A Rare Catch in a Nonhealing Wound.

INTRODUCTION: Mycobacterium smegmatis is a common microbe found in soil, dust, and water that rarely causes infections in humans. CASE REPORT: A 45-year-old man with a past medical history of hypertension presented with a nonhealing surgical wound in his anterior chest wall, measuring 0.5 cm x 0.5 cm x 0.3 cm with minimal serosanguinous drainage, that had been present for more than 1 year. Wound swab showed M smegmatis. He required a 3-month course of antibiotic treatment and advanced wound care that included packing the sinus wounds with silver-alginate dressings for the first 2 weeks followed by iodoform packing; once the infection and drainage had improved after 2 months of treatment, packing was changed to a collagen dressing. He responded well to treatment, and the ulcers completely closed at the end of his 3-month course. CONCLUSIONS: This case illustrates the importance of considering atypical microbial infections in the workup for chronic nonhealing wounds.

Hypercapnic Conditions After Experimental Blunt Chest Trauma Increase Efferocytosis of Alveolar Macrophages and Reduce Local Inflammation.

Blunt chest trauma induces severe local and systemic inflammatory alterations and an accumulation of apoptotic polymorphonuclear granulocytes (aPMN) in the lungs, frequently followed by bacterial infection. Alveolar macrophages (AM) represent one of the main actors for their clearance. However, little is known regarding regulatory and influencing factors of AM efferocytic and phagocytic activities. In this context, we investigated the influence of impaired gas exchange on AM activity.Male rats underwent blunt chest trauma or sham procedure and aPMN or Escherichia coli (E. coli) were instilled. Subsequently, the efferocytic and phagocytic activities were assessed by analyzing AM obtained from bronchoalveolar lavage fluids at three time points. To determine whether efferocytic and phagocytic activities of AM are affected by shifting gas concentrations, AM were subjected in vitro to hypoxic and hypercapnic conditions.Trauma significantly upregulated the capacity of AM to ingest E. coli starting 24 h after trauma, whereas the aPMN uptake rate remained virtually unchanged. In vitro, AM reacted to hypercapnic conditions by enhanced efferocytosis associated with increased release of anti-inflammatory cytokines. Additionally, phagocytosis and the pro-inflammatory reaction of AM after trauma appeared to be impaired. In contrast, hypoxic conditions displayed no regulatory effect on AM.In conclusion, blunt chest trauma enhances phagocytic activity of AM. On the other hand, hypercapnic conditions in the lungs may significantly contribute to the clearance of aPMN. The application of CO2 in clinical settings must be properly assessed, with the benefits of CO2 balanced against the detrimental effects of impaired bacterial clearance.

Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma.

Most mediastinal abscesses result from infections after thoracotomy, esophageal perforation or pene- trating chest trauma. This disease is rarely caused by closed blunt chest trauma. All previously reported such cases after closed blunt chest trauma presented with hematoma and sternal osteomyelitis resulting from sternal fracture. Here we report a 15-year-old sumo wrestler who presented with an anterior mediastinal abscess without any mediastinal fracture. The mediastinal abscess resulted from the hematogenous spread of Staphylococcus aureus to a hematoma that might have been caused by a closed blunt chest trauma incurred during sumo wrestling exercises.

The role of thoracic trauma in inflammatory responses, apoptosis and bacterial translocation following multiple traumas.

BACKGROUND: Blunt chest trauma and its complications are commonly encountered in emergency medicine. Herein, we used a rat model to investigate the role of thoracic trauma in inflammation, apoptosis and bacterial translocation following multiple traumas. METHODS: Ninety Wistar rats were divided equally into nine groups. Rats underwent a standardized blunt thoracic and/or head trauma and were sacrificed 24 or 48 hours after the trauma. Specimens from various organs and blood samples were collected and quantitatively cultured for aerobic organisms. Interleukins, TNF-α, and MCP-1 levels were assessed in the sera and markers of apoptosis were detected in the lungs. RESULTS: Levels of interleukins, TNF-α and MCP-1 in all of the groups undergoing trauma were significantly higher than those of the control group (p=0.001). Levels of apoptotic cells in the groups undergoing head and thoracic trauma (HTT) were significantly higher than those of the control group (p=0.009). Light microscopic evaluation indicated that damage in the HTT groups was significantly higher than that in the control group. The incidence of bacterial translocation was also significantly higher in the HTT groups (p=0.003). CONCLUSION: Multiple inflammatory mediators are activated in multiple traumas (including blunt thoracic trauma), which allow bacterial translocation and apoptotic processes to occur. Our results indicate that thoracic trauma plays a major role in post-traumatic bacterial translocation, inflammation, and apoptosis following multiple traumas.

[Surgical treatment of a wound defects of torso and extremities].

The results of examination and treatment of 179 patients, suffering the wound defects, localized on corpus and extremities, were presented. The patients were divided on groups, depending on the etiology of the defect, they were examined in accordance to algorithm proposed. Ultrasound duplex scanning was applied for diagnosis of regional hemodynamics disorders with the objective to choose a correcting intervention and investigation of a donor site vessels. The surgical tactics choice have depended on anatomic-functional and hemodynamical peculiarities of the affected locus present. In all the patient a microbiological monitoring of wounds was conducted and a rational antibioticotherapy prescribed.

Blunt trauma as a cause of rib chondro-osteitis: a case study.

Rib chondro-osteitis is rare and usually caused by tuberculosis. A 63-year-old man presented with fever, painful swelling, and a burning sensation in the parasternal right submammary region. He had a history of cardiac interventions: percutaneous transcatheter angioplasty with stenting 1 year prior and coronary artery bypass graft surgery 16 years before; therefore, he was on dual antiplatelet therapy. He sustained blunt chest trauma 5 months before admission. A chest wall abscess was suspected and fine needle aspiration of the lesion revealed the presence of purulent fluid. Culture results were positive for Staphylococcus aureus and intravenous antibiotic therapy was started. Computed tomography showed a lesion involving the sternal, chondral, and proximal costal portions of the fourth, fifth, and sixth anterior costal arches. The patient was diagnosed with costal chondo-osteitis following blunt trauma. Following aggressive surgical debridement, the wound was managed with topical negative pressure therapy (constant -125 mm Hg setting with daily dressing changes). After 15 days, culture results were negative, the wound bed contained healthy granulation tissue, and the defect was surgically closed using a myocutaneous flap. No recurrence or complications have been observed during the 2-year follow-up. This is the first reported case of pyogenic, posttraumatic, costal chondro-osteitis secondary to a blunt trauma of the chest wall.

Open thoracic window: a useful alternative for retained infected pleural collections in critically ill trauma patients.

Historically, tube thoracostomy, image-guided drainage, or an open thoracotomy has been indicated as the standard procedure for the management of patients with retained infected pleural collections (RIPC). These infections can be a debilitating and potentially lethal complication in already critically ill trauma patients. The purpose of this review was to evaluate the usefulness of an open thoracic window (OTW) as definitive therapy for the management of RIPC refractory to conventional therapies. The medical records of patients who underwent an OTW for RIPC were reviewed for the following: demographic data, primary diagnosis, clinical findings that explained the failure of the conventional management, bacteriology of the retained collection, and final outcome. Over a 3-year period, eight critically ill trauma patients who had sustained multiple system trauma and developed a RIPC were identified (six males and two females; average age, 47 years). Of the eight patients identified, six collections were in the right and two in the left pleural cavity. Staphylococcus aureus and Acinetobacter were the two most common bacterial isolates from these collections. All patients had undergone multiple and unsuccessful drainage attempts by thoracostomy tubes. Additionally, two of the patients also underwent image-guided drainage procedures, which proved to be unsuccessful. After creation of the OTW, all patients had complete resolution of the RIPC, and all were discharged alive from the hospital. During outpatient follow up, the OTW was found to have completely healed and required no further surgical intervention. The creation of long-term pleural drainage, with an OTW, facilitates and expedites the resolution of persistent infected pleural collections by providing more efficient surgical drainage and mechanical débridement. Our experience also shows this uncommon operation to be an effective alternative when conventional measures have failed.

[Diagnostic value of the procalcitonine test in purulent-septic complications of chest traumas].

The aim of the present work was to assess the value of the semi-quantitative procalcitonine test (PCT) in diagnosis of purulent-septic complications of chest traumas, efficacy of the therapy carried out, and outcome prognosis. For this, 71 patients with chest traumas were enrolled in the study. Concentrations of PCT were assessed in dynamics using an immunochromatographic, semi-quantitative quick test. Semi-quantitative quick PCT test is highly sensitive diagnostic marker that can be used for the assessment of a chest trauma, infectious-septic complication severity, and efficiency of the therapy indicated. Thus, it can be successfully used for monitoring trauma therapy. PCT sensitivity during first 12 hrs of infectious-septic complication development is 2-3-times higher than that of routine methods for laboratory diagnostics, and even more sensitive that IL-6 and CRT, when we are dealing with combined chest traumas. PCT concentration increase is 4-times more frequent in gram-positive bacterial processes than in gram-negative ones. This has to be taken into account, when appropriate antibacterial treatment is selected for restricted infectious-septic complications.

Clue to fine-needle aspiration diagnosis of pleural pneumocystoma: neovascularization and Langhans' giant cell reaction.

Pneumocystis pneumonia is a common component of the acquired immunodeficiency syndrome (AIDS) in the United States. Extrapulmonary pneumocystosis, however, is much less common. Rare cases have been reported in lymph nodes, bone marrow, spleen, pleura, gastrointestinal tract, liver, common bile duct, pancreas, skin, thyroid, and eye. A 39-yr-old man with history of chest wall injuries from gunshot and stabbing presented with multiple pleural masses clinically suspicious of metastatic deposits from an unknown primary. Fine-needle aspiration biopsy of the largest pleural mass revealed extrapulmonary pneumocystis, which led to the diagnosis of AIDS. Similar to the previous reports of pneumocystis mass lesions in extrapulmonary sites, the current case is associated with exuberant vascular proliferation and Langhans' giant cell reaction. Neovascularization and histiocytic influx from the newly formed blood vessels and Langhans' giant cell reaction seem to be a common tissue reaction to the massive deposition of pneumocystis organisms in extrapulmonary sites in patients with AIDS.

[Effect of severe thoracic trauma combined with endotoxin challenge on phagocytosis function of alveolar macrophages and pulmonary interstitial macrophages].

OBJECTIVE: To observe the difference of phagocytosis between alveolar macrophages and pulmonary interstitial macrophages, and to investigate their responses to severe thoracic trauma with or without lipopolysaccharide (LPS) challenge. METHODS: A rat model of severe thoracic trauma was reproduced by thoracic impact machine. The alveolar macrophages and interstitial macrophages were isolated before injury and at 2, 4, 8, 16, 24 hours after injury respectively. The dynamic changes of these macrophage phagocytosis were tested by malachite green colorimetry. RESULTS: Macrophage phagocytosis function was increased during the early stage after trauma (2 and 4 hours) and then decreased. The phagocytosis function of alveolar macrophages was stronger than that of interstitial macrophages in all time points before and after trauma. After challenge with LPS, no further significant effect on the alveolar macrophages was found, while LPS challenge could stimulate the phagocytosis of interstitial macrophages. CONCLUSION: Alveolar macrophages and pulmonary interstitial macrophages are functional heterogeneous, and their response to trauma and combined with endotoxin challenge are different. The results indicate that the two subgroups of macrophages play different roles in immune function disorder after trauma.