Eumycetoma Osteomyelitis Calcaneus in Adolescent; report of case and literature review

Background Mycetoma is the most common neglected disease in humans. It is a chronic, progressive, and destructive disease primarily caused by fungi or bacteria characterized by formation of dark pale grains commonly involve skin, soft tissue and rarely bone. Case presentation A 19 year old male patient with chronic right ankle pain, swelling and abscess formation for more than 1 year, patient was treated repeatedly with incision and drainage without any success. No X-ray, biopsy or swab for culture and sensitivity had been considered through the course of presentation. Patient was referred to Omdurman hospital where osteomyelitis secondary euomycetoma infection has been confirmed based on radiological and pathological assessment. Patient was treated surgically with aggressive debridement and bone curettage plus postoperative Itraconazole for 1 year. Conclusion Clinicians must consider osteomyelitis as important differential diagnosis during initial assessment Eumycetoma infection in adults. Aggressive bone curettage followed by regular X-ray follow up can be limb saving procedure in such cases.

Post COVID-19 invasive mucormycosis and actinomycosis co-infection: a case report

<p>Actinomyces are commensals of human oropharynx and actinomycosis is considered mainly as an endogenous infection that is triggered by a mucosal lesion. Typically, the disease presents as a slowly progressive painless indurated mass evolving into multiple abscesses with draining sinus tracts sometimes expressing a typical yellow exudate with characteristic sulfur granules. The gold standard of diagnosis is histological examination and bacterial culture of the tissue. Most isolates are susceptible to beta lactams and they are the treatment of choice along with surgical management with drainage of abscesses and excision of recalcitrant fibrotic lesions and debridement of necrotic bone tissue. Here we present a case of 37-year-old male patient who has developed severe COVID-19 infection following which he developed invasive mucormycosis followed by actinomycosis. We postulate that the lymphopenia and the use of immunosuppressants used in treatment of COVID-19 lead to mucormycosis and aggressive debridement used as a strategy in treatment of mucormycosis led to colonization of actinomyces leading to cervicofacial actinomycosis.</p>

Rare Intercondylar Distal Femoral Brodie’s Abscess in a 21-Year-Old Man Who Refused Medical Care for Three Years after Initial Symptoms

Brodie’s abscess is a rare form of sub-acute osteomyelitis that implies the collection of pus inside bone tissue. The present paper presents an extremely rare case of Brodie’s abscess located in the distal femur in a young male patient who refused medical care for three years and presented directly with spontaneous fistula and septic complications. Laboratory tests also suggested chronic septic alterations. Complex imaging investigations including X-ray (RX), computer tomography (CT) and Magnetic Resonance imaging (MRI) confirmed the diagnosis with characteristic aspects, such as the penumbra sign on the T1 weighted MRI image. Management included aggressive debridement, defect reconstruction, and long-term specific antibiotics according to culture harvested intra-operatively. Evolution was positive with inflammatory blood tests returning to physiological values within four weeks and patient full recovery within six months, without any physical deficits. The novelty aspect found in this case presentation is represented by the long-term natural evolution of this pathology, and the fact that even in these conditions, the Brodie’s abscess did not evolve into a ‘malignant’ septic condition, but remained rather benign until the spontaneous fistula prompted the patient to seek medical care.

IL-7 Immunotherapy in a Non-Immunocompromised Patient with Intractable Fungal Wound Sepsis

A non-immunocompromised patient developed life-threatening soft-tissue infection with Trichosporon asahii, Fusarium, and Saksenaea that progressed despite maximum anti-fungal therapies and aggressive debridement. IL-7 immunotherapy resulted in clinical improvement, fungal clearance, reversal of lymphopenia, and improved T-cell function. Immunoadjuvant therapies to boost host immunity may be efficacious in life-threatening fungal infections.

MukB Is a Gene Necessary for Rapid Proliferation of Vibrio vulnificus in the Systemic Circulation but Not at the Local Infection Site in the Mouse Wound Infection Model

Vibrio vulnificus causes rapid septicemia in susceptible individuals who have ingested contaminated foods or have open wounds exposed to seawater contaminated with the bacteria. Despite antibiotic therapy and aggressive debridement, mortality from septicemia is high. In this study, we showed that MukB mutation (mukB::Tn) affected the proliferation of V. vulnificus in the systemic circulation but not at the inoculation site in the wound infection model. A comparison of mukB::Tn with WT and a mukB complement strain (mukB::Tn/pmukB) on the bacterial burden in the muscle at the infection site showed that spreading and proliferation of the mukB::Tn strain was similar to those of the other strains. However, the bacterial burden of mukB::Tn in the spleen was reduced compared to that of the WT strain in the wound infection model. In a competition experiment, we found a lower bacterial burden of mukB::Tn in the spleen than that of the WT strain infecting the systemic circulation. Here, we report on a gene required for the rapid proliferation of V. vulnificus only in the systemic circulation and potentially required for its survival. Our finding may provide a novel therapeutic target for V. vulnificus septicemia.

Eumycetoma Osteomyelitis Calcaneus in Adolescent; Report of Case and Review in Literature.

Background: Mycetoma is the most common deep mycosis in humans. It is a chronic, progressive, and destructive disease primarily caused by actinomycetes (98%). It involves the skin, soft tissues and occasionally bone, central nervous system as well as internal organs, and characterized by formation of black grains and poor response to treatment. Case presentation: We present a case report about 19 year old male patient with annoying Right ankle pain and swelling for more than 1 year. Diagnosed initially as abscess and drainage was done 8 months ago without any improvement. No X-ray, biopsy or swab for culture and sensitivity done at time of first presentation. On his current presentation at Omdurman hospital mycetoma foot with osteomyelitis was diagnosed based on radiological and pathological assessment. Patient treated with aggressive debridement and bone curettage plus postoperative Itraconazole for 1 year. Conclusion: Surgical Debridement with aggressive bone curettage followed by regular follow up and X-ray can improve the prognosis and achieve good surgical outcome with very low risk of recurrence.

The study of the prognostic outcome of necrotizing fasciitis patients with and without diabetes mellitus

Background: Necrotizing fasciitis is highly lethal infection. It can be defined as infection of any layers within the soft tissue compartment (dermis, subcutaneous tissue, superficial fascia, deep fascia or muscle). Early diagnosis and management with identification of co morbidities and treating them brings down the morbidity and mortality rate. To make a full assessment of the cause, all patients require a detailed history, examination and, investigations.Methods: This is a cross sectional comparative study of 50 patients having symptoms of necrotizing fasciitis to be divided into two groups of 25 patients each where one group is having diabetes mellitus and other group without diabetes mellitus.Results: Diabetes mellitus patients have more morbidity and mortality in term of more days of hospital stay, rate of amputations and number of debridements. Early diagnosis and early aggressive debridement is the mainstay of management. Aggressive surgical debridement at initial stages of presentation can halt the clinical process and patient can have better prognosis. In neglected diabetic patient’s debridement alone is not sufficient and amputation may be required in some cases. Conclusions: Early diagnosis and aggressive debridement in necrotizing fasciitis patients results in better outcomes.

Case Series of Opportunistic Deep Seated Fungal Infections in Surgical Practice in an Agrarian Society

This article is to highlight the atypical presentations of fungal infections which may be encountered in surgical practice and to help surgeons to recognise these cases early and provide appropriate management. Three cases of skin and soft tissue fungal infections with atypical presentations have been discussed. All the patients are aged above 45 years and farmers by occupation with type 2 diabetes mellitus as a common co-morbidity. These cases showed aggressive progression of the disease and were started on anti-fungal agents along with serial aggressive debridement. Two patients deteriorated rapidly, as they succumbed to their illness. Fungal agents being commonly present in the environment, are likely to cause infection in immunocompromised states like diabetic patients, especially in those with a preceding history of trauma.

Successful Surgical Strategy for Graft-esophageal Fistula After Total Arch Replacement : A Case Report.

BackgroundGraft infection is one of the catastrophic complications in the aortic surgical area. Case presentationA 62-year-old man was diagnosed graft-esophageal fistula after total arch replacement. We have experienced aggressive debridement, that includes the infected previous graft and unhealthy esophagus under the same operative field, and staged esophageal reconstruction was performed 4 months later. ConclusionsWe believe that this successful surgical strategy, which involves aggressive debridement using re-median incision plus a left posterolateral thoracotomy under the same operative field, is useful and safe and achieved a favorable result.

Comparison of angiosome based incision with conventional aggressive debridement for the treatment of diabetic foot ulcers.

Objectives: To compare the efficacy of angiosome based incisions versus aggressive debridement for the treatment of diabetic foot ulcer. Study Design: Randomized Controlled Trial. Setting: Surgical Unit 1 Nishtar Medical University/ Hospital Multan. Period: 9 months duration, from 1st January 2017 to 30th September 2017. Material & Methods: Sample Size: Total 210 patients, 105 in each group. Sampling Technique: Non-probability, consecutive sampling. 210 patients of both genders with history of diabetes mellitus having Grade II diabetic foot ulcer below the ankle. Before the procedure, foot ulcers were measured and ulcer dimensions equal or greater than 4 cm2 were included in the study. 105 patients were in angiosome based incision group (Group A), while105 patients were in aggressive debridement group (Group B). Patients were called for follow up after every 5 days. Regular dressings were done to allow more regular wound inspection and cleansing to avoid infection. Efficacy of treatment was finally determined after 30 days by measuring the ulcer dimension by similar procedure as done before the start of procedure. Data was noted on especially designed proforma. Results: Age range in this study was from 30 to 60 years with mean age of 45.971± 4.89 years in Group A while 46.457± 6.22 years in Group B. Mean duration of diabetes was 10.171±4.09 years in Group A and 10.561±5.58 years in Group B. Mean duration of foot ulcer was 3.895±2.72 months in Group A and 3.790±2.03 months in Group B. Mean size of foot ulcer was 5.047±1.52 cm2 in Group A and 4.895±1.67 cm2 in Group B. Mean weight of the patients was 68.238±10.44 kg in Group A and 67.742±9.53 Kg in Group B. Majority of the patients were of 46-60 years in group A (63.8%) and in group B (66.7%). Male gender was dominant in both group (73.3% and 55.25). In group A efficacy was seen in 96 (91.4%) patients as compare to 47 (44.8%) patients in group B, (P=0.000). Conclusion: Angiosome based incision in the treatment of diabetic foot ulcer has shown outstanding outcome with respect to wound healing compared with aggressive debridement.