Cranial melioidosis presenting as a mass lesion or osteomyelitis

OBJECT: Melioidosis is caused by Burkholderia pseudomallei and causes multiple abscesses in different organs of the body. Cranial melioidosis, although uncommon, is sometimes confused with tuberculosis and is therefore under-recognized. The authors report on 6 cases of cranial infections caused by Burkholderia pseudomallei, presenting as mass lesions or cranial osteomyelitis, and review the literature. METHODS: The authors performed a retrospective review of the records of patients with cranial melioidosis treated at their institution between 1998 and 2005 to determine the presentation, management, and outcome of patients with this infection. RESULTS: Of the 6 patients diagnosed with cranial melioidosis during this period, 4 had brain abscesses and 2 had cranial osteomyelitis. All patients were treated surgically, and a diagnosis was made on the basis of histopathological studies. All patients were started on antibiotic therapy following surgery and this was continued for 6 months. One patient died soon after stereotactic aspiration of a brain abscess, and the other 5 patients had good outcomes. CONCLUSIONS: Cranial melioidosis is probably more prevalent than has been previously reported. A high index of suspicion, early diagnosis, initiation of appropriate antibiotic therapy and treatment for an adequate period are essential for assuring good outcome in patients with cranial melioidosis. The authors recommend surgery followed by intravenous ceftazidime treatment for 6 weeks and oral cotrimoxazole for 6 months thereafter in patients with cranial melioidosis.     

Prostatic abscess caused by community‐acquired methicillin‐resistant Staphylococcus aureus

Prostatic abscess is uncommon and difficult to diagnose, because its clinical presentation mimics lower urinary tract symptoms. Prostatic abscess is often caused by gram‐negative organisms and occasionally by Staphylococcus aureus. Community‐acquired methicillin‐resistant S. aureus (MRSA) often causes skin and soft‐tissue infections, and rarely causes genitourinary infections. We report what we believe is the second case of a prostatic abscess as a result of MRSA in a healthy diabetic patient who was treated with transurethral resection of the prostate and intravenous administration of vancomycin.     

Diagnosis and treatment of patients with prostatic abscess in the post‐antibiotic era

We reviewed the pathogenesis, clinical presentation, treatment options and outcomes of prostatic abscess in the post‐antibiotic era, focusing on how patient risk factors and the emergence of multidrug‐resistant organisms influence management of the condition. A MEDLINE search for “prostate abscess” or “prostatic abscess” was carried out. Prostate abscess is no longer considered a consequence of untreated urinary infection; now, men with prostatic abscess are typically debilitated or immunologically compromised, with >50% of patients having diabetes. In younger men, prostatic abscess can be the initial presentation of such chronic conditions. In older men, prostatic abscess is increasingly a complication of benign prostatic hyperplasia or prostate biopsy. Diagnosis is based on a physical examination, leukocytosis, leukocyturia and transrectal ultrasound, with magnetic resonance imaging serving as the preferred confirmatory imaging modality. Treatment of prostatic abscess is changing as a result of the emergence of atypical and drug‐resistant organisms, such as extended‐spectrum β‐lactamase‐producing enterobacteriaceae and methicillin‐resistant Staphylococcus aureus. As many as 75% of infections are resistant to first‐generation antibiotics, necessitating aggressive therapy with broad‐spectrum parenteral antibiotics, such as third‐generation cephalosporins, aztreonam or antibiotic combinations. A total of 80% of patients require early surgical drainage, frequently through a transurethral approach. In the post‐antibiotic era, prostatic abscess is evolving from an uncommon complication of urinary infection to a consequence of immunodeficiency, growing antibiotic resistance and urological manipulation. This condition, primarily affecting patients with chronic medical conditions rendering them susceptible to atypical, drug‐resistant organisms, requires prompt aggressive intervention with contemporary antibiotic therapy and surgical drainage.     

前列腺脓肿2例报告及近10年国内文献复习

目的:结合2例前列腺脓肿病例及文献复习,评估我国前列腺脓肿的新特点。方法:报告2例前列腺脓肿病例,以前列腺脓肿作为关键词或篇名检索中国期刊全文数据库及万方数据数字化期刊全文数据库1997～2006年的资料,进行荟萃分析。结果:2病例既往均无糖尿病史但均有血糖升高,1例发病前曾行下尿路器械检查。2例均表现为显著排便困难,会阴疼痛伴有高热,外周血白细胞均不高,尿常规检查无感染表现。病例1通过MRI确诊,脓肿破溃至尿道经用抗生素痊愈;病例2通过经直肠B超及CT确诊,经直肠B超穿刺引流后治愈。荟萃分析结果表明,糖尿病、留置尿管或尿道器械操作是前列腺脓肿的主要致病因素,致病菌主要是金黄色葡萄球菌和大肠埃希菌,临床表现主要是膀胱刺激症状、排尿困难及会阴疼痛,多数患者经B超确诊,需行穿刺引流或开放手术引流。结论:现阶段前列腺脓肿表现不典型、可疑病例应及时行经直肠B超或CT检查确诊,B超引导下脓肿穿刺引流简便有效。     

A case of prostatic abscess

A 53-year-old man presented with high fever and urinary retention. The patient had diabetes, and alcoholic liver cirrhosis. Clinical diagnosis was prostatic abscess by magnetic resonance imaging (MRI), and we performed anti-biotic therapy. Because there was no improvement of symptoms, we performed percutaneous cystostomy and transurethral resection (TUR) of the abscess walls. Drainage by TUR is suggested to be a useful strategy for prostatic abscess.     

前列腺脓肿12例诊疗分析

目的 总结前列腺脓肿患者的临床表现及影像学特点,提升诊断符合率,同时为临床治疗提供一定的参考.方法 回顾2006年2月至2014年9月本院12例诊断为前列腺脓肿患者的既往病史、临床表现、实验室检查及影像学表现特点,总结其诊疗特点及临床疗效.结果 最常见的临床表现及体征为寒颤、发热及尿路刺激症状;9例尿培养阳性,培养结果以大肠杆菌为主(7/9),穿刺液培养亦以大肠杆菌为主(8/9),其中4例行经直肠超声引导下前列腺穿刺引流术及5例行经尿道前列腺脓肿电切去顶引流术,术后予以抗感染而控制病情;术后随访3个月,其中单纯抗感染治疗复发2例.结论 直肠指诊、PSA、经直肠超声及CT检查有助于尽早诊断前列腺脓肿,CT可准确反应脓肿的大小、位置及分隔情况,可作为诊断前列腺脓肿的常规检查;超声引导下穿刺引流或经尿道前列腺脓肿电切去顶引流术可有效控制病情.     

Prostatic abscess after transrectal ultrasound guided biopsy.

We report a case of a diabetic man who had bilateral prostatic abscesses after ultrasound guided biopsy of the prostate. As is typical of prostatic abscesses, the diagnosis was not evident at presentation. We discuss the morbidity of transrectal biopsy and recommend consistent antimicrobial prophylaxis. We also recommend transrectal ultrasound in the diagnosis of such abscesses, and support the standard treatment of drainage and parenteral antimicrobial therapy. We anticipate that the incidence of prostatic abscess will increase due to the increasing number of men undergoing transrectal biopsy in the current age of transrectal ultrasound guided biopsy.     

Ultrasound-guided needle aspiration in prostatic abscess

OBJECTIVES: To review the clinical presentation of prostatic abscess and to assess the usefulness of ultrasound-guided needle aspiration as a treatment option for this condition. METHODS: Between October 1984 and November 1997, prostatic abscess was diagnosed in 31 patients. The average age was 60 years (range 29 to 79). Prostate ultrasound was performed using either a hypogastric or transrectal approach. Initial therapy included ultrasound-guided needle aspiration in 24 (77.4%), transurethral resection of prostate (TURP) in 5 (16.1%), or conservative management with antibiotic therapy. During follow-up, ultrasound examinations and urine cultures were performed on an outpatient basis. RESULTS: Past medical history most often included previous urinary infection (15 patients, 48%) and bladder outlet obstruction (13 patients, 42%). Sixty-one percent of patients presented with irritative voiding symptoms at the time of diagnosis. Ultrasound-guided needle aspiration resolved 83.3% of cases; 2 patients needed a second procedure. Three patients required TURP for drainage and 2 to remove an obstruction after abscess resolution. CONCLUSIONS: A high degree of suspicion is needed to diagnose prostatic abscess clinically. Transrectal ultrasound is necessary for the differential diagnosis. Transrectal ultrasound-guided needle aspiration is a technically simple and effective therapeutic procedure with no morbidity and, in case of failure, may be repeated or a drainage TURP may be undertaken.     

Transurethral resection of prostatic abscess under sonographic guidance

Transrectal ultrasound may establish the diagnosis of prostatic abscess in an ambiguous clinical setting. Transurethral resection (deroofing) is the treatment preferred by many clinicians, yet intraoperative complete abscess obliteration may be difficult to confirm endoscopically. We report on a patient with a complex prostatic abscess endoscopically resected under transrectal ultrasound guidance. Adequacy of treatment was proved pathologically.     

Early-onset liver abscess after blunt liver trauma: report of a case

A 23-year-old male patient underwent nonoperative management for his blunt liver trauma as he was hemodynamically stable without any signs of peritonitis initially after injury. A fever of 39.5°C and severe right upper quadrant abdominal pain developed on the second day, and an abdominal computed tomography (CT) scan showed the formation of a gas-containing liver abscess in the traumatized liver. An emergency laparotomy revealed a foul-smelling liver abscess at the traumatized site, which was finally disclosed to be the result of a Clostridium species infection. A liver abscess is a rare complication following the nonoperative management of liver injury, and such an occurrence is even more rare within 1 day after injury. A Clostridium species infection is responsible for the fulminant progressing nature of the disease because the devitalized, ischemic liver parenchyma is ideal for such growth, and this is the first time that a such condition has been shown by CT images. Close observation with a high degree of suspicion is required for the successful treatment of such abscesses. Received: March 28, 2002 / Accepted: July 2, 2002 Reprint requests to: C.-H. Hsieh     

Ascaris-induced Liver Abscess

The prevalence, symptomatology, and outcome of Ascaris-induced liver abscess was studied prospectively in Kashmir, India, which is an endemic area of ascariasis, from December 1987 to December 1997. Of 510 patients with liver abscess admitted during this period, 74 had biliary ascariasis as the cause (14.51%). Of these 74 patients, 11 had intact ascaridae (live or dead) within the abscess. Six patients had a single abscess, and five had multiple abscesses. Seven patients had associated worms in the bile ducts. Ultrasonography was the main diagnostic procedure used. Ten patients were diagnosed based on clinical and ultrasound findings, and one was diagnosed during laparotomy. Most of the patients were young (age range 3–40 years) with a mean age of 17.20 years. Seven were females, and four were males. Ten patients underwent surgery; nine recovered completely, and one died postoperatively due to septicemia. Another patient died as well: a young child who presented late, was in refractory septic shock following suppurative cholangitis and liver abscess, and could not be taken for surgery. The mortality thus was 9.9%. Liver abscess following invasion of intrahepatic biliary radicles by ascaridae through the ampulla is an unusual complication of an otherwise common disease in Kashmir Valley, affecting children and young adults. The outcome depends on early diagnosis and surgical drainage of the abscess with extraction of worms from the ducts.     

Renal abscess: recovery without hospitalization and drainage

BACKGROUND: Renal absceeses in childhood are rare and require hospitalization, antibiotic therapy and drainage. PATIENTS: Two cases of renal abscess in childhood are described. In both cases there was no history of either antecedent skin infection or urinary tract infection or reflux. Flank pain and fever had a sudden onset. RESULTS: The diagnosis was made in the first case by ultrasound and gadolinium-enhnaced magnetic resonance, in the second case ultrasound and computerized axial tomography were used. The patients were successfully treated at home with antibiotic therapy but without drainage. CONCLUSION: Renal abscesses must be suspected in children with loin pain, fever and leukocytosis. They may heal even without hospitalization and drainage.     

Melioidotic septic arthritis and its risk factors

BACKGROUND: Melioidotic septic arthritis is an infection caused by the gram-negative bacillus Burkholderia pseudomallei. It is commonly found in Northeast Thailand. The goal of our study was to identify specific characteristics of patients with melioidotic septic arthritis by comparing them with patients with non-melioidotic septic arthritis and to describe the results of treatment of melioidotic septic arthritis. METHODS: We conducted a retrospective study of seventy-seven patients with septic arthritis who were treated in our hospital over a period of four years. Twenty-five of the patients had melioidotic septic arthritis, and fifty-two had non-melioidotic septic arthritis. Univariate and multivariate analyses were conducted to identify the risk factors for melioidotic septic arthritis, and the clinical course of the twenty-five patients with melioidotic septic arthritis was followed until the infection resolved. RESULTS: Patients with melioidotic septic arthritis differed significantly (p = 0.002 ) from those with non-melioidotic septic arthritis with regard to the frequency of diabetes mellitus and of involvement of an upper-extremity joint. The odds ratio that melioidosis was the cause of the infection was 15.7 (95% confidence interval, 4.5 to 55.6) in a patient with diabetes mellitus and 4.51 (95% confidence interval, 1.04 to 19.65) in a patient with involvement of an upper-extremity joint. Twenty-two of the twenty-five patients with melioidotic septic arthritis responded to treatment, which consisted of six months of antibiotic therapy combined with needle aspiration, as well as surgical drainage of the affected joint when necessary (sixteen patients). CONCLUSIONS: A diagnosis of melioidotic septic arthritis should be considered when septic arthritis is seen in an individual who is indigenous to or has recently visited Southeast Asia. The infection is more likely to be melioidotic septic arthritis if it involves an upper-extremity joint and if the patient has diabetes mellitus.     

Gas-forming infections in genitourinary tract.

Diabetes mellitus associated with urinary tract infections and ureteral obstruction can be predisposing factors leading to emphysematous pyelonephritis. Fever, flank pains, and a palpable renal mass, associated with dehydration and hyperglycemia, were the most frequent presenting symptoms associated with emphysematous pyelonephritis. Computerized tomography (CT) scan is the best method to identify a renal or perirenal abscess and its ramifications. Intravenous antibiotic therapy is determined by blood and urine cultures. Mortality was zero in patients treated by nephrectomy. One patient who had incision and drainage of a renal abscess died of sepsis, and 1 patient died of sepsis following incision and drainage of a prostatic abscess. Patients with cystitis emphysematosa require antibiotic therapy and relief of bladder outlet obstruction. Prostatic abscess is best treated by perineal incision and drainage. Periurethral scrotal abscesses should be incised, drained, and the overlying necrotic skin debrided. Early diagnosis and aggressive medical and surgical management of gas-forming infections of the genitourinary tract are vital.     

Pyogenic liver abscess complicated by endogenous endophthalmitis

Background: Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess. Methods: Over an 18‐month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed. Results: There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye. Conclusion: Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.     

Predictive value of resistive index, detrusor wall thickness and ultrasound estimated bladder weight regarding the outcome after transurethral prostatectomy for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction

Objectives: To evaluate the value of three parameters from preoperative ultrasonography in predicting the outcome of transurethral prostatectomy in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Methods: A total of 239 patients with lower urinary tract symptoms suggestive of benign prostatic obstruction entering our department for surgical therapy were prospectively recruited. All of them underwent both ultrasound and urodynamics before receiving standard transurethral prostatectomy by the same team of surgeons. For 202 patients, 6‐month follow‐up data were available after the surgery, including the International Prostate Symptom Score, the Quality of Life score and the maximum flow rate. Preoperative data stratified by different degree of recovery were compared and the influence of ultrasound parameters on the surgical outcome was analyzed by using logistic regression and receiver–operator characteristic curve analyses. Results: Baseline transitional zone index, intravesical prostatic protrusion, resistive index, detrusor wall thickness and ultrasonic estimation of bladder weight were significantly different between patients with an effective outcome and those with an ineffective outcome (P < 0.05). Resistive index, detrusor wall thickness and ultrasonic estimation of bladder weight were selected as independent factors correlated with the efficacy of transurethral prostatectomy by logistic regression (P < 0.05). All three factors had adequate area under receiver–operator characteristic curve with resistive index having the largest area (0.816, 95% CI 0.759–0.874). The combined positive predictive value in effective surgical outcome of resistive index, detrusor wall thickness and ultrasonic estimation was 96.3%. Conclusions: Resistive index, detrusor wall thickness and ultrasonic estimation adequately predict the outcome of transurethral prostatectomy. Measuring these parameters by preoperative ultrasound might aid in determining the need for surgical intervention.     

Intravesical prostatic protrusion is better than prostate volume in predicting the outcome of trial without catheter in white men presenting with acute urinary retention: a prospective clinical study

PURPOSE: Trial without catheter after a short course of an alpha-blocker in men presenting with acute urinary retention is successful in up to 50% of cases. The ability to better predict outcome could avoid a trial without catheter for some men. Intravesical prostatic protrusion and not prostate volume has been shown to predict trial without catheter outcome in an Asian cohort. We investigated the relationship between the outcome of trial without catheter and prostate volume and intravesical prostatic protrusion in white men given alpha-blockers before a trial without catheter. MATERIALS AND METHODS: Consecutive men 50 years old or older presenting with acute urinary retention were prospectively recruited based on strict selection criteria. At presentation factors thought to precipitate acute urinary retention were treated, alpha-blocker therapy started and the patient brought back for a trial without catheter after 2 weeks. Prostate volume and intravesical prostatic protrusion were measured by standard transrectal ultrasonography. RESULTS: Of 121 men presenting with acute urinary retention 57 fulfilled the study selection criteria. Mean (+/- SD) age, prostate volume and intravesical prostatic protrusion of recruited men were 70 +/- 9.2 years, 69.7 +/- 36.3 ml and 12.8 +/- 10.1 mm, respectively. A total of 25 men (43.9%) had a successful trial without catheter. Mean intravesical prostatic protrusion was significantly smaller in those who had a successful trial without catheter (7.2 vs 16.5 mm, 95% CI 4.5-14, p <0.001). With intravesical prostatic protrusion correlating well with prostate volume (r = 0.588), mean prostate volume was also smaller in men with a successful trial without catheter, albeit with a smaller effect size. Men with an intravesical prostatic protrusion of 10 mm or less, compared to those with a larger intravesical prostatic protrusion, were 6 times more likely to have a successful trial without catheter. CONCLUSIONS: In this cohort presenting with acute urinary retention related to benign prostatic hyperplasia and receiving alpha-blockers before a trial without catheter, intravesical prostatic protrusion appears to strongly predict the outcome of a trial without catheter. A trial without catheter is more likely to fail in patients with intravesical prostatic protrusion larger than 10 mm.     

A randomized trial comparing transurethral resection of the prostate, laser therapy and conservative treatment of men with symptoms associated with benign prostatic enlargement: The CLasP study

PURPOSE: We evaluated the effectiveness of a new technology (noncontact laser therapy) versus that of standard surgery (transurethral prostatic resection) and conservative management for lower urinary tract symptoms associated with benign prostatic enlargement. MATERIALS AND METHODS: Men with uncomplicated lower urinary tract symptoms, that is no acute or chronic urinary retention, were randomized to receive laser therapy with a noncontact, side firing neodymium:YAG probe, standard transurethral prostatic resection or conservative management, including monitoring without active intervention, in a large multicenter pragmatic randomized controlled trial called the CLasP study. Primary outcomes were International Prostate Symptom Score (I-PSS), maximum urinary flow rate, a composite measure of success based on I-PSS and maximum urinary flow rate categories, I-PSS quality of life score and post-void residual urine volume. Secondary outcomes included treatment failure, hospital stay and major complications. Followup was 7.5 months after randomization. Intent to treat analysis was done using analysis of covariance, proportional odds models and the Newman-Keuls multiple comparisons procedure. RESULTS: Of symptomatic patients 117, 117 and 106 were randomized to receive laser therapy, transurethral prostatic resection and conservative management, respectively. Baseline characteristics were similar. All primary outcomes indicated that transurethral prostatic resection and laser therapy were superior to conservative management, and resection was superior to laser therapy. As measured by combined improved symptoms and maximum urinary flow, a successful outcome was achieved in 81%, 67% and 15% of men who underwent transurethral prostatic resection, laser therapy and conservative management, respectively. Hospital stay was significantly shorter and complications fewer for laser therapy than for resection but catheters were in place significantly longer. Men treated conservatively did not have deterioration or treatment failure. CONCLUSIONS: Laser therapy and transurethral prostatic resection are effective for decreasing lower urinary tract symptoms and post-void residual urine volume as well as improving quality of life and maximum urinary flow in the short term in men presenting with moderate to severe symptoms. Transurethral prostatic resection is superior to laser therapy in terms of effectiveness but some patients may elect laser therapy due to the shorter hospital stay and lower risk of complications. Conservative management may be acceptable and safe in men with lower urinary tract symptoms since we observed no marked deterioration in the short term.     

Nocardia spinal epidural abscess: 14-year follow-up

This article describes an immunocompetent patient with a spinal abscess that developed from Nocardia asteroides. Nocardia is a rare etiology for spinal abscesses, especially in immunocompetent patients. Nocardia usually affects the lungs and brain of immunocompromised individuals. Few reports of Nocardia involving bones or the spine have been published.The patient had a history of chronic back pain and had several procedures to alleviate the pain. In August 1997, the patient had an epidural block and a subsequent infection that was treated with antibiotics. In October 1997, she developed increasing back pain greater than her baseline chronic low back pain. Additional presenting symptoms were fever, chills, and nausea. On admission, magnetic resonance imaging (MRI) revealed an epidural abscess. The patient underwent irrigation and debridement. Postoperatively, the patient was initially placed on broad-spectrum antibiotics. After 38 days, the culture was identified as N asteroides, and the patient was placed on appropriate antibiotics. The patient has been followed with MRI prior to the discovery of the abscess and annually since the abscess due to her baseline chronic low back pain. No residual abscess was discovered.     

Hepatic abscess in patients with chronic granulomatous disease

OBJECTIVE: To evaluate the clinical presentation, diagnostic procedures, and surgical management of hepatic abscesses in patients with chronic granulomatous disease (CGD). SUMMARY BACKGROUND DATA: Chronic granulomatous disease is a rare inherited primary immunodeficiency in which phagocytes cannot destroy catalase-positive bacteria and fungi. Defects in the phagocytic cells' respiratory burst lead to life-threatening infections, including hepatic abscess. These abscesses are recurrent and often multiple and are treated differently from bacterial abscesses in patients without CGD. METHODS: Between 1980 and 2000, 61 cases of hepatic abscess in 22 patients with CGD were treated at the National Institutes of Health. Clinicopathologic features were investigated by retrospective review of the medical records, radiographs, and histopathology. RESULTS: Twelve of the 61 cases were primary hepatic abscesses. Twenty-nine of the cases were recurrent hepatic abscesses, and 20 cases were persistent hepatic abscesses. The median age at the time of initial hepatic abscess presentation was 14 years. Subjective fever was the most frequent presenting symptom, and the erythrocyte sedimentation rate was elevated in 98% of cases. Fifty-two cases were managed surgically and eight cases were managed with percutaneous drainage. One patient refused surgery. The surgical complication rate was 56%; however, there were no deaths directly related to the hepatic abscesses. Staphylococcus aureus was the most frequent organism identified in culture (88% of positive cultures). Aggressive surgery and antibiotics ultimately resulted in successful treatment of all patients. CONCLUSIONS: Hepatic abscesses occurring in patients with CGD represent a difficult diagnostic and treatment challenge. Early excision and treatment with antibiotics directed against S. aureus is necessary. General surgeons should be aware of this rare immunodeficiency and should aggressively manage hepatic abscesses in these patients.