Primary obturator-muscle pyomyositis in immunocompetent children

Purpose

Primary pyomyositis in immunocompetent children in non-tropical regions (countries with temperate climates) is very uncommon. It is rarely found in the intrapelvic muscles, and even more rarely in the obturator muscles. We try to draw attention to the potential occurrence in these conditions.

Methods

Five new cases of primary obturator-muscle pyomyositis in immunocompetent children aged between 6 and 11 years in a temperate climate are presented. They present with symptoms as follows: fever, pain (thigh, abdominal, inguinal, and/or hip pain), and limp. Three of them had no hip movement limitation. All of them had tenderness in the perineum zone.

Results

Laboratory tests may reveal high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) counts, but depend on the length of diagnostic delay. The evolution time oscillated from 1 to 5 days. Fever and limp disappearance depends on the evolution time previous to the onset of the antibiotics administration. In 4 out of 5 patients, Staphylococcus aureus was present in the blood cultures. In all cases of obturator-muscle pyomyositis, diagnosis was confirmed using computed tomography (CT) scan (one) and/or magnetic resonance imaging (MRI) (four).

Conclusions

Obturator-muscle pyomyositis is aimed at emphasizing the diagnostic difficulties associated with the condition, due to its deep location and to the fact that the disease presents with multiple manifestations that may initially cause confusion, since they mimic other conditions occurring in the abdomen, hip (septic arthritis, osteomyelitis), spine, etc. The diagnosis is only confirmed using CT scan and/or MRI. In the five patients with antibiotics treatment, the condition resolves without sequelae, even at long-term follow-up.     

斜仰卧截石位下输尿管软镜钬激光治疗肾盂旁囊性疾病

目的 探讨输尿管软镜钬激光切开内引流术治疗肾盂旁囊性疾病的有效性和安全性.方法 回顾性分析2012年1月至2016年10月本院收治的11例肾盂旁囊性疾病患者的临床资料,其中肾盂旁肾囊肿患者10例(合并囊内结石1例),腹膜后尿液囊肿1例,平均直径(5.2±1.2)cm,患者均于全麻下行输尿管软镜钬激光切开内引流术治疗,合并囊内结石者同时行钬激光碎石术.术后留置双J管2个月,拔管1周后行B超或CT复查.结果 11例患者均手术成功,无严重并发症发生.平均手术时间55 min(40～70 min),术后随访6～12个月,经B超或CT复查,8例囊肿消失,3例囊肿缩小约50％,未见囊肿复发.结论 输尿管软镜钬激光切开内引流术治疗肾盂旁囊性疾病创伤小、疗效确切,有良好的安全性和有效性,可作为推荐治疗方案之一.     

Computed tomography scanning after chymopapain injection for herniated nucleus pulposus. A prospective study

Fifty consecutive patients treated with chymopapain injection for a clinical and radiographic diagnosis of herniated nucleus pulposus were evaluated prospectively. All patients had a prechymopapain computed tomography (CT) scan and a three-month postinjection CT scan. In addition, ten patients (20%) had a six-month postinjection CT scan. All scans were interpreted blindly. Only six patients (12%) had obvious changes in the size of the disc when preinjection and three-month postinjection CT scans were compared. By six months, however, seven of ten patients (70%) had obvious changes in their CT scan. Seven patients (14%) were considered chymopapain treatment failures and were later treated with surgical discectomy. Only two of these seven patients (30%) had obvious changes in their three-month CT scan. Chymopapain injection did not alter the size of the herniated portion of the disc during the first three months after chymopapain injection. A decision to operate for presumed chymopapain failure should therefore be based on clinical grounds, rather than on the three-month CT appearance of the herniated disc.     

Early decortication in childhood empyema thoracis

Thoracic empyema is a life-threatening condition in paediatric surgical practice and the appropriate management still remains controversial. The authors reviewed 79 (37 boys, 42 girls) cases of empyema thoracis who underwent thoracotomy and decortication between 1990 and 2005. The initial diagnosis based on history, physical examination and radiology was confirmed by thoracentesis. Fever, cough and dyspnoea were the most common presenting symptoms. In all cases aerobic cultures were performed and Staphylococcus aureus was the most common microorganism isolated. All patients except three received antibiotics and tube drainage as an initial treatment. The decision for early decortication was based on persistence of fever, dyspnoea, air leakage and lack of resolution on CT scan, in spite of medical therapy and tube drainage, at the end of 10 days. All but one with wound dehiscence showed rapid recovery and they were discharged on the fifth to eighth postoperative days. In conclusion, early decortication is a safe and curative treatment in childhood empyema thoracis with low morbidity.     

Pancreatic injuries in the United Arab Emirates

PURPOSE: To study the mechanism, management and outcome of patients who had sustained pancreatic trauma. METHODOLOGY: Patients who were treated for pancreatic trauma in Al-Ain Hospital between October 2002 and August 2007 were retrospectively studied. RESULTS: All eleven patients were males having a median age of 30 years (range 24-52 years). Nine had blunt trauma while two had suffered penetrating injury. Three presented with shock. associated injuries were present in nine patients (head, chest, and extremities) while seven had other intra-abdominal injuries. Only one patient had isolated pancreatic injury. Early serum amylase was elevated in six patients. CT abdomen was diagnostic for pancreatic injury in seven patients. Two cases were missed by early CT scan (sensitivity of 78%) while the remaining two patients were taken immediately to the operating theater. All patients underwent laparotomy. Five patients were treated by drainage alone, four had distal pancreatectomy, abdominal packing was performed in one patient and in another gastrocystostomy was carried out. Pancreatic fistula occurred in three patients. Median hospital stay was 25 days (range 12-152 days). Two patients (18%) died. CONCLUSIONS: Blunt trauma is the main cause of pancreatic injury in our country. Early CT scan may miss pancreatic injury in almost a quarter of the patients. Thin sliced CT scan, with special views in a dedicated abdominal pancreatic study, is recommended. A high index of clinical suspicion, depending on the mechanism of injury, is important for diagnosis of pancreatic injury. Mortality is mainly attributable to other associated injuries so simple procedures should initially be adopted for pancreatic injury, especially in haemodynamically unstable patients.     

超声引导下穿刺注射乙醇治疗肾盂旁囊肿

目的 总结超声引导下穿刺治疗肾盂旁囊肿的经验体会,探讨其临床效果。方法 对169例肾盂旁囊肿患者行超声引导下穿刺注射乙醇治疗。其中囊肿压迫致肾积水36例（21．3％）,合并肾结石8例（4．7％）,全部经B超和静脉肾盂造影（IVP）检查,59例行cT检查。诊断明确后行经皮肾穿刺,穿出囊液立即行尿胺试验,对尿胺试验阴性者,以及尿胺阳性但囊肿造影确定与肾盂不相通者,用95％乙醇进行硬化治疗。自穿刺后1,3,6个月和1年时复查B超观察囊肿大小,以后每年随访1次。随访时间为6个月至5年。结果 囊肿治愈165例（97．6％）,囊肿缩小至≤1．5cm4例（2．4％）。36例肾积水全部缓解;8例肾结石,4例行体外冲击波碎石术（ESWL）后结石排出,2例行经皮肾镜取石,2例结石未治疗。穿刺后出现肉眼血尿5例,3～5d自行消失。结论 超声引导下经皮穿刺治疗肾盂旁囊肿,具有安全、有效、微创、合并症少等优点。     

The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma center

BACKGROUND: Orbital fractures associated with head trauma are not always easy to diagnose. The real incidence of such fractures is unknown. The aim of this study was to evaluate the usefulness of routine primary computed tomographic (CT) scanning for diagnosis of orbital fractures in head trauma patients. METHODS: Over a 3-year period, 600 consecutive patients admitted with head trauma were examined clinically; these patients then underwent cranial helical CT scanning, irrespective of severity of head injuries and presence or absence of fracture-related symptoms. RESULTS: Orbital fractures were diagnosed on CT scan in 118 cases (19.7%). All patients with symptoms directly related to an orbital fracture had radiologically diagnosed fractures, compared with 58.3% of patients with isolated blepharohematoma and 3.8% of asymptomatic patients. CONCLUSION: CT scan of the orbits is indicated for any head trauma patient who presents either one or more symptoms directly related to an orbital fracture or just isolated blepharohematoma. CT scan of the orbits is not indicated in asymptomatic head trauma patients. Inclusion of the orbits in the scanning is recommendable only if a CT scan is already being obtained for a head injury. Clinical follow-up is important to detect any late-appearing symptoms. Accurate clinical examination still plays a crucial role in the diagnosis of orbital fractures.     

Primary Psoas Abscess. Report of Three Cases

Abstract

Background: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections.

Early diagnosis and appropriate management are therefore challenging aspects for physicians. Patients and methods: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36–51 years were admitted with fever, abdominal pain and a palpable tender mass.

Results: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor.

Conclusions: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.     

Mastoiditis in adults: diagnostic and therapeutic aspects

The purpose of the present study is to report our experience in the diagnosis and treatment of mastoiditis in adults. Five patients with an active chronic otitis and mastoiditis were presented. All of them had a history of chronic ear discharge for long period of time and have been diagnozed and treated sufficiently. All relevant data were analyzed from the medical records. The most common symptoms of the disease were otalgia, otorrhea and hearing loss, but the physical signs of mastoiditis (swelling, erithema and tenderness of the retroauricular region) were presented in all cases. Localization and enlargement of the pathological process within the middle ear spaces was determined by CT. All patients were treated surgically and with intravenous antibiotics. In one patient the other treatment was applied due to a specific (TBC) process in the ear. Early diagnosis and adequate treatment (surgery combined with an effective antibiotics therapy) is most important to prevent a serious complications of mastoiditis (extracranial and/or intracranial).     

Splenic microabscesses in the immune-compromised patient

Four immune-compromised children who were receiving antineoplastic chemotherapy (three for leukemia), presented with recurrent episodes of fever and left upper abdominal pain. Blood cultures grew enteric gram-negative organisms in three children. Multiple blood cultures were negative for fungus although three patients had mucocutaneous and urinary candidiasis. All remained febrile and symptomatic despite treatment with broad spectrum antibiotics and antifungal chemotherapy. Computed tomography (CT) scans in all patients showed 2- to 10-mm focal defects in the spleen. The larger defects could be seen by ultrasonography but not on the live-spleen nuclear scan. A splenectomy was performed 2 to 4 weeks after the onset of symptoms in each child, and the cut surface of the spleens showed multiple small abscesses. All operative cultures were negative. A histological examination confirmed Candida infection in two patients and Aspergillus in one. Necrotizing granulomas strongly suggestive of fungus were seen in the fourth child. The patients defervesced and appeared well within three days. Antifungal therapy was continued. One child remains in remission from acute lymphocytic leukemia; one continues on chemotherapy; and one has recurrent widespread tumor. The patient with Aspergillus died following a bone marrow transplantation 6 months after the splenectomy. He had disseminated aspergillosis. An immune-compromised patient with persistent unexplained fever should have a CT scan of the abdomen. The presence of multiple splenic lesions strongly suggests fungal disease. If antifungal therapy does not result in complete resolution of fever and the splenic lesions, a splenectomy is indicated.     

Adult Chiari malformation--five operative cases

Recently, the diagnosis of adult Chiari malformation seems to have easy, because of the development of high resolution CT. During the last two years, we experienced with five cases of adult Chiari malformation diagnosed by CT metrizamide myelography. There were two males and three females aged from 15 to 55 years. Three cases had both foramen magnum compression and cerebellar symptoms. One of them had lower cranial nerve symptoms too. Another case had central cord symptoms, and the rest of them complained only of headache and vertigo. All cases underwent suboccipital craniectomy and upper cervical laminectomy. After operation, the cerebellar symptoms improved remarkably. Some of the central cord symptoms improved too. In one case with headache and vertigo, the result was unsuccessful. All cases were followed up in the outpatient clinic more than one year after operation. One case unchanged. Another case deteriorated seven months after surgery. The other three cases were in good condition. Operated cases of adult Chiari malformation are relatively rare in Japan. However, this type of malformation can be found easily by CT metrizamide myelography. A good many patients should be operated on carefully in consideration of their symptoms and severities.     

Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study

BACKGROUND: We prospectively evaluated whether computed tomographic (CT) scanning and selective laparoscopy (LP) for the diagnosis of blunt bowel injury (BBI) could prevent nontherapeutic laparotomy and delayed diagnosis. METHODS: Between April 1994 and May 2002, hemodynamically stable patients suspected of having BBI were enrolled in this study. Patients with hemodynamic instability or solid organ injuries with hemoperitoneum were excluded. All patients underwent a physical examination and contrast CT scanning at admission and once again approximately 12 hours (range, 6-24 hours) after admission. LP was performed under general anesthesia in patients who had local peritoneal signs and indirect CT signs (bowel thickening or isolated intraperitoneal fluid) or in whom abdominal pain or tenderness increased or intraperitoneal fluid increased on the repeat CT scan. The indications for a celiotomy were diffuse peritonitis, pneumoperitoneum on the abdominal CT scan, or bowel perforation visible on LP. RESULTS: During the study period, 399 of 1,074 patients admitted for blunt torso injuries were enrolled in this study. Eleven patients underwent emergency celiotomy and 11 underwent LP immediately after admission to the emergency department. One nontherapeutic laparotomy was performed among the patients who underwent celiotomy. The LPs revealed seven bowel perforations and one mesenteric laceration. After a repeat CT scan, three and seven of the patients underwent laparotomy and LP, respectively. Four bowel perforations were found by LP. The remaining 198 patients were treated conservatively, and no complications related to a delayed BBI diagnosis occurred. CONCLUSION: CT scanning and selective LP can prevent nontherapeutic laparotomy and delayed diagnosis in patients with suspected BBI.     

Pyogenic vertebral osteomyelitis with paralysis. Prognosis and treatment

In the interval between 1983 and 1988, 14 patients were treated for pyogenic spondylitis complicated by neurologic compromise. There were nine males and five females aged 39-80 years. The average time between onset of symptoms and diagnosis was 2.8 months. Predisposing factors were diabetes mellitus in four patients and urinary tract infections in five patients. The infection was blood borne in all 14 patients. In two patients, the infection was superimposed on a recent vertebral fracture. The cervical spine was involved in one patient; the thoracic spine in seven; and the lumbar spine in six patients. Six patients presented with a Frankel B paralysis, six with a Frankel C paralysis, and two with grade D paralysis. The neurologic symptoms lasted between one day and six weeks before surgery. Twelve patients had anterolateral decompression. Two of the 12 patients had a second stage posterior stabilization. Two patients were deemed inoperable. All surviving patients were managed by parenteral antibiotics for three to six weeks followed by enteral route for a total of three to six months. All 12 operated patients had a significant neurologic improvement (one grade or more on the Frankel scale) with solid interbody fusion.     

Adult colonic intussusception

Objective: To study the clinical characteristics, investigations, management and pathology in adult colonic intussusception. Methods: A retrospective study of seven adult patients who were operated on for the diagnosis of colonic intussusception in our department from January 1999 to September 2003 was carried out. The case records of the seven patients were retrieved. Their clinical presentations, investigations, operative records and pathology were studied. Results: The mean age of the patients was 67.4 years. There were four men and three women. Five of the patients presented with chronic non‐specific symptoms and the other two patients presented with acute symptoms. Transabdominal ultrasonography (USG) and computed tomography (CT) scan were used for investigation. In the majority of the patients (87.5%), radiological features of intussusception were shown by USG or CT scan. All seven patients underwent laparotomy exploration with bowel resection. Six patients (85.7%) had lead points with definable pathology. Within the lead points, five patients had primary malignant lesions. Conclusion: With more liberal use of imaging techniques, more adult intussusception can be diagnosed before explorative surgery. Ultrasound would be an ideal tool for initial evaluation. In view of the high chance of associated malignancy, adult colonic intussusception should be resected without prior reduction at the time of surgery.     

Occult infections causing persistent low-back pain

Occult infections caused by indolent organisms may produce persistent back pain that may be difficult to diagnose. The usual findings considered indicative of spinal infection are not reliable in these cases. The authors describe nine patients who presented with occult infections of the lumbar spine. Two of the nine had no antecedent lumbar surgeries nor open wounds. The predominant organisms were diptheroids and coagulase-negative staphylococci. The diagnosis was established by the clinical course, pathologic tissue changes at surgery, cultures, and response to antibiotic therapy. Normal Westergren sedimentation rates were noted in seven of nine patients, and normal white blood cell counts in six of nine patients. With the exception of two positive computed tomography (CT) scans, one positive gallium scan, and one positive magnetic resonance imaging (MRI) scan, all remaining imaging studies were negative for infection. In many cases, the infection neither was limited to nor involved the disc space.     

The role of carcinoembryonic antigen as a predictor of the need for preoperative computed tomography in colon cancer patients

A retrospective study of 117 patients with the diagnosis of colon cancer was performed to evaluate the clinical utility of the preoperative computed tomography (CT) scan and to assess the role of carcinoembryonic antigen (CEA) as a predictor of the need for CT scan in colon cancer patients. Forty-nine patients had a CT scan that altered their treatment. One hundred per cent of stage IV patients versus only 26.5 per cent of stage I, II, and III patients had their operative and/or treatment planning altered by the preoperative CT. The sensitivity of CT scan in predicting metastatic disease was 90.3 per cent. All patients with stage IV disease had an abnormal CEA (>3 ng/mL). There was 89.7 per cent of stage IV patients who had a CEA twice that of normal or above. By using a CEA level of 3.1 ng/mL or above as a prerequisite for preoperative tomography, 34 nonmetastatic patients would not have had preoperative CT scans. Using a prerequisite of 6.1 ng/mL or above, 49 nonmetastatic patients would not have had a preoperative CT scan, and 90 per cent of the stage IV patients would have been imaged. We recommend obtaining a preoperative CT scan on those patients with a CEA value twice that of normal or greater.     

巨大肾血管平滑肌脂肪瘤临床分析(附27例报告)

目的 探讨巨大肾血管平滑肌脂肪瘤(renal angiomyolipoma,RAML)的临床特点,总结诊治经验.方法 回顾性分析2008年1月至2017年1月我院收治的27例巨大RAML患者(肿瘤直径8 cm及以上)的临床资料.其中男4例,女23例,年龄16~66岁,平均38岁.肿瘤位于左侧14例,右侧13例.16例有临床症状,其中7例为RAML破裂出血,11例为无症状体检发现.27例术前均行CT检查,3例行MRI检查.结果 本组27例均行手术治疗,其中11例行肾切除术,9例行保留肾单位手术,4例行腹腔镜保留肾单位手术,3例行肾癌根治术.7例RAML破裂出血患者中,1例行急诊肾切除术,1例行急诊保留肾单位手术,其余5例待症状稳定,完善相关检查后予手术治疗.根据术后肿瘤大体标本,肿瘤直径为8~27 cm,平均13.7 cm.术后21例患者获得随访,随访时间1~108个月,中位随访时间42个月,无复发或因肿瘤导致死亡者.结论 巨大RAML临床少见,多数具有腰部酸胀不适等临床症状,CT检查为主要的诊断方式,B超可以作为患者随访的首选检查.8 cm及以上巨大RAML肿瘤破裂出血风险明显增加,建议积极行手术治疗.巨大RAML以良性为主,预后较好.     

Bone scan patterns in acute osteomyelitis

Sixteen patients with acute hematogenous osteomyelitis underwent serial Tc-99m-diphosphonate bone scanning on admission and at intervals of four to seven days thereafter. Scans were analyzed by computer-assisted determination of the ratio of activity in the lesion to that in a corresponding area of normal bone. Two patterns were observed. In seven children this ratio was low initially and increased during hospitalization despite clinically adequate therapy. In nine children the ratio was high initially and decreased during therapy. Lack of focal uptake within bone on the initial scan performed within the first three days of the onset did not exclude the diagnosis of osteomyelitis.     

Complications of misdiagnosed Bochdalek hernia in adults. Literature review

AIM OF THE STUDY: To report 3 new cases of complicated Bochdalek hernia (BH) in adulthood and to review the literature about this rare condition. CASE REPORT: Three adult patients were operated on for a BH undiagnosed until occurrence of acute complication. The first patient, 27 years-old, had small bowel obstruction and the diagnosis of BH, unrecognized on chest X-ray, was established on barium meal and CT scan. The second patient, 38 years-old, had epigastric pain and gastric obstruction: diagnosis of BH, unrecognized at a previous laparotomy, was established on CT scan and barium enema. The third patient, 88 years-old, had respiratory failure and gastric obstruction: diagnosis of BH, unrecognized on chest X-ray, was established on CT scan. The 3 patients were operated on through laparotomy (n = 2) ou thoracotomy (n = 1) with one post-operative death. DISCUSSION: In adulthood, BH can remain asymptomatic for a long time before occurrence of a acute digestive or respiratory complication. Chest X-ray can be normal or misinterpreted. CT scan seems to be the most reliable examination to diagnose BH. CONCLUSION: In adulthood, diagnosis of BH should be evocated in case of respiratory or upper digestive symptoms.     

Surgical management of intestinal malrotation in adults

Objective The aim of this study was to review our experience with diagnosis and surgical management of intestinal malrotation in adult patients. Patients and Methods A retrospective review of the surgical outcome of adults with intestinal malrotation was performed. Twelve patients were observed and treated between July 1996 and July 2006 (4 women and 8 men; the mean age of the patients was 28.5 years). Surgical outcomes, including postoperative complications, deaths, and resolution of preoperative symptoms, were measured. Results A diagnosis of malrotation was made preoperatively in five patients by upper gastrointestinal contrast study, barium enema, or computed tomography scan. The anomaly was discovered incidentally at laparotomy in seven patients. All cases were proved to be malrotation intraoperatively. Nine patients underwent laparotomy and three underwent laparoscopic surgery (one converted to an open procedure). Follow-up ranged from 2 months to 118 months. Three patients had complications: one had wound infection, one had delayed gastric emptying, and one developed adhesive ileus. There were only two recurrences detected and one patient with recurrence required reoperation. No one died. Conclusions Intestinal malrotation is a rare but important cause of abdominal pain in adults. It may present with chronic or acute symptoms. Laparotomy and laparoscopy are alternative and feasible techniques with low rates of complications for the treatment of intestinal malrotation in adults.