Asplenic fulminant sepsis secondary to a dog bite complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome.

We report a case of asplenic fulminant sepsis in Australia following a dog bite which was complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome (TENS/SJS). Capnocytophaga canimorsus, the infective organism, is a rare cause of septicaemia: a high degree of suspicion of this unusual organism and its early aggressive management is paramount. The diagnostic and management difficulties of TENS/SJS in the context of a patient with fulminant sepsis, DIC and on inotropes are also highlighted.

Achieving autologous breast reconstruction for breast cancer patients in the setting of post-mastectomy radiotherapy.

INTRODUCTION: Breast cancer is now associated with long-term disease-free and overall survival, and in the setting of mastectomy, long term psycho-sexual health becomes an important consideration. To this end, breast reconstruction has been shown to significantly improve quality of life for mastectomy patients. With adjuvant radiotherapy often required in the setting of breast reconstruction, it is unclear what interaction the two can have. METHODS: A thorough literature review was undertaken to assess the impact of radiotherapy on autologous breast reconstruction, and in particular, the influence of its timing on vessel selection, post-operative complications and both oncologic and cosmetic outcomes. RESULTS: A clear benefit was established for delaying reconstruction until after radiotherapy to improve cosmetic outcomes. Although the timing of radiotherapy administration may influence vessel selection and the nature of post-operative complications encountered, overall outcomes were not dissimilar. Likewise, oncologic outcomes have not been shown to be significantly affected by the timing of radiotherapy. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Both immediate and delayed breast reconstruction are safe modes of treatment, however patients that are expected to require adjuvant radiotherapy may benefit from delaying reconstruction until completion of oncologic treatment.

Post-mastectomy breast reconstruction: a history in evolution.

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the "stacked" deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.

Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?

BACKGROUND: Breast reconstruction is increasingly performed with the use of the abdominal wall donor site, with potential complications including donor site morbidity and impaired flap viability. As a tool for selecting the optimal perforators which will ultimately supply the flap, preoperative imaging with computed tomography angiography (CTA) has become increasingly popular. Potential benefits include reduced intramuscular dissection, with faster and safer dissection, reduced donor site morbidity and improved flap vascularity and survival. Despite the potential for improvements in operative outcome, any benefits are yet to be established. METHODS: A cohort study of 104 breast reconstructions in 88 patients was conducted. All patients underwent breast reconstruction based on an abdominal wall free flap. Of these, 40 patients undergoing preoperative imaging with CTA and 48 patients not undergoing CTA were included, with all CTAs undertaken at a single institution. Length of operation, length of stay, and operative complications were assessed. An evaluation of operative stress was achieved with the use of visual analogue scales (VAS) administered to the surgeons. RESULTS: The use of CTA was associated with decreased operating time (mean: 77 min for bilateral cases), significantly decreased complications related to flap viability (particularly partial flap loss), and a statistically significant reduction in donor site morbidity. Psychometric testing of surgeons revealed a statistically significant decrease in operative stress (41% decrease) with the use of preoperative CTA. CONCLUSION: The use of CTA for preoperative imaging in breast reconstruction is associated with improved operative outcomes.

Nephrogenic systemic fibrosis in a gadolinium-naive renal transplant recipient.

A 36-year-old woman presented with a 2-year history of multiple, raised, brown papules and indurated skin over her lower legs. She had received a renal transplant 11 years earlier, and had a history of recurrent deep vein thromboses despite a negative thrombophilic screen. The patient had no history of exposure to gadolinium. Histology at this time revealed a light perivascular lymphoid infiltrate, activated fibroblasts and prominent capillary vessels. The patient re-presented 1 year later with persistence of these lesions, in the setting of worsening renal function requiring haemodialysis. Repeat skin biopsies demonstrated increased dermal collagen and angiogenesis. The dermatopathological findings, in association with renal insufficiency and multiple deep vein thromboses, led to the diagnosis of nephrogenic systemic fibrosis.

Sweet's syndrome in an Australian hospital: a retrospective analysis.

A retrospective analysis was performed of patients meeting the clinicopathological diagnosis of Sweet's syndrome identified over a 10-year period, in a metropolitan hospital. Nine patients met the inclusion criteria. Two patients had preceding streptococcal infection, two had associated inflammatory bowel disease, two had idiopathic Sweet's syndrome, and three had an underlying malignancy, one of whom was receiving granulocyte colony-stimulating factor. Although only three patients were found to have an elevated white cell count, erythrocyte sedimentation rate or C-reactive protein was elevated in all patients when measured. There was a wide spectrum of clinical presentations, with variations in lesion distribution and the presence/absence of systemic symptoms such as fever and arthralgia. Fever was observed in two-thirds of cases. Seven patients responded to oral corticosteroids, while one patient cleared spontaneously and one patient was lost to follow up. As erythrocyte sedimentation rate or C-reactive protein was elevated in all cases when measured, it may be a useful diagnostic tool.

Heterozygous prothrombin gene mutation associated with livedoid vasculopathy.

A 53-year-old woman presented with a chronic history of recurrent, painful ulcers, predominantly involving her lower legs. Both her clinical picture and histopathological findings were consistent with a diagnosis of livedoid vasculopathy, although she did have unusual findings of deep tender nodules and the presence of lesions over her elbows. Multiple investigations were undertaken, the only abnormality being a heterozygous mutation of the prothrombin G2021A gene. Although various coagulopathic states have been associated with livedoid vasculopathy, the finding of an associated prothrombin gene mutation is quite rare. Warfarin has ameliorated the clinical course when anti-inflammatory drugs and other anticoagulants were unhelpful.

Facial Sweet's syndrome mimicking rosacea fulminans.

A 36-year-old man presented with a non-pruritic, erythematous facial rash with peri-oral and peri-orbital sparing. The initial clinicopathological diagnosis was rosacea fulminans, which was treated with 25 mg oral prednisolone and cephalexin. The patient re-presented 1 week later with exacerbation of his rash in addition to constitutional symptoms of fever and malaise. A further skin biopsy was taken and the marked neutrophilic infiltrate in the absence of vasculitis made the diagnosis of Sweet's syndrome (acute febrile neutrophilic dermatosis). High-dose prednisolone (50 mg daily), topical hydrocortisone cream and ichthammol in zinc ointment were commenced with rapid clinical improvement. This case highlights the importance of considering Sweet's syndrome as a differential diagnosis when presented with a facial eruption.

Occupational allergic contact dermatitis to cobalt octoate included as an accelerator in a polyester resin.

A 46-year-old woman, who worked as a laminator of spa baths, presented with hand dermatitis, which was suspected to be related to her occupation. Patch testing revealed strong reactions to both cobalt chloride and a polyester resin that the patient had been using at her workplace. She also reacted to latex and had been wearing cotton gloves underneath rubber gloves at work. It was later discovered that cobalt octoate (synonym: cobalt-2-ethylhexanoate), a compound not listed on the manufacturer's material safety data sheet, was included as an accelerator in the polyester resin. She was then tested to cobalt octoate, which was also strongly positive. Her successful treatment included protection of her hands at work with cotton lined PVC gloves. This case highlights the role of cobalt salts as sensitizers and their presence as accelerators used in polyester resins, and the importance of recognizing concomitant latex allergy that may complicate occupational dermatitis. It also illustrates the difficulties in relying on material safety data sheets to identify all possible allergens.