invading microorganisms. Early infections, first three (3) days of symptoms, are primarily caused by aerobic streptococci which are sensitive to penicillin. amoxicillin is classified as an extended spectrum penicillin. The addition of clavulanic acid to amoxicillin (Augmentin) increases the spectrum to staphylococcus and other anaerobes by conferring beta-lactamase resistance. In late infections, more than three (3) days of symptoms, the predominant microorganisms are anaerobes, predominantly peptostreptococcus, fusobacterium, or bacteroides, that are resistant to penicillin. clindamycin is an attractive alternative drug for first line therapy in the treatment of these infections. The addition of metronidazole to penicillin is also an excellent treatment choice. Alternatively, Unasyn (ampicillin/Sublactam), should be considered. The mainstay of management of these infections remains appropriate culture for bacterial identification, timely and aggressive incision and drainage, and removal of the etiology. It is usually preferable to drain multi-space infections involving the submandibular, submental, masseteric, pterygomandibular, temporal, and/or lateral pharyngeal masticator spaces, as early as possible from an extraoral approach. trismus and airway management are important considerations and may preclude the selection of other surgical approaches. The patients with multi-space infections should be hospitalized and patient care provided by experienced clinicians capable of management of airway problems, in administration of parenteral antibiotics and fluids, utilization of interpretation of laboratory and diagnostic imaging studies, and control of possible surgical complications.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
9/59. Mycobacterium infection directly observed in a surgical outpatient centre.BACKGROUND: This study aims to check the presence and the role of the mycobacterium tuberculosis infection, in an Ambulatory and Day Surgery Out-Patient Centre. methods: Two periods of activity in this Centre are evaluated corresponding separately to the years 1989-1993 and 1994-1998 and the total number of patients, coming for examination, ambulatory or day surgery, hospitalization, postoperative follow-up, is considered, in order to identify the number of cases and the clinical signs of this disease. All cases were examined by the same team and the checks were completed, in the selected cases in which it was advisable, with radiological, bacteriological, bioptical, radiometrical exams and with the Elisa test (after informed consent). RESULTS: In the first period 1989-1993, 21,220 patients were examined and no case of tubercular infection was observed. In 1994-1998, 24,347 patients were examined and 4 cases of tubercular infection detected, which represent 0.016% of the patients attending the service. The clinical cases are as follows. Case 1: right sub-mammary lump, diameter 7 x 5 cm, smooth, oval, firm. Case 2: right breast swelling, diameter 5 cm, not sore, with deep attachments. The mammography and ultrasound scan indicate: the opacity is compatible with mali moris breast lesion. Case 3: coloured, immigrant, who presents back swelling, diameter 8 cm, with fluctuation. CT of the chest indicates opacity near left latissimus dorsi muscle, diameter 10 cm, without bronchopleural connections. Case 4: bleeding neoplastic ulcer of the wrist. At physical exam a right subclavear amphoric breath sound is noticed, corresponding at chest X-ray to an opacity including cavitation. In the 4 cases no lymph node in the regional effusion areas is detected. In the 4 cases surgical therapy is integrated with antituberculous chemotherapy till 6 months after operation. CONCLUSIONS: mycobacterium tuberculosis infection has been increasing in the second group of years considered, as it is observed in European industrialized countries and north america. This increase corresponds to 0.016% in 24,374 patients examined in the period 1994-98. This infection must not be connected with the classic sites and traditional primary and post-primary symptons, but must be considered and identified in a surgical hospital out-patient centre, in unusual sites, sometimes masquerading as a false positive carcinoma, in patients with predisposition, because of old age, race, immunodepression (also if hiv negatives), resistance to treatment, previous tuberculous infection. In the cases identified deep diagnostic definition, the surgical treatment and a prolonged antituberculous chemotherapy are necessary.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
10/59. Retrorectal cyst: a rare tumor frequently misdiagnosed.BACKGROUND: The rarity of retrorectal cysts and their nonspecific clinical presentations often lead to misdiagnoses and inappropriate operations. In recent years, several such patients have been referred to our institutions for evaluation and treatment of misdiagnosed retrorectal cysts. A review of these patients is presented. STUDY DESIGN: medical records of the colorectal surgery divisions at two institutions were reviewed. patients found to have previously misdiagnosed retrorectal cysts were identified. Preliminary diagnoses, radiologic examinations, operative procedures, and final diagnoses were obtained. RESULTS: Seven patients with retrorectal cysts who had been misdiagnosed before referral were identified. These patients had been treated for fistulae in ano, pilonidal cysts, perianal abscesses; psychogenic, lower back, posttraumatic, or postpartum pain, and proctalgia fugax before the correct diagnosis was made. patients underwent an average of 4.1 operative procedures. physical examination in combination with CT scanning made the correct diagnosis in all patients. All patients underwent successful resection through a parasacrococcygeal approach, and six of seven did not require coccygectomy. The resected tumors included four hamartomas, two epidermoid cysts, and one enteric duplication cyst. CONCLUSIONS: Retrorectal cysts are a rare entity that can be difficult to diagnose without a high index of clinical suspicion. A history of multiple unsuccessful procedures should alert the clinician to the diagnosis of retrorectal cyst. Once suspected, the correct diagnosis can be made with physical examination and a CT scan before a definitive surgical procedure.- - - - - - - - - - ranking = 6.1039117633053keywords = physical examination, physical (Clic here for more details about this article) |
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