Toxic shock syndrome associated with suction-assisted lipectomy

Toxic shock syndrome (TSS) is a serious, potentially life-threatening condition resulting from an exotoxin of Staphylococcus aureus. Presenting symptoms include high fever, diarrhea, nausea, and vomiting progressing to hypotension, oliguria, conjuctival hyperemia, and an erythematous rash over the trunk, abdomen, and extremities. TSS has been associated both with and without the use of tampons during menstruation, postsurgical infections, and stab wounds, and can occur in postrhinoplasty patients with and without nasal packing. There has been one case reported in the literature of TSS associated with suction-assisted lipectomy (SAL). This article discusses the diagnosis and treatment of two cases in which the patients developed TSS after outpatient use of SAL. In the first case, an abdominoplasty and SAL were performed in a healthy young female. The second case involved the harvesting of abdominal fat via syringe suction and subsequent facial fat injection in a female with systemic lupus erythematosus and severe facial atrophy.Presented at the Midwestern Association of Plastic Surgeons Conference, Chicago, IL, June 1993     

Toxic shock syndrome in transsphenoidal neurosurgery

Summary An overlooked toxic shock syndrome (TSS) may leed to a fatal outcome. In neurosurgery a transsphenoidal approach with post-operative nasal tamponade may promote toxic shock syndrome without signs of local wound infection. By discussing the case history of a patient after hypophysectomy by the transsphenoidal route, we propose that after the appearance of the first signs of toxic shock syndrome, quick removal of the nasal tamponade is a life saving procedure.     

Streptococcal pancreatitis and toxic shock syndrome in a 2-month-old infant

The rare clinical scenario of an infant with group A streptococcal pancreatitis associated with toxic shock syndrome is reported. The presentation, evaluation, and management of this unusual clinical entity are discussed.     

Postoperative Toxic Shock Syndrome After Excision of a Ganglion Cyst From the Ankle

Postoperative toxic shock syndrome (PTSS) after orthopedic surgery is rare, but early recognition and prompt intervention are essential to minimize morbidity and potential mortality. The diagnosis should be considered in all postoperative patients presenting with fever, hypotension, and systemic illness. The treating surgeon must have not only knowledge of the clinical entity, but also an extremely high index of suspicion, because the diagnosis can be elusive with surgical wounds appearing deceptively benign. Treatment consists of antibiotics, surgical wound debridement, and, more importantly, aggressive supportive care with intravenous fluids and intensive care surveillance. To date, the literature contains relatively few case reports of PTSS after orthopedic procedures, with even fewer cases encountered after foot and ankle surgery. This report describes a patient who developed the rare complication of PTSS after an elective ganglion cyst excision from the ankle.     

Calcaneal osteomyelitis after puncture wound to foot: case report and review of the literature

Abstract Puncture wounds of the foot are relatively common injuries that occur in persons of all ages. A small percentage of puncture wounds becomes infected and can lead to complications such as osteomyelitis, osteochondritis and soft tissue abscess. These wounds must be followed up routinely one week after injury. We report a case of calcaneus osteomyelitis caused by a mixed infection with Escherichia coli and Staphylococcus aureus subsequent to puncture wound of the foot. The characteristics of the patient, the pathogenic organisms, treatment and outcome are presented.     

Toxic epidermal necrolysis/Stevens-Johnson syndrome: current trends in management

BACKGROUND: Toxic epidermal necrolysis (TEN) is an uncommon but potentially life-threatening condition that involves sloughing of the skin at the dermoepidermal junction. TEN is a well-recognized syndrome and is part of a range of severe mucocutaneous intolerance reactions, mostly elicited by drugs and/or their metabolites. Reported mortality rates vary widely from 20 to 75%. Several systemic treatment protocols for TEN have been published; however, none has been formally standardized in a randomized controlled trial. The present study documents the current management principles and trends seen in 16 patients admitted with TEN or Stevens-Johnson syndrome over a 5-year period at the Concord Repatriation General Hospital Burns Unit. METHOD: Data were collected by retrospective chart review, and parameters included in the study were patient demographics, causative agents, percentage total body surface area and/or mucosal involvement, complications, treatment and outcome. In particular, dressing choice and documented healing of skin lesions were noted. RESULTS: Sixteen patients were identified, with the beta-lactam antibiotics most commonly implicated as the cause. Complications tended to relate to degree of sepsis and/or mucous membrane involvement. Nanocrsytalline silver dressings, such as Acticoat (Smith & Nephew, Mount Waverley, Victoria, Australia), were used predominantly in more recent cases. CONCLUSION: The shift in dressing choice from traditional Vaseline-impregnated gauze coincided with a general trend towards the use of nanocrystalline silver dressings for superficial burns after 2003. The nanocrystalline silver dressings have shown considerable advantage over previously used dressings, with no adverse reactions noted and good healing of the skin lesions for all patients.     

Toxic shock syndrome toxin-1 (TSST-1) antibody levels in Japanese children

Children with burns have a greater risk of developing toxic shock syndrome (TSS) than adults. This risk is thought to be associated with colonisation by toxic shock syndrome toxin-1 (TSST-1)-producing Staphylococcus aureus in children with insufficient antibody titers. The diagnosis of TSS is difficult because, in the early stages, its signs and symptoms resemble those of other common childhood illnesses such as scarlet fever. If the condition is not treated promptly, the mortality rate is high. This study was designed to determine the titers of TSST-1 serum antibody in Japanese children, in order to prevent TSS and facilitate its early diagnosis.     

Genetic forms of nephrotic syndrome

Mutations of NPHS1, NPHS2 , or WT1 may be responsible for severe forms of nephrotic syndrome in children, progressing to end-stage renal failure. Recent studies have shown that congenital nephrotic syndrome may be secondary to mutations of one of these three genes and that some patients have a digenic inheritance of NPHS1 and NPHS2 mutations. The clinical spectrum of NPHS2 mutations has broadened, with the demonstration that mutations in the respective gene podocin may be responsible for nephrotic syndrome occurring at birth, in childhood, or in adulthood. It is now well recognized that podocin mutations are found in 10%–30% of sporadic cases of steroid-resistant nephrotic syndrome with focal segmental glomerulosclerosis. Data from large cohorts indicate that the risk of recurrence of nephrotic syndrome after renal transplantation in patients with podocin mutations is very low.     

Toxic Shock Syndrome Following Thoracic Surgery for Lung Cancer: Report of a Case

Postoperative toxic shock syndrome (PTSS) caused by toxin-producing Staphylococcus aureus has incidentally been reported to be experienced following various surgical procedures or wounds. This syndrome includes sudden high fever, headache, muscle ache, a sunburn-like rash, hypotension, and tachycardia, while also often showing a rapid progression and a fatal outcome. To date, no such cases have ever been reported after thoracic surgery. We herein describe a highly probable case of PTSS in a 61-year-old man who underwent a pulmonary resection for lung cancer. The patient recovered after immediate and intensive antibiotic and steroid therapies. PTSS can occur incidentally even in the field of thoracic surgery; therefore, thoracic surgeons should be aware of this possible onset in order to recognize and treat this disease in a timely manner.     

Review: Staphylococcus aureus and MRSA in cystic fibrosis

Background

Staphylococcus aureus (S. aureus) is one of the earliest bacteria detected in infants and children with cystic fibrosis (CF). The rise of methicillin resistant S. aureus (MRSA) in the last 10 years has caused a lot of attention to this organism.

Results

The aim of this review is to provide a general overview of methicillin sensitive S. aureus (MSSA) and MRSA, discuss special aspects of S. aureus in cystic fibrosis, and to review treatment concepts. Microbiology of the organism will be reviewed along with data regarding the epidemiology of both MSSA and MRSA. Antibiotic treatments both in regards to acute management and eradication of MSSA and MRSA will be reviewed. Prophylaxis of MSSA in CF remains controversial. Treatment with anti-staphylococcal agents reduces the infection rate with MSSA but may lead to a higher rate of infection with P. aeruginosa. In regards to MRSA, there is a paucity of clinical data regarding approaches to eradication.

Conclusions

To advance the care of CF patients, controlled clinical trials are urgently needed to find the optimal approach to treating CF patients who are infected with either MSSA or MRSA.     

On the use of prophylactic antibiotics in prevention of toxic shock syndrome

No consensus exists among burn surgeons on the role of prophylactic antibiotics in prevention of toxic shock syndrome (TSS). We recently reported a series of 71 children admitted with burns to our burn unit. By Centres for Disease Control (CDC) criteria, six of these were ‘definite’ and four ‘probable’ cases of TSS. Prior to this report, none of our patients were given prophylactic antibiotics. Thereafter, prophylactic therapy was included in the management of children admitted to the burns unit. The aim of this study was to assess whether prophylaxis with a one off single dose of systemic antibiotics prevented the occurrence of TSS.

Data were collected prospectively between 1 January and 31 December 2001, on all children admitted to the burns unit. Out of 50 children admitted to the burns unit, 39 received prophylactic antibiotics in the referring accident and emergency. Two of these became unwell but none fulfilled the CDC criteria. The remaining 11 patients were given antibiotics on admission out of which one child required direct admission to the intensive care unit with a working diagnosis of TSS. Retrospectively, his features did not conform to the CDC criteria. In conclusion, this study suggests that prophylaxis may prevent TSS in children.     

Hemolytic uremic syndrome associated with Clostridium difficile colitis

Pediatric Nephrology -     

Identification of the first AHI1 gene mutations in nephronophthisis-associated Joubert syndrome

Joubert syndrome (JBTS) is an autosomal recessive multisystem disease characterized by cerebellar vermis aplasia, mental retardation, muscular hypotonia, an irregular breathing pattern in the neonatal period and abnormal eye movements. Some individuals have progressive renal failure characterized by nephronophthisis (NPHP) and/or retinal dystrophy. Homozygous deletions of NPHP1 on chromosome 2q13 have been identified in individuals with NPHP-associated JBTS. Recently, mutations in AHI1 on chromosome 6q23.3 were found in JBTS patients without NPHP. Here, by direct sequencing, we identify novel truncating mutations within AHI1 in affected patients from two families. One patient had the association of JBTS and NPHP with chronic renal failure. This is the first report of AHI1 mutations causing JBTS associated with NPHP, confirming the clinical and genetic heterogeneity of NPHP.Boris Utsch and John A. Sayer contributed equally to this work     

Recurrent skin and soft tissue infections due to methicillin-resistant Staphylococcus aureus requiring operative debridement

Background

The aim of this study was to examine clinical factors associated with the recurrence of community-onset skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus.

Methods

An observational case-comparison study based on a retrospective review of medical records was conducted in a public health system. All patients with community-onset skin and soft tissue infections caused by methicillin-resistant S aureus who underwent operative debridement from January 1999 to December 2003 were included. The outcome of interest was recurrence within 1 year.

Results

Two hundred fifty-three patients met the criteria for inclusion. Fifty-three (21%) patients returned with recurrent episodes. These patients were compared with 200 patients (79%) who did not develop recurrence. On multivariate analysis, factors independently predictive of recurrence were medical history of abscess requiring surgical debridement within the previous year (adjusted odds ratio, 2.6; 95% confidence interval, 1.4–5.0; P = .002) and obesity (adjusted odds ratio, 3.4; 95% confidence interval, 1.4–8.8; P = .008).

Conclusions

Patients with obesity or histories of methicillin-resistant S aureus infection are at significantly increased risk for recurrent soft tissue infection.     

Does focal destruction of the thoracic aorta wall by Staphylococcus aureus lead to the development of infected aneurysms? An experimental study

Objective: The infrequency of infected aneurysms suggests that either infection of segments of the aortic wall is uncommon, or that infections do not always lead top infected aneurysm formation. The purpose of the study was to determine whether focal Staphylococcus aureus infection of aortic wall segments leads consistently to the development of infected aneurysms and to evaluate the segments in which infection did not lead to the infected aneurysm formation. Methods: Twenty pigs were inoculated with 0.1 ml of a Staphylococcus aureus inoculum in three segments of the thoracic aorta wall (study group). In another 10 pigs, 0.1 ml of saline solution was injected in three segments of the thoracic aorta wall (control group). Study group: histological abnormalities and bacterial culture of the inoculation sites were evaluated at 10 days (n=5 pigs), 30 days (n=5 pigs), and 90 days (n=10 pigs). Control group: histological abnormalities were evaluated at 10 days (n=5 pigs) and 90 days (n=5 pigs). Results: Study group: infected aneurysms developed in only two animals killed at 30 days. At 90 days, destruction of the elastic tissue, scar tissue and neointima formation were found in all the aortic segments studied. Control group: no significant changes were found in any of the segments evaluated. Conclusion: In our experimental model, acute local infection by S. aureus caused the development of infected aortic aneurysm in only 10% of the animals. In the remaining 90%, healing of the site of infection followed resolution of the infection.     

Prevention of Staphylococcus aureus burn wound colonization by nasal mupirocin

BACKGROUND: There are two important routes for the transmission of Staphylococcus aureus to the burn wound. In the endogenous route, patients naturally carrying S. aureus colonize their own wounds, whereas in the exogenous route burn wounds are cross-infected from other sources. In this study we evaluated the effect of blocking the endogenous route on S. aureus burn wound colonization by mupirocin application in the nose of patients at the time of admission. METHODS: From September 2000 to January 2002 all patients with burns admitted to a single dedicated Burn Centre received nasal mupirocin upon admission. This period was compared to two control periods (C1: July 1999 to July 2000 and C2: January 2002 to January 2003) for S. aureus burn wound colonization. The colonization risk was analysed, adjusting for confounding, with Cox proportional hazard regression. RESULTS: A total of 98 patients did not have S. aureus burn wound colonization at the time of admission and were, thus, considered at risk for S. aureus acquisition during their stay. As compared to C1, the relative risk of acquiring S. aureus in their wound was 0.48 (95% CI: 0.24-0.97) in the mupirocin period and 0.55 (95% CI: 0.28-1.1) during the C2 period. S. aureus nasal/pharyngeal colonization was a significant independent risk factor for wound colonization (RR: 2.3; 95% CI: 1.2-4.2). CONCLUSION: Nasal mupirocin may contribute to risk reduction of S. aureus wound colonization in patients with burns.     

Surveillance of bacteriological examinations at hospitalization in a pediatric surgical ward

Purpose

Bacteriological examinations at hospitalization were monitored to identify carriers of pathogenic bacteria and prevent the outbreak of nosocomial and postoperative infections.

Methods

In 557 patients, bacteriological examinations were performed within 48 hours after hospitalization. All people were instructed to wash their hands before and after treating carriers of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and/or Pseudomonas aeruginosa (PA). The disposal of stool and urine of carriers was segregated instead of administration of sensitive antibiotics.

Results

The 1176 samples comprised 557 throat swabs, 532 stool samples, and 87 other samples. At hospitalization, 9.2% of the patients were carriers of MRSA; 22.3% of the patients were carriers of MRSA, MRSE, PA, and/or other pathogenic bacteria. This percentage increased to 29.3% in 352 patients with a history of hospitalization, and 35.2% in 244 patients who were hospitalized within 1 year after previous hospitalization. Nosocomial and postoperative infections did not occur during the study period.

Conclusion

Many patients were detected as carriers of pathogenic bacteria at hospitalization. A history of hospitalization was found to be a risk factor for carrying pathogenic bacteria; hospitalization within 1 year after previous hospitalization was a high-risk factor.