Pneumococcal necrotizing fasciitis in a patient with Type 2 diabetes.

Necrotizing fasciitis (NF) is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen or perineum. Progression to septic shock can occur very rapidly with its associated high morbidity and mortality. NF is usually caused by beta haemolytic streptococci; less often a poly-microbial isolate is the cause. It typically occurs in patients with some degree of immune dysfunction. We present a case of severe pneumococcal necrotizing fasciitis in an obese patient with Type 2 diabetes. There was no history of trauma or evidence of diabetes-related complications. The initial presentation was with features of septic arthritis of the left knee, which subsequently progressed to NF. Differentiation from cellulitis is often difficult in the early stages. Invasive pneumococcal infections are extremely rare, with only a few reported in the literature. Moreover, our case highlights the need to consider other differential diagnoses (and to look out for complications) in patients with diabetes, especially if there is little clinical response to the initial treatment.

Volvulus of the splenic flexure of colon: a case report and review.

We report a case of splenic flexure volvulus in a patient who had previously been operated upon for a sigmoid volvulus. The clinical features and management of splenic flexure volvulus are discussed.

Hydatid disease: the alveolar variety in Australia. A case report with comment on the toxicity of mebendazole.

The alveolar form of hydatid disease, caused by the larval stage of the cestode Echinococcus multilocularis, is virtually confined geographically to the northern hemisphere. It produces clinically malignant multivesicular infiltrating lesions most often in the liver, and is quite different from the usual cystic variety caused by E. granulosus. We present a case report of a patient with alveolar hydatid disease, whose treatment with mebendazole was brief due to side effects of alopecia and granulocytopenia; and review the features of this disease which, with increasing international migration, may be encountered more frequently in Australia.

The pharmacokinetics and bioavailability of a tracer dose of [3H]-mebendazole in man.

Five volunteers, whose ages ranged between 37 and 64 years, took part in a crossover study to determine the pharmacokinetics and bioavailability of mebendazole in man following intravenous and oral administration of a tracer dose of [3H]-mebendazole. Following intravenous administration, the average distribution half-life, elimination half-life and rate of clearance were 0.20 h, 1.12 h, and 1.063 min respectively. After oral administration of the solution, the average elimination half-life was 0.93 h, the apparent rate of clearance was 0.846 l/min, the average time to peak plasma concentration was 0.42 h, and the bioavailability of mebendazole was 22%. Comparison of metabolite area under the plasma concentration vs time data from each route of administration indicates that absorption of mebendazole from the gastrointestinal tract at this dose level is almost complete. The low bioavailability observed following oral administration at this dose level is postulated to be due to high first pass elimination. Approximately half of the administered dose of radioactivity following intravenous and oral administration was detected in the urine, and the major unconjugated metabolite of mebendazole was found to be 2-amino-5(6) [alpha-hydroxybenzyl]benzimidazole (IV), not 2-amino-5(6)benzoylbenzimidazole (II), as previously reported.

Cyst and host tissue concentrations of mebendazole in patients undergoing surgery for hydatid disease.

Mebendazole levels were assayed by high performance liquid chromatographic assay in plasma, host tissues, and hydatid material taken from four patients who underwent surgery for hydatid disease. The drug was absorbed and had penetrated both into the host and into the parasite material. The levels of the drug in viable hydatid cysts were much lower than those in dead cysts. The possibility of exclusion or detoxification of the drug by viable hydatid cysts is raised.

Hydatid disease: epidemiology and pathology.

Information regarding the epidemiology and pathology of Echinococcus granulosus in Australasia is not well presented in standard surgical textbooks. This review presents the basic science of E. granulosus in Australasia, emphasizing those areas which are not well known, are misunderstood, or are of particular relevance to current surgical practice.

Clostridial myonecrosis after resection of skin tumours in an immunosuppressed patient.

This paper reports a case of clostridial myonecrosis (gas gangrene) which occurred in a vegetable gardener receiving immunosuppression therapy with prednisolone and azathioprine for renal allograft preservation. The infection developed after the excision of crusted squamous-cell carcinomata from the dorsum of the hand, the circulation of which was compromised by the presence of a radial artery/cephalic vein arteriovenous fistula. Amputation, followed by treatment with hyperbaric oxygen, was successful.

Clinical pharmacokinetics of high dose mebendazole in patients treated for cystic hydatid disease.

The plasma concentrations of mebendazole and its metabolites have been monitored in twelve patients after receiving a 10 mg/kg dose for cystic hydatid disease. The mebendazole plasma concentration-time profiles differed considerably between patients; elimination half-lives ranged from 2.8-9.0 h, time to peak plasma concentration after dosing ranged from 1.5-7.25 h and peak plasma concentrations ranged from 17.5 to 500 ng/ml. The mean peak plasma concentration of mebendazole after an initial dose (69.5 ng/ml) was lower than found in patients during chronic therapy (137.4 ng/ml). The plasma AUCTS for the major metabolites of mebendazole (methyl 5-(alpha-hydroxybenzyl)-2-benzimidazole carbamate and 2-amino-5 benzoylbenzimidazole) were about five times the plasma AUCT found for mebendazole in patients on chronic therapy. It is suggested that the slower clearance of these polar metabolites relative to mebendazole results from enterohepatic recycling. Since mebendazole is also highly plasma protein bound, caution should be observed in administering mebendazole to patients with liver disease. Concentrations of mebendazole found in the tissue and cyst material collected from two patients during surgery ranged from 59.5 to 206.6 ng/g wet weight.

Vertebral hydatid disease: radiological assessment.

The computed tomographic (CT) appearance and the pain radiographic and myelographic findings of vertebral hydatid disease (caused by Echinococcus granulosus) in two patients are presented. CT proved to be more useful in the initial assessment and measurement of progress of this disease than conventional radiography and myelography.

Long-term high-dose mebendazole for cystic hydatid disease of liver: failure in two cases.

Mebendazole was given as definitive therapy to four patients with cystic hydatid disease of the liver who were later explored surgically. Viable hydatid material was removed from two patients after continuous therapy with 40 mg/kg/day for eight and three months respectively. The hydatid material was necrotic in the other two patients. This drug appeared to be ineffective as definitive treatment of two of these four patients with established hydatid disease of the liver.

Changing trends in breast carcinoma.

In view of the more open medical and public discussion of breast cancer, and considering the general dissatisfaction with radical forms of surgery and radiotherapy, we examined computer records of 1,014 patients with carcinoma documented by the Tasmanian Breast Survey between 1956 and 1976. In the two epochs, 1956 to 1966 and 1967 to 1976, there was a 14% increase in the proportion of patients presenting with Stage I carcinoma, and a 9% decrease in the proportion of patients with Stage II (P = 0.0075) but there was no change in the proportion of patients with Stages III and IV. The utilization of radical mastectomy decreased markedly, irrespective of stage (P = 0.0000), as did the utilization of radiotherapy (P = 0.0000). The mean age at presentation did not change significantly.