Tube thoracostomy-related necrotizing fasciitis: a case report.

Spontaneous pneumothorax is a serious complication of pulmonary tuberculosis that requires immediate treatment. Necrotizing fasciitis is a serious, rapidly progressive infection of the subcutaneous tissue and fascia, most related to trauma or surgery. Here, we report a case of pulmonary tuberculosis with spontaneous pneumothorax. A standard procedure of tube thoracostomy was performed for lung re-expansion. Two days after the tube was removed, necrotizing fasciitis developed from the puncture site. Computed tomography of the chest showed focal thickness with gas formation and loss of the fat plane over the chest wall, which is compatible with the diagnosis of necrotizing fasciitis. Aggressive treatment was given, including emergency fasciectomy and adequate systemic antibiotic and antituberculous treatment. The necrotizing fasciitis was successfully treated. The patient was discharged and sent home with maintenance antituberculous therapy.

Influence of cutaneous nerves on keratinocyte proliferation and epidermal thickness in mice.

We evaluated the influence of skin innervation on the epidermis in mice. The rich innervation of skin was demonstrated by immunocytochemistry with protein gene product 9.5, a ubiquitin carboxy hydrolase. Protein gene product-immunoreactive nerve fibers were in the epidermis, subepidermal plexus, dermal nerve trunks, and nerve terminals around sweat glands. Effects of denervation on the plantar surface of the hind foot was assessed by comparing the thickness of the epidermis, which was innervated by the sciatic nerve. Within 48 h after sectioning of the sciatic nerve, protein gene product (+)-nerves in the territory of the sciatic nerve were completely degenerated. There was a significant thinning of the denervated epidermis 72 h post-transection (30.5+/-1.1 vs 41.4+/-2.9 microm, 74+/-4% of the control side). The reduction in epidermal thickness persisted when skin remained denervated (69-75% of the control side). Incorporation of bromodeoxyuridine was reduced 24 h after denervation (71+/-6% of the control side). Reduction in bromodeoxyuridine-incorporation was most pronounced within 48 h after denervation (19+/-6% of the control side). Therefore, the reduction in bromodeoxyuridine-labeling followed a similar temporal course as the thinning of the epidermis (25-50%). Both epidermal thinning and reduced bromodeoxyuridine-labeling were reversed by epidermal reinnervation three months after denervation. Patterns of keratinocyte differentiation and programmed cell death were unaffected by skin denervation. These findings are consistent with the notion that skin innervation exerts influence on the proliferation of keratinocytes and the thickness of the epidermis, and offers a new look at the interaction between nociceptive nerves and their innervated targets.

Regional difference in epidermal thinning after skin denervation.

Denervation of skin has a profound influence on epidermis; epidermal thinning was a consistent finding in rats. However, it is not clear whether the degree of epidermal thinning was similar in the region receiving the same innervation. In mice, how early epidermal nerves were degenerated after nerve injury remained unknown. To address these issues, we transected the sciatic nerve in mice and compared the changes of epidermal thickness in different areas of the hind foot skin. Epidermal nerves degenerated within 48 h after nerve transection, similar to what was observed in rats. Seven days after nerve transection, there was differential thinning of epidermis. The interpad area, in the center of the sciatic nerve-innervated region, exhibited the most profound degree of epidermal thinning (34.6 +/- 3.1 vs 47.8 +/- 2.4 microns, P < 0.01). The heel area, in the periphery of the sciatic nerve-innervated zone, did not show significant thinning of epidermis after denervation (37.3 +/- 4.8 vs 41.5 +/- 5.1 microns, P > 0.05). The degree of epidermal thinning after denervation in the pad area was the intermediate one: with 98.8 +/- 4.8 vs 120.1 +/- 7.3 microns, P < 0.02, in the rete pegs, and 51.1 +/- 4.1 vs 62.1 +/- 6.0 microns, P < 0.02, in the dermal papilla. The differential thinning was obvious when the thickness of the denervated epidermis was normalized to that of the control epidermis with the ratios of 0.73 +/- 0.03 in the interpad area, 0.83 +/- 0.04 in the rete peg, 0.85 +/- 0.05 in the dermal papilla, and 0.92 +/- 0.05 in the heel. Epidermal thinning was reversed by reinnervation of the epidermis after sciatic nerve crush (41.5 +/- 1.5 vs 45.0 +/- 2.0 microns in the interpad area, P > 0.05). These findings suggest that sensory nerves exhibit trophic influences on the epidermis presumably through the effects of diffusible factors.

Ultrastructural localization and regulation of protein gene product 9.5.

Protein gene product 9.5 (PGP), a ubiquitin hydrolase, is abundant in the nervous system. To investigate the ultrastructural localization of PGP and the regulation of its expression, we performed electron microscopic immunocytochemistry and reverse transcription-polymerase chain reaction (RT-PCR) on normal and transected rat sciatic nerves. In normal nerves, strong PGP-immunoreactivity was localized in the myelinated and unmyelinated axons with virtually no staining in the Schwann cells. After nerve degeneration, denervated Schwann cells exhibited intense staining for PGP, corroborated with up-regulation of PGP transcripts by RT-PCR. The present data suggest that the pattern of expression of PGP is more complicated than was expected previously, and reflects the integrity of nerves and status of axon-Schwann cell interactions.

Skin Innervation and Its Effects on the Epidermis.

Sensory innervation of the skin subserves protective sensations for the body to prevent thermal and noxious injuries. Neurophysiologically, they belong to the categories of Adelta and C fibers, usually with caliber less than one micro m in diameter. Morphological demonstration of the terminals of these nerves in the epidermis has been recognized recently by sensitive immunocytochemistry and an axonal marker, the protein gene product 9.5 (PGP). PGP is a ubiquitin C-terminal hydrolase, which is abundantly present in the nervous system, and particularly enriched in the unmyelinated nerves. Sensory nerves positive for PGP arise from the dorsal root ganglion, pass through the dermis, parallel the epidermis-dermis border, penetrate the basement membrane, move vertically and upwards in the epidermis with tortuous course and knobby appearance, and finally terminate at the granular layers of the epidermis. In rodents, denervation of the skin results in degeneration of epidermal nerves within 48 h of nerve transection, and thinning of the epidermis. In humans, application of this technique to evaluate disorders of the peripheral nervous system makes study of the degeneration of sensory nerve terminals possible. Patients with sensory neuropathy had fewer epidermal nerves than normal subjects, consistent with the notion of distal axonopathy. This approach has the potential to evaluate human sensory neuropathy in temporal and spatial domains. In addition, the influences of epidermal denervation open a new field to explore the interactions between sensory nerves and keratinocytes.

Toxic shock syndrome following septoplasty and partial turbinectomy.

A rare case of toxic shock syndrome developing after an elective septoplasty and partial turbinectomy is reported. The sterile vaseline gauze packing acting as a "nasal tampon" is postulated as the mechanism of insult. The symptomatology, investigation and management of this case are discussed. Early recognition and appropriate treatment may avert the significant morbidity associated with this condition.