First case report of Cryptococcus laurentii knee infection in a previously healthy patient.

BACKGROUND: The purpose of this case report was to report a case of Cryptococcus laurentii infection in the left knee of a previously healthy 29 year old male patient. CASE PRESENTATION: After an initial misdiagnosis and 7 months of failed treatment, the patient received nearly a month of treatment with voriconazole (200 mg IV q12 h) and knee irrigation with amphotericin B until the infection was controlled. The treatment continued with fluconazole for nearly 7 months and approximately 5 weeks of antibiotic treatment for a skin bacterial coinfection. In the end, the patient's symptoms disappeared completely, the left knee recovered well, and there was no recurrence of infection. CONCLUSION: The key points of successful treatment in this case were the thorough debridement, the adequate course of knee irrigation with antifungal drugs and more than 6 months of oral antifungal drugs that were able to eradicate the infection.

[The place of otorhinolaryngology in modern medicine].

This publication is devoted to the peculiar features of the development of otorhinolaryngology as an integral component of modern medical science and practice and the place it now occupies among other disciplines. Much attention is given to the formation of the scientific views of focal infections with special reference to tonsillitis, the role of immune pathology an allergic reactions in etiology and pathogenesis of ENT diseases. Also considered is the problem of the elaboration of the new surgical methods and their application for the treatment of ENT pathology.

Focal intradural brain infections in children: an analysis of management and outcome.

INTRODUCTION: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. MATERIALS AND METHODS: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. RESULTS: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. CONCLUSIONS: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Microbiology and management of deep facial infections and Lemierre syndrome.

This review describes the microbiology, diagnosis and management of deep facial infections and Lemierre syndrome. The origins of most of these infections are odontogenic infections that spread to fascial spaces of the lower head and upper neck. Other sources include pharyngotonsillar, nasal, otologic, salivary gland and dermatologic infections, hematogenic spread, cervical adenitis and trauma. These space infections can be divided into those around the face (masticatory, buccal, canine and parotid), the suprahyoid area (submandibular, sublingual and lateral pharyngeal) and the infrahyoid region or lateral neck (retropharyngeal and pretracheal spaces). The organisms accounting for these infections are aerobic and anaerobic that arise from the oropharyngeal flora. Complications of these infections can be life threatening and can result from hematogenic or direct spread. Complications that arise following local extension include suppurative jugular thrombophlebitis, cavernous sinus thrombosis, carotid erosion, maxillary sinusitis and osteomyelitis of the jaws. Management includes surgical drainage and antimicrobial therapy.

[Descending necrotizing mediastinitis. A diagnosis not to be ignored]. / La médiastinite descendante nécrosante. Un diagnostic à ne pas méconnaître.

BACKGROUND: Acute descending posterior mediastinitis is a very serious condition which can develop after common ear-nose-throat infections. Clinical manifestations are typical and must be recognized rapidly for early diagnosis. CASE REPORTS: We report two cases. In the first case, a 28-year-old man had a retropharyngeal abscess which fistulized into the left pleural cavity. Three operations were necessary to achieve cure and favorable outcome. In the second case, mediastinitis was diagnosed in a 39-year-old patient following a throat infection. Despite early surgery, outcome was fatal due to development of pericarditis and tamponnade. DISCUSSION: These two cases illustrate the variable course of descending mediastinitis and emphasize the importance of early medicosurgical cure. Treatment is based on intravenous antibiotics using a combination of 2 or 3 drugs at high doses in association with emergency surgery and extensive mediastinal washings. Despite well-conducted treatment, descending necrotizing mediastinitis may lead to a fatal outcome.

Subdural empyema due to salmonella infection.

A case of a 6-month-old child with a Salmonella subdural empyema is reported. The causative organism was never suspected until the culture report was available. The child responded well to surgical drainage and antibiotic therapy.

Descending cervical mediastinitis.

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

The abdomen as source of sepsis in critically ill patients.

Among patients with life-threatening sepsis that has no clear site of origin, the abdomen continues to be a probable and tractable possibility. The cavity has the microbiologic and anatomic potential for sudden or indolent sepsis and the cause may be either obvious or obscure. The abdomen or the various structures may be primary sources that are secondary and independent of disease that brought the patient to peril. They also could be secondary and dependent upon an abdominal operation complicated by sepsis. The partnership of intensivist and surgical consultant, addressing possibilities and challenges, must identify the most probable cause and the most timely response for positive intervention in the critically ill patient threatened by sepsis.

[The therapeutic results of programmed relaparotomy in diffuse peritonitis]. / Therapie-Ergebnisse der programmierten Relaparotomie bei der diffusen Peritonitis.

The therapeutical concept of programmed relaparotomy was performed in 184 patients with diffuse peritonitis from 4/1984 to 4/1991. Clinical results were prospectively documented and a total of 46 variables (e.g. risk factors, clinical parameters, laboratory tests, microbiological screenings, score systems) both univariate and multivariate were tested for prognostic significance. Total lethality rate was 26% (48/184 patients). If complete eradication of the source of infection was surgically achieved (150 patients/82%) lethality rate was only 9%. In contrast, lethality rate was 100% in patients with unsuccessful surgical focus eradication. Eradication of the source of infection during the first operation (104 patients/56%) resulted in a lethality rate of 6%, compared to 17% for patients who needed two or even more operations (46 patients/25%). Eradication of the source of infection during the first laparotomy ("focus eradication on time") was the most important prognostic parameters. Of further prognostic significance but with declining importance where serum-creatinine at the beginning of the treatment, patient's age (greater than less than 70 years) and preexistent hepatic disease.

Treatment of severe intra-abdominal sepsis and/or necrotic foci by an 'open-abdomen' approach. Zipper and zipper-mesh techniques.

Undrained necrotic tissue or septic foci contribute to continued "activation" of host processes that in turn lead to multiple organ failure and death. We hypothesized that if wide-open drainage of the abdominal cavity is provided, thus not allowing intra-abdominal collections to form, mortality in these patients can be reduced. Since 1982 we have treated 49 patients with necrotic pancreatitis and related infections and 15 patients with severe intra-abdominal sepsis from intestinal perforations. The surgical treatment was based on the provision for daily laparotomies in the intensive care unit with the patient under epidural anesthesia by using an "open-abdomen" technique (zipper alone or a zipper-mesh combination). The APACHE II score and the functional classification were used to derive expected mortalities. The patients with intraabdominal sepsis had a mean APACHE II score of 25 and an expected mortality of 45%, vs the 26.5% mortality that we observed. The lowest mortality in the necrotic pancreatitis group was associated with noninfected pancreatic necrosis (6%) and single abscess (9%) vs 22% mortality rate in the patients with infected pancreatic necrosis. The mean expected mortality in this group was 47%, vs the observed 22%. We attributed this result to the daily abdominal explorations that achieved a complete excision of infected or necrotic tissue.

Focal vulvitis: a characteristic syndrome and cause of dyspareunia. Features, natural history, and management.

Based on the study of 67 affected women during a period of 15 years, we report the clinical features and natural history of focal vulvitis, a unique syndrome characterized by severe and persistent superficial dyspareunia and the presence of one to 11 (median three) minute, exquisitely tender areas of focal inflammation or ulceration on the mucosa of the vestibule. Three fourths of all lesions occur around the Bartholin gland ducts or between them posteriorly. Histopathologic study of tissues from seven patients has not shown a characteristic pattern of inflammation and fails to confirm a reported association between these lesions and the minor vestibular glands. These histologic studies and an in-depth clinical and epidemiologic investigation in nine patients, including microbiologic studies to identify infection by herpes simplex virus. Neisseria gonorrhoeae, Staphylococcus aureus, beta-hemolytic streptococci, Chlamydia trachomatis, mycoplasmas, Candida sp., trichomonads, or Mycobacterium sp., have not established an infectious etiology for this syndrome or evidence that it represents an unusual form of an autoimmune disease or Behcet's syndrome. Treatment with topical antimicrobial or corticosteroid creams, antibiotics given systemically, or cryotherapy has not been of demonstrable benefit. Approximately one half of patients eventually experience spontaneous remission but many appear to remain symptomatic indefinitely. Surgical excision of the hymenal ring and contiguous mucosa of the vestibule has brought relief and permitted resumption of sexual activity in seven of eight treated patients. While promising, operation should be reserved for patients who have experienced unremitting dyspareunia associated with the characteristic focal inflammatory lesions for at least 6 months.