Infectious Tenosynovitis of the Tibialis Anterior Due to Mycobacterium chelonae After Intravenous Heroin Injection

Mycobacterium chelonae is a ubiquitous Gram-positive, acid-fast, non–spore-forming bacterium commonly encountered in nature associated with aquatic animals, soil, and water, including tap water. Nontuberculous mycobacterial tenosynovitis infections caused by M. chelonae in the lower extremity are uncommon, leading to a paucity of literature documenting the diagnosis and treatment of such cases. This report is of a 65-year-old male patient who was found to have an M. chelonae infection along the tibialis anterior tendon after injecting himself with heroin into the dorsal foot veins. This review covers the diagnosis and treatment as well as a case report on the outcome of infectious tenosynovitis of the tibialis anterior associated with M. chelonae. To date, this is the only reported case of tibialis anterior infectious tenosynovitis caused by M. chelonae after intravenous heroin injection.     

Achilles Tendon Infection Due to Mycobacterium chelonae

Atypical tuberculous tenosynovitis of the foot and ankle is extremely rare. The determination of the Mycobacterium species is essential because resistance of atypical mycobacterial strains to antituberculous drugs is often encountered. We report a case of Mycobacterium chelonae paratendinous and intratendinous infection involving the Achilles tendon. Repeat aggressive irrigation and debridement procedures, coupled with removal of foreign materials and the appropriate use of prolonged antibiotic therapy, can result in a successful long-term outcome.     

Mycobacterial endocarditis: a comprehensive review

Objective

A systematic analysis was made in view of the epidemiology, clinical features, diagnosis, treatment and main outcomes of mycobacterial endocarditis.

Methods

The data source of the present study was based on a comprehensive literature search in MEDLINE, Highwire Press and Google search engine for publications on mycobacterial endocarditis published between 2000 and 2013.

Results

The rapidly growing mycobacteria become the predominant pathogens with Mycobacterium chelonae being the most common. This condition has changed significantly in terms of epidemiology since the 21^st century, with more broad patient age range, longer latency, prevailed mitral valve infections and better prognosis.

Conclusion

Mycobacterial endocarditis is rare and the causative pathogens are predominantly the rapidly growing mycobacteria. Amikacin, ciprofloxacin and clarithromycin are the most frequently used targeted antimicrobial agents but often show poor responses. Patients with deep infections may warrant a surgical operation or line withdrawal. With periodic multidrug therapy guided by drug susceptibility testing, and surgical managements, patients may achieve good therapeutic results.     

Mycobacterium chelonae Peritonitis in a Patient on Peritoneal Dialysis

Non-tuberculous mycobacteria peritonitis is uncommon with the majority of cases reported in patients on peritoneal dialysis with diagnostic and therapeutic challenges. Here we present a case of Mycobacterium chelonae peritonitis and review other cases in the literature to discuss the clinical spectrum, diagnostics, regimens and duration of treatment, and outcome.     

Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients

While nontuberculous mycobacterial peritonitis is uncommon among peritoneal dialysis (PD) patients, these infections have serious consequences. They present a significant diagnostic and therapeutic challenge for clinicians. Diagnosis can be delayed due to the slow growth rate of some mycobacterial species. These organisms can also be overlooked when adequate culture media are not used in the microbiological evaluation process. The choice of antimicrobial therapy depends upon isolation and speciation of the infecting Mycobacterium species, and prompt catheter removal is essential. Because serious intra-abdominal complications may follow infection, identifying patient risk factors for nontuberculous mycobacterial peritonitis and initiating prompt diagnosis and treatment are essential. We report three cases of peritonitis associated with Mycobacterium chelonae and Mycobacterium gordonae, each with a unique presentation, and discuss the appropriate diagnosis and treatment strategies for the management of PD-associated mycobacterial infections.     

Efficacy of percutaneous ethanol sclerotherapy for venous malformation in lower extremities: a retrospective review of 21 cases

Background

Venous malformations (VM) of lower extremities have characteristic symptoms, especially swelling, pain at rest or with dependence, or in the morning, or with exertion. Sclerotherapy has been applied and has been showed to alleviate the associated signs and symptoms. The aim of this study is to evaluate the outcomes of ethanol sclerotherapy for VM of lower extremities.

Methods

The 21 patients of intramuscular VM of the lower extremities, who received percutaneous sclerotherapy using absolute ethanol in our institute, were reviewed retrospectively. The average age at the time of the initial diagnosis was 18.6 years, and average follow-up period after last sclerotherapy is 19.4?±?13.5 months. The postinterventional changes of the associated signs and symptoms were evaluated by utilizing original VM scoring system.

Results

The average number of sclerotherapy sessions was 2.6 times per case. The average total amount of ethanol used in each patient was 41.3 ml. Sclerotherapy reduced the associated signs and symptoms in many of the patients (n?=?19/21). Preinterventional VM score as the overall baseline status was 10, and the average VM score after sclerotherapy was 4.1. There was no inverse correlation between the amount of ethanol used and the VM score. In seven cases treated more than three times, reverse correlation between the “VM score” and the number of sclerotherapy sessions was demonstrated (p?<?0.05, ρ?=?0.8214).

Conclusions

The characteristic symptoms and signs of the VM were improved by sclerotherapy. More than three sessions of ethanol sclerotherapy improved the overall status of extensive intramuscular VM in lower extremities. Level of Evidence: Level IV, therapeutic study.     

A Systematic Review and Meta-Analysis of the Effectiveness of LRINEC Score for Predicting Upper and Lower Extremity Necrotizing Fasciitis

This review and meta-analysis aims to assess the prognostic value of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing fasciitis in the extremities. The LRINEC score has been validated in multiple studies as a clinical tool for differentiating necrotizing fasciitis from non-necrotizing infections however many studies do not specify the location of infection. As the prevalence of diabetes and diabetic foot infections continues to rise, the utility of LRINEC scores in these populations becomes of increased importance. Four databases were reviewed for citations between January 2010 and December 2020. English, full text articles reporting the diagnostic effects of LRINEC were utilized in the systematic review portion of this paper. Further inclusion of 2 × 2 tables and discussion specific to the extremities were applied for citations implemented in the meta-analysis. Of the 111 results, 12 citations (n = 932) were included in this review. The diagnostic sensitivity of the LRINEC score ranged from 36% to 77% while specificity ranged from 72% to 93%. Cumulative odds ratio for LRINEC ≥6 among the 4 studies assessing extremity necrotizing fasciitis was 4.3 with p value of <.05. Sensitivity, specificity, positive predictive value, and negative predictive value was 49.39%, 83.17%, 34.91%, and 89.99%, respectively. Accuracy, the classification by whether a patient was correctly classified, was 77.95%. LRINEC score is effective at distinguishing necrotizing fasciitis from other soft tissue infections however the LRINEC's score greatest clinical application may be its ability to rule out necrotizing fasciitis while its ability to accurately identify the presence of infection remains suboptimal.     

A clinical sign of adenocystic tumour of the trachea

Singh, H. M., and Thomas, D. M. E. (1973). Thorax, 28, 442-443. A clinical sign of adenocystic tumour of the trachea. Three patients with intrathoracic adenocystic tumour of the trachea presented as difficult diagnostic problems. All three patients had been labelled as psychiatric problems. Present in two of the cases, the sniff sign proved diagnostic and occurred at a stage when occlusion of the trachea during expiration was almost total. In order to breathe, the patients drew in small sharp, sniffing breaths. The sign owes its name to this pattern of breathing.     

End-to-side anastomosis for coarctation of the aorta and type a aortic arch interruption with hypoplastic aortic arch

Objective: We investigated the advantages of reconstructing the aortic arch in neonates and infants by end-to-side anastomosis (ESA) in aortic coarctation and type A aortic arch interruption. Subjects and Methods: The patients were 28 neonates and infants who underwent median full sternotomy for correction of aortic coarctation (CoA) and type A interrupted aortic arch (IAA), at our institute, from October 1997 to September 2002. The cases were divided into two groups: ESA was performed in 16 cases (group A) and extended end to end anastomosis in 12 cases (group B). All repairs were made using simple clamping of the descending aorta under cardiac arrest. We compared groups A and B with regard to duration of simple clamping, postoperative blood pressure in the upper and lower extremities, echocardiographic pressure gradient, and the presence or absence of tracheal stenosis as diagnosed by postoperative clinical symptoms and chest radiography. Results: No significant difference between the groups was found in age, gender, body weight, or the ratio of CoA to IAA. In addition, there was no defference between the two groups in the duration of simple clamping or the difference in blood pressure between the lower and upper extremities. However, the echocardiographic pressure gradient at the site of anastomosis in group A was significantly lower than that in group B. There were no cases with symptoms of bronchial stenosis in either group. Conclusion: ESA is a relatively simple method for treating CoA or IAA with hypoplastic aortic arch, and was found to be effective for the elimination of residual stenosis.     

Non tuberculous mycobacteria in surgical wounds- a rising cause of concern?

Introduction  

The non-tuberculous mycobacteria (NTM) have emerged as important opportunistic pathogens in the recent years. The NTM are rapid growing mycobacteria (RGM), which include Mycobacterium fortuitum and M. chelonae and are grouped as M. fortuitum-chelonae complex. Non-healing postoperative wound infections that do not respond to antibiotics used for pyogenic infections and having sterile routine aerobic cultures should raise a suspicion of NTM.     

Non‐tuberculous Mycobacteria in Wild Boar (Sus scrofa) from Southern Spain: Epidemiological,Clinical and Diagnostic Concerns

Non‐tuberculous mycobacteria (NTM) are widely distributed in the environment, particularly in wet soil, marshland, rivers or streams, but also are causative agents of a wide variety of infections in animals and humans. Little information is available regarding the NTM prevalence in wildlife and their effects or significance in the bovine tuberculosis (bTB) epidemiology and diagnosis. This research shows the most frequently NTM isolated in lymph nodes of wild boar (Sus scrofa) from southern Spain, relating the NTM presence with the individual characteristics, the management of animals and the possible misdiagnosis of Mycobacterium bovis in concurrent infections. A total of 219 NTM isolates were obtained from 1249 wild boar mandibular lymph nodes sampled between 2007 and 2011. All but 75 isolates were identified by the PCR‐restriction analysis‐hsp65, and a partial sequencing of the 16S rDNA was carried out to identify the rest of the isolates. Results showed that Mycobacterium chelonae was the most frequently isolated NTM specie (133 isolates, 60.7%), followed by Mycobacterium avium (24 isolates, 11%). No relation was found regarding sex, body condition and management, but M. chelonae was more frequently detected in adults, whereas M. avium was more prevalent in subadults. The high NTM prevalence observed in the studied wild boar populations could make difficult the bTB diagnostic.     

Necrotizing fasciitis in children: diagnostic and therapeutic aspects

Background

Necrotizing fasciitis (NF) is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. Its incidence owing to invasive Streptococcus pyogenes has significantly increased in children recently. Our experience with NF in children to describe diagnostic and therapeutic aspects is hence presented herein.

Methods

Records of children who were treated for NF in our unit from 1999 to 2006, inclusive, were reviewed retrospectively. Information recorded for each patient included medical history, clinical characteristics, diagnostic procedures, treatment methods, and the outcome.

Results

Thirteen patients with a mean age of 35 months were treated for NF during the study period. All of the 13 children had no previous immunosuppression. The predisposing factors were composed of varicella lesions, intramuscular injections, application of a cream containing menthol to the cervical region, penetrant gluteal trauma, omphalitis, dental abscess, and streptococcal toxic shock syndrome. The most common site of the initial involvement was the abdominal wall, followed by the gluteal region and thigh, head and neck, and upper and lower extremities. The initial skin presentations were induration or cellulitis and erythema and edema with progression to skin discoloration and bullae formation. Fever and tachycardia were the most common clinical features. S. pyogenes was the most common causative microorganism, followed by Staphylococcus epidermidis and Pseudomonas aeruginosa. All patients underwent extensive surgical debridement and received appropriate antibiotics and supportive therapy. Twelve patients survived, and 1 patient with delayed diagnosis of NF died of septic shock.

Conclusion

Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized. All children with NF should undergo early surgical debridement to prevent delay in treatment. The mortality and morbidity associated with NF in children can be decreased with clinical awareness, early diagnosis, and adequate and urgent surgical debridement followed by intensive supportive care and early wound resurfacing.     

Atypical mycobacterial spondylitis in HIV-negative patients identified by genotyping

Non-tuberculous mycobacterial infections pose a significant diagnostic and therapeutic challenge. We report two cases of such infection of the spine in HIV-negative patients who presented with deformity and neurological deficit. The histopathological features in both specimens were diagnostic of tuberculosis. The isolates were identified as Mycobacterium intracellulare and M. fortuitum by genotyping (MicroSeq 16S rDNA Full Gene assay) and as M. tuberculosis and a mycobacterium other than tuberculosis, respectively, by culture. There is a growing need for molecular diagnostic tools that can differentiate accurately between M. tuberculosis and atypical mycobacteria, especially in regions of the developing world which are experiencing an increase in non-tuberculous mycobacterial infections.     

Skin and joint infection by Mycobacterium chelonae: rescue treatment with interferon gamma

IntroductionAtypical mycobacteria are environmental organisms that cause opportunistic infections in humans.Case reportA 50-year-old electronics engineer sought advice about starting TNFα antagonist therapy for ankylosing spondylitis. Disease duration was 23 years and current treatment was methylprednisolone 4 mg/d. Atypical skin lesions and knee arthritis were noted. Fluid aspirated from the knee showed inflammatory properties and a few acid-fast bacteria, which a line probe assay identified as Mycobacterium chelonae. The same organism was found in a skin biopsy from a thigh lesion. Antimicrobial treatment was started immediately. Inadequate results 6 months later prompted synovectomy of the knee followed by interferon gamma, 50 μg/m² body surface area subcutaneously 3 times a week. After 16 months, there were no new skin or joint lesions, and the antimicrobials and interferon gamma were therefore discontinued.ConclusionThis highly unusual case suggests that interferon gamma may be effective in patients with M. chelonae infection that fails to respond adequately to antimicrobials.     

Aortocaval Fistula Associated with Abdominal Aortic Aneurysm: A Diagnostic Challenge

The purpose of this study is to determine the clinical features with the best preoperative diagnostic value for aortocaval fistulas (ACF) associated with abdominal aortic aneurysm (AAA). A review of our experience of seven patients presenting ACF between 1980 and 1994 as well as an extensive study of the literature provide a clearer picture of the signs and symptoms allowing diagnosis of ACF: edema of the lower extremities and signs of venous hypertension are the most predictive findings; continuous abdominal murmur is noted in 66% of cases and is of good diagnostic value. (Ann Vasc Surg 1997;11:464–466.)     

Nontuberculous mycobacterial infections in left ventricular assist device patients

Left ventricular assist devices (LVADs) are integral for the management of medically refractory heart failure, and LVAD infections are common following device placement. Most infections are caused by Staphylococcal spp. and Gram-negative enteric bacteria but nontuberculous mycobacterial (NTM) infections have been reported. We present the second-ever reported case of a driveline infection caused by Mycobacterium fortuitum in a 75-year-old male with a continuous-flow LVAD. After receiving meropenem, azithromycin, and ciprofloxacin, he underwent device exchange and ultimately died after failing to recover neurologically. Management of NTM infections presents a clinical challenge due to the propensity for rapidly growing mycobacterial species to form biofilms and the possibility of negative cultures delaying diagnosis. To address the literature gap surrounding NTM infections in LVAD patients, we performed a systematic review and present all previously reported cases.     

Mycobacterium chelonae peritonitis in a patient on peritoneal dialysis

Non-tuberculous mycobacteria peritonitis is uncommon with the majority of cases reported in patients on peritoneal dialysis with diagnostic and therapeutic challenges. Here we present a case of Mycobacterium chelonae peritonitis and review other cases in the literature to discuss the clinical spectrum, diagnostics, regimens and duration of treatment, and outcome.     

Distinct Clinical Characteristics of Unplanned Excision in Synovial Sarcoma

Background

We aimed to describe the clinical characteristics and outcomes of unplanned excisions of synovial sarcomas.

Methods

In total, 90 patients with synovial sarcomas in the extremities were retrospectively reviewed. Patients were divided into unplanned excision (n = 38) and planned excision (n = 52) groups. The average follow-up period was 6 years. The clinicopathological characteristics and oncologic outcomes were compared.

Results

The unplanned excision group showed longer duration of symptoms before diagnosis (p = 0.023), smaller lesion dimensions (p = 0.001), superficial location (p = 0.049), and predilection in the upper extremities (p = 0.037). Synovial sarcomas were most commonly misdiagnosed as neurogenic tumors (56%) in the upper extremities or as cystic masses (47%) in the lower extremities. Oncological outcomes, including disease-specific survival, metastasis-free survival, or local recurrence were not significantly different between the 2 groups (p = 0.159, p = 0.444, and p = 0.335, respectively). Repeated unplanned excision (p = 0.012) and delayed re-excision (p = 0.038) were significant risk factors for local recurrence in the unplanned excision group.

Conclusions

Synovial sarcomas treated with unplanned excision had distinct characteristics. These findings are important for developing diagnostic and therapeutic strategies for synovial sarcoma.     

Vanishing bone disease (Gorham-Stout syndrome): A review of a rare entity

Vanishing bone disease (Gorham-Stout syndrome) is a rare entity of unknown etiology, characterized by destruction of osseous matrix and proliferation of vascular structures, resulting in destruction and absorption of bone. Despite the extensive investigation of the pathogenetic mechanisms of the disease, its etiology hasn’t been clarified and several theories exist. The syndrome can affect one or multiple bones of the patient, including the skull, the upper and lower extremities, the spine and pelvis. The clinical presentation of a patient suffering from vanishing bone disease includes, pain, functional impairment and swelling of the affected region, although asymptomatic cases have been reported, as well as cases in which the diagnosis was made after a pathologic fracture. In this short review we summarize the theories regarding the etiology as well as the clinical presentation, the diagnostic approach and treatment options of this rare disease.