Squamous cell carcinoma complicating chronic suppurative hydradenitis.

A 69-year-old male patient underwent excision of hidradenitis suppurativa (HS) affecting both gluteal areas and the perineum. The perineal specimen contained a 1-cm superficially invasive, well-differentiated keratinizing squamous cell carcinoma. The patient was free of recurrence 1 year after surgery. A 66-year-old male patient was diagnosed with massive perineal HS more than 40 years previously. More than 30 abscesses and suppurative sinus tracts were surgically treated over the years. He eventually died of unresectable pelvic squamous carcinoma. Search of the literature and available bibliography revealed 47 retrospective studies of skin carcinoma arising in HS since 1959, including a total of 64 patients together with the two patients treated by our team. Squamous cell carcinoma is a rare but potentially fatal complication of HS. Surgery is the only known treatment method that provides a real chance for cure for both HS and a carcinoma that complicates it. HS must be treated early with complete excision to avoid chronic progression of the disease that can cause cancerous degeneration. A high index of suspicion, early tissue diagnosis, and immediate referral for radical surgery carry the only hope for cure in those whose HS harbors malignancy.

Can paronychia cause a remote necrotizing soft tissue infection?

Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome.

Sciatic hernia: a comprehensive review of the world literature (1900-2008).

BACKGROUND: Sciatic hernias are considered the rarest pelvic floor hernias, with a very limited number of published reports worldwide. The condition has received limited attention in the surgical literature. DATA SOURCES: The data reported herein are based on a literature review including MEDLINE and CURRENT CONTENTS computerized database searches. The existing bibliographies on sciatic hernia were explored for articles pertaining to the review. Finally, the Internet was searched for articles not listed in the available medical databases. CONCLUSIONS: Sciatic hernia is unusual, and can present the physician with diagnostic and treatment dilemmas. The hernia may present with obscure pelvic pain, intestinal obstruction, life-threatening gluteal sepsis, or as an asymptomatic, reducible mass that distorts the gluteal fold. Small sciatic hernia can remain hidden behind the gluteus maximus muscle. The diagnosis requires imaging studies in such cases. Treatment of sciatic hernia is always surgical and requires prosthetic reinforcement for the best result.

Large neomucosal space 25 years after mesh repair of ventral hernia.

A 64-year-old, otherwise healthy, male patient presented with a malodorous abdominal wall fistula of recent onset. He gave a history of mesh repair of ventral hernia 25 years ago. Computed tomography scan of the abdomen revealed a 15 cm x 15 cm thick-walled cavity inside the abdomen adjacent to bowel loops and the prosthetic mesh. Resection of the mass included a 25-cm segment of small bowel. Histopathology revealed a thick-walled large cavity lined with mucosa, surrounding a large wrinkled sheet of permanent mesh.

Ogilvie syndrome and herpes zoster: case report and review of the literature.

BACKGROUND: The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature. OBJECTIVES: This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions. CASE REPORT: An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion. DISCUSSION: Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy. CONCLUSION: Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe.

Equivalent outcomes with primary and retransplantation in African-American deceased-donor renal allograft recipients.

BACKGROUND: Graft survival following renal retransplantation has been inferior to that following primary allografting, particularly in African Americans (AAs) receiving deceased-donor (DD) kidneys. METHODS: Among 166 AA DD renal allograft recipients transplanted from July 2001 through July 2007, we compared the outcomes of 26 (16%) receiving a second graft with those of 140 primary cases. All patients received either thymoglobulin (ATG) or an IL-2 receptor antagonist for induction, and were maintained on either tacrolimus or sirolimus + mycophenolate mofetil +/- prednisone. RESULTS: When compared with primary transplants, regrafts received kidneys from older donors, were younger, more sensitized, more likely to receive ATG and to be maintained on prednisone, received more doses of ATG, and were less likely diabetic. There was no difference between primary and retransplant groups in overall patient or graft survival; incidence of acute rejection, CMV infection, BK nephropathy, or new-onset diabetes mellitus; and serum creatinine at 1 year. CONCLUSION: AA renal allograft recipients can undergo a second DD transplant with intermediate-term outcomes comparable to that of a primary graft, despite the presence of multiple immunologic and non-immunologic high-risk factors, by extending the course of ATG induction and continuing prednisone therapy in the vast majority of cases.

Sternal osteomyelitis after minor trauma.

Sternal osteomyelitis secondary to minor trauma occurs rarely. Only a handful of cases have been reported. A 24-year-old male patient who had history of intravenous drug abuse and recent minor sternal trauma presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal resection, with a successful outcome. Sternal osteomyelitis should be suspected in immunocompromised patients, including intravenous drug abusers presenting with sternal inflammatory symptoms. Increased awareness, rapid diagnosis, and appropriate empiric antibiotic and radical surgical treatments can successfully manage life-threatening osteomyelitis of the sternum.

Elective inguinal hernia repair: a unified informed consent, or who wants to know what?

Informed consent is increasingly being standardized. We sought to evaluate variability in the amount and quality of information desired by patients in choosing whether to undergo elective surgical hernia repair, a prototypical low- to moderate-risk common procedure. Consecutive stable outpatients were asked to assume that they were considering hernia repair and interviewed with a standard questionnaire that asked them to rate their interest in learning about the natural history, pathology, and management of inguinal hernia as well as herniorrhaphy complications and postoperative recovery. Ninety-eight consecutive patients exhibited substantial interpersonal variability in their level of interest in receiving information. Although interest in some types of information tended to correlate with interest in other types of information, patients' degree of interest in receiving information about anesthesia during the procedure was independent of other variables. Education and previous exposure to individuals with hernias also affected interest in receiving potentially important information before deciding whether to consent to hernia surgery. Patients may vary with regard to the information they want to receive when deciding whether to consent to an invasive procedure. It may be preferable to individualize the consent process to patients' preferences rather than adhering to standardized content.

Outcome predictors in African-American deceased-donor renal allograft recipients.

The relative importance of donor and recipient risk factors in predicting outcomes in African-American (AA) renal allograft recipients receiving contemporary immunosuppression, including early steroid withdrawal, has not been previously examined. We assessed the impact of 21 risk factors on five primary outcomes in 132 deceased-donor AA renal allograft recipients transplanted from July 2001 to August 2006 with follow-up 6-67 (mean 35 +/- 17) months by univariate and multivariate analysis. Thymoglobulin or basiliximab was given for induction, and mycophenolate mofetil with either tacrolimus or sirolimus (SRL) +/- prednisone for maintenance. Non-compliance accounted for 26% of graft loss (GL) and 19% of acute rejection (AR) episodes, and was more prevalent in patients who were HCV+ and those on prednisone. Delayed graft function remained a significant predictor of GL, but not via increased AR, and donor ethnicity emerged as an important predictor of patient death. De novo use of SRL resulted in increased AR, and only increased recipient age significantly predicted new-onset diabetes mellitus. Our preliminary results suggest the need for improvements in patient education, pre-transplant psychosocial assessment, and late post-transplant psychosocial support and can be utilized to help guide donor/recipient selection and tailor immunosuppressive management to optimize outcomes in this challenging group of patients.

Preliminary experience with renal transplantation in HIV+ recipients: low acute rejection and infection rates.

BACKGROUND: Only four centers have reported their results with renal transplantation in human immunodeficiency virus (HIV)+ recipients on highly active antiretroviral therapy, and acute rejection (AR) rates have consistently ranged from 43% to 67%. METHODS: We examined the outcomes of eight adult HIV+ primary renal allograft recipients with median 15 (range 8-47) months follow-up with multiple other high-risk factors, including African American ethnicity, hepatitis C virus (HCV) positivity, long waiting times, prior sensitization, paucity of live donors, and delayed graft function. Our immunosuppressive protocol consisted of an anti-interleukin-2 receptor antibody for induction, and mycophenolate mofetil, cyclosporin A, and prednisone for maintenance. Initial and 3- to 6-month cyclosporin A trough level targets were 250 to 300 and 225 to 275 ng/mL, respectively, and mycophenolate mofetil dose was adjusted according to 2 to 4 week surveillance and subsequent as needed mycophenolic acid predose concentrations during the first 6 months. RESULTS: Patient and graft survival were 100% and 88%, respectively, with an AR rate of 13% and excellent renal function. No patients developed new-onset diabetes, opportunistic or other serious infections, malignancy, or progression of hepatitis C virus-related liver disease. Excellent suppression of HIV replication with maintenance of CD4 counts was noted in all cases. CONCLUSIONS: Our findings suggest that HIV+ patients on highly active antiretroviral therapy can undergo successful renal transplantation with a low incidence of both AR and AIDS-associated and non-AIDS associated infections, despite associated risk factors for poorer outcome. Our encouraging but preliminary results with this protocol will need to be verified in larger numbers of HIV+ renal allograft recipients with longer follow-up.

Liver hemangioma complicated by obstructive jaundice.

This report describes a liver hemangioma causing obstructive jaundice, an extremely rare condition that has been reported on 3 previous occasions. A hemangioma can compress the major bile ducts and require partial hepatectomy for a successful outcome.

Can mitochondrial DNA mutations in circulating white blood cells and serum be used to detect breast cancer?

Circulating mitochondrial DNA (mtDNA) affected by mutations have been detected in melanoma, prostate cancer, and digestive neoplasms involving the pancreas, liver, and the colon. We sought to detect such mutations in women with breast cancer to assess if the method could be used to aid in the diagnosis of breast cancer. Blood was collected and mtDNA extracted; 27 samples included 14 patients who had breast cancer and 13 healthy controls. White blood cells and serum were separated. The mitochondrial D-loop region was amplified using PCR followed by automated DNA sequencing. The collected data was analyzed with computer software to detect both polymorphisms and mutations. mtDNA sequencing was successful in 93% of the samples (n=23). No mutations were found in any of the study groups. Polymorphisms were detected in all specimens, three of which had not been previously reported. The method used did not detect mtDNA mutations in the blood of women with breast cancer, but was extremely sensitive in polymorphism detection.