Anorectal abscesses in immunosuppressed patients.

The results of surgery in 14 immunosuppressed patients with 17 anorectal abscesses are presented. Abscess incision was followed by almost immediate relief of pain. Healing was obtained in 15 cases, but two patients died of causes unrelated to surgery. Symptoms, therapeutic possibilities and prognosis are discussed. The authors conclude that surgery should be performed in all cases to prevent development of septicemia. Fluctuation should not be awaited, but surgery should be minimized if granulocyte and platelet counts are low. Each patient must be managed individually, according to the nature of malignant disease, general state of health and degree of immunosuppression. Antibiotic cover is important, and primary closure of the abscess cavity should never be attempted.     

Cutaneous mucormycosis infection by absidia in two consecutive liver transplant patients

Mucormycosis, although an infrequent fungal infection, has a high mortality in patients undergoing orthotopic liver transplantation. We present two cases of cutaneous Absidia mucormycosis in two successive patients undergoing liver transplantation in our hospital. In our literature search, we encountered only one published case of Absidia infection in liver transplantation.     

Primary cutaneous mucormycosis in trauma patients

Primary cutaneous mucormycosis in trauma patients has been rarely reported. We describe three cases occurring in noncompromised hosts and review the literature. Prompt diagnosis and aggressive treatment with vigorous local care and appropriate antibiotics are recommended.     

Upper-extremity mucormycosis infections in immunocompetent patients

PURPOSE: Mucormycosis can produce an aggressive and sometimes fatal soft tissue infection seen most commonly in immunocompromised individuals. Eradication consists of surgical resection and antifungal chemotherapy. Knowledge regarding infectious mucormycosis in the upper extremity has been limited to case reports involving mainly immunocompromised individuals. The purpose of this study was to identify risk factors for the development of mucormycosis infections within the upper extremity in immunocompetent individuals and to evaluate the effectiveness of the present therapies. METHODS: A 12-year retrospective review of all fungal infections involving the upper extremity was conducted in our institution. Seven immunocompetent patients with infectious cutaneous mucormycosis of the upper extremity were identified from 223 primary upper-extremity fungal infections. RESULTS: In the 7 patients 3 infections resulted from heavy soil contamination after motor vehicle collisions and 4 resulted from conveyor belt injuries in agricultural facilities. All patients had considerable upper-extremity soft tissue loss and 6 of the 7 patients had upper-extremity fractures or dislocations. Patients had an average of 10 surgical debridements. Four infections resulted in amputations: 1 partial hand amputation, 1 below the elbow, 1 above the elbow, and 1 at the glenohumeral joint. CONCLUSIONS: Mucormycosis can produce limb-threatening infections in an immunocompetent host. Hand surgeons must have suspicion of such infections in patients with grossly contaminated open wounds.     

Difficulties in the diagnosis of brain abscesses

The diagnosis of brain abscesses has been improved during the last 10 years because to introduction of computerized tomography (CCT) and improved methods for the analysis of cerebrospinal fluid (CSF). Typical ring-like enhancement in the CT and an elevated CSF cell count combined with disturbances of the blood-brain barrier and elevated CSF lactate are common and confirm preliminary diagnoses. However, in spite of these procedures, brain abscess is still sometimes misdiagnosed because of the lack of pathological CT findings or a misleading case history sometimes causing cerebral affections. We present the case histories of two young patients in whom diagnosis of brain abscess was delayed. We recommend the immediate performance of contrast-enhanced CT and CSF analysis. If these procedures do not exclude a brain abscess, antibiotic treatment should be begun immediately.     

Outcomes in immunosuppressed anal cancer patients

BackgroundImmunosuppressed patients have an increased risk of developing anal cancer, but little data exists regarding outcomes of this population.MethodsA retrospective review of anal cancer patients at a single academic institution from 2006 to 2017 was performed.Results19 (14%) of 136 anal cancer patients were immunosuppressed. Immunosuppressed patients were more likely to be hypoalbuminemic (21% vs. 6%, p = 0.025), less likely to complete chemotherapy (58% vs. 80%, p = 0.031) or exhibit a complete response to chemoradiation (57% vs. 82%, p = 0.037), and more likely to experience recurrence (53% vs. 25%, p = 0.013). Hypoalbuminemia was significantly associated with worse overall (HR 6.4, CI 2.2–19.2, p < 0.001) and progression-free (HR 4.4, CI 1.8–10.4, p < 0.001) survival.ConclusionsImmunosuppressed patients have poor tolerance of chemotherapy and response to chemoradiation, and an increased rate of recurrence. This finding is possibly due to the relationship between immunosuppression and hypoalbuminemia, which was associated with worse overall and progression-free survival.     

Surgical treatment of pulmonary aspergillosis/mycosis in immunocompromised patients

Invasive pulmonary aspergillosis is a severe complication in immunosuppressed patients. Surgical resection can be curative in certain patients after antifungal treatment. Over a 7-year period, ten patients with suspected invasive pulmonary aspergillosis of two university hospitals were retrospectively reviewed. A literature review was undertaken. Patient's age was 48.1 years (mean); the cause of immunosuppression was a hematological disease with consecutive therapy in seven patients and chronically corticoid therapy in three patients. After an antifungal therapy, surgical resection was performed with lobectomy/segmentectomy in 60% and with wedge-resection in 40%. Postoperative course were uneventful in seven patients, two patients died due to infectional circumstances, and one patient was reoperated because of empyema. The underlying disease marked long-term follow-up. Resection of focal pulmonary invasive aspergillosis can be curative. Clinical circumstances and dissemination must be taken into consideration to indicate surgery. To point out the best pathway randomised prospective studies are necessary.     

EEG topographic changes of brain abscesses in children

EEG topography was investigated before and after surgical treatment in 4 patients with brain abscess aged from 5 to 13 years. According to the recording technique designed by Matsuoka and Ueno, the recorded EEG for each 5 seconds was analyzed to obtain square roots of power spectra for each band of delta (2-3.8 Hz), theta (4-7.8 Hz) and alpha (8-12.8 Hz) which were then added for the 60-seconds duration of each trial. After that, numerical matrix presenting the topographic distribution of spectral energy of each band were constructed and displayed as color images. In addition, the EEG topographies of brain abscesses were compared with the CT scans simultaneously obtained. In all of four cases before surgical treatment of the brain abscess, the location of the focal delta wave on the EEG topography was more closely related to the site of brain abscess comparing with its correlation between the location of the delta focus on the conventional EEG and the site of brain abscess. In contrast, as for the theta wave, there was no prominent correlation to the site of the brain abscess. In the early stage of 10-15 days after aspiration of the brain abscess, the most characteristic change of the EEG topography was an approximately 25% reduction of the maximum equivalent voltage of delta band with associated disappearance of the sharply located focal delta wave being noted before aspiration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intestinal mucormycosis in hemodialysis patients following deferoxamine

Two maintenance hemodialysis patients receiving deferoxamine to chelate iron and aluminum developed intestinal mucormycosis. One patient had pulmonary mucormycosis as well. The patients lacked the usual predisposing factors to mucormycosis, ie, diabetes and acidosis, but both had liver disease. The role of siderophores such as deferoxamine in promoting certain infections is discussed with reference to this particular clinical setting.     

小儿肾毛霉菌病(附三例报告)

目的 探讨小儿原发性肾毛霉菌病的临床特点。方法 对3例小儿原发性肾毛霉菌病的症状、体征、CT和IVU表现、手术情况等进行分析，结合文献讨论其临床特点。结果 1例新生儿患者无明显症状，表现为肾区肿块；另2例均有高热、腰痛、血尿、肾脏肿大和肾区压叩痛。CT可见肾内多个低密度病灶。1例尿液镜检见毛霉菌。3例均行肾脏切除术加两性霉素B治疗，诊断经病理证实。结论 毛霉菌病单独累及肾脏者罕见，具有不同于全身性毛霉菌病的临床特点。早期诊断、积极手术并抗真菌治疗可改善预后。     

Fungal infection in burn patients: Results of using 5-fluorocytosine (flucytosine)

Fungal infection and use of 5-fluorocytosine were studied prospectively among burn patients receiving multiple antibiotics. From 22 out of 23 patients positive cultures for Candida were obtained. Cultures from the mouth and rectum became positive first. Averaging 6 days later, 16 patients had positive urine cultures. Candida in urine was the best way to detect systemic candidiasis.Nine patients received 5-fluorocytosine. Although this drug did not influence survival among patients with burns of less than 59 per cent of body surface area, it prevented death from disseminated Candida infection among patients with burns of greater than 60 per cent body surface area.Patients with large surface burns receiving multiple antibiotics should have prophylaxis against fungi. If Candida is detected in urine, systemic treatment should be given. 5-Fluorocytosine is a safe and effective systemic drug for this purpose.     

Management of perianal sepsis in immunosuppressed patients

Despite improvements in the supportive care of immunosuppressed patients controversy still surrounds the surgical management and outcome of anorectal sepsis in these patients. We reviewed 83 immunocompromised patients with diagnosis of perianal sepsis from 1995 to 1997. Sixty-six patients (80%) were followed for a mean of 15 months. Mean age was 44 years and 76 per cent were males. Twenty-eight per cent were HIV+, 34 per cent had inflammatory bowel disease on steroids, 20 per cent had malignancies, and 18 per cent had diabetes. Twenty-eight per cent had anal fistula, 2 per cent had perianal abscess, and 40 per cent had both. Primary sites of fistula were: transsphincteric (38%), intersphincteric (33%), superficial (20%), and suprasphincteric (3%), and multiple tracks (6%). Horseshoeing was present in 14 per cent of cases. The most commonly practiced surgical procedures were primary fistulotomy (n = 23) and fistulotomy plus drainage (n = 28). Seven patients underwent fistulotomy and ostomy and eight patients were treated with fistulectomy plus drainage. Most wounds (91%) healed within 8 weeks. Incontinence (6%) and recurrence (7%) were the most commonly observed complications. These results are similar to those seen in the general population. Perianal sepsis can be safely managed in immunocompromised patients, with high rates of healing and low complication rates. An aggressive sphincter-preserving approach in the management of these patients may be undertaken.