The predictive value and reliability of ultrasound-guided synovial aspiration and biopsies for diagnosing periprosthetic shoulder infections.

INTRODUCTION: Preoperative diagnosis of periprosthetic shoulder infections (PSI) is difficult. Infections are mostly caused by low virulence bacteria and patients do not show typical signs of infection. The aim of this study was to determine the diagnostic value and reliability of ultrasound-guided biopsies for cultures alone and in combination with multiplex polymerase chain reaction (mPCR), serum markers, and/or synovial markers for the preoperative diagnosis of PSI in patients undergoing revision shoulder surgery. MATERIALS AND METHODS: A prospective explorative diagnostic cohort study was performed including 55 patients undergoing revision shoulder replacement surgery. A shoulder puncture was performed preoperatively before incision to collect synovial fluid for mPCR analysis and for measurement of interleukin-6, calprotectin, white blood cell count (WBC), and polymorphonuclear cells. Also prior to revision surgery, six ultrasound-guided synovial tissue biopsies were collected for culture and two for mPCR analysis. A blood sample was obtained to determine serum C-reactive protein, WBC, and erythrocyte sedimentation rate. Six routine care tissue biopsies were taken during revision surgery and served as reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV; the primary outcome measure), and accuracy were calculated for ultrasound-guided biopsies, blood and synovial markers, mPCR, and combinations thereof. RESULTS: Routine tissue cultures were positive for infection in 24 patients. Cultures from ultrasound-guided biopsies diagnosed infection in 7 of these patients, yielding a sensitivity, specificity, PPV, NPV, and accuracy of 29.2%, 93.5%, 77.8%, 63.0%, and 65.6%, respectively. The best diagnostic value was found for the combination of ultrasound-guided biopsies for culture, synovial WBC, and calprotectin with a sensitivity of 69.2%, specificity of 80.0%, PPV of 69.2%, and NPV of 80.0%. CONCLUSION: Ultrasound-guided biopsies for cultures alone and in combination with mPCR, and/or blood and/or synovial markers are not reliable enough to use in clinical practice for the preoperative diagnosis of PSI. LEVEL OF EVIDENCE: Diagnostic study level II.

Priapism caused by infection and an inflammatory process in the pelvic region.

Priapism caused by an inflammatory process is rare. We report on a 25-year-old man with priapism due to an infiltration in the pelvic region, enclosing the right sacral plexus. Blood cultures revealed Staphylococcus aureus to be the causal organism. Treatment consisted of parenteral antibiotics, aspiration of the corpora cavernosa and injection of epinephrine, resulting in a flaccid penis and full recovery of potency after 3 weeks. A literature review was conducted for infection and inflammatory processes as a cause for priapism.

Preventive treatment of intranasal fluticasone propionate reduces cytokine mRNA expressing cells before and during a single nasal allergen provocation.

BACKGROUND: The local production and release of a number of cytokines regulate allergic upper airway inflammation. Medication is usually used at the presentation of the first symptoms. There are, however, clues that it is advisable to start taking the corticosteroid before the grass pollen season begins. METHODS: This single allergen provocation study was conducted in autumn, out of the hay fever season. Nasal mucosa biopsies were taken twice before provocation (before and after 4 weeks of preventive treatment) and three times after allergen provocation (1 h, 24 h and 1 week). The preventive treatment used was fluticasone propionate aqueous nasal spray (FPANS) (n = 10) or a placebo (n = 9). Eosinophils and mRNA positive cells (in situ hybridization for IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, IFNgamma, RANTES and TNFalpha) were counted in the biopsies. RESULTS: Preventive treatment with FPANS out of season resulted in a decrease in eosinophils and mRNA positive cells for IL-5 and IL-6. After allergen provocation, levels of most of the measured cytokines (IL-3, IL-5, IL-6, IL-13, IFNgamma, RANTES and TNFalpha) and eosinophils were reduced using corticosteroids. The numbers of cells (eosinophils, IL-3, IL-6 and IL-8) correlated with nasal symptoms. Significant correlations in the early and late allergic phase were found between eosinophils and cytokines (IL-3, IL-10 and IL-13). CONCLUSION: These results indicate that preventive treatment with FPANS prior to contact with grass pollen is effective in reducing the increase of cytokine mRNA positive cells in reaction to grass pollen contact.

Increase in IL-8, IL-10, IL-13, and RANTES mRNA levels (in situ hybridization) in the nasal mucosa after nasal allergen provocation.

BACKGROUND: Allergic inflammation is regulated by the local production and release of several cytokines. OBJECTIVES: This study was designed to assess the changes in mRNA cytokine-positive cells after allergen provocation and to compare these cytokines with tissue eosinophilia as a marker of allergic inflammation. METHODS: A grass pollen allergen provocation study was conducted in autumn, out of the hay fever season. Nasal mucosal biopsy specimens were taken before provocation and 1 hour, 24 hours, and 1 week after allergen provocation. Eosinophils and mRNA-positive cells (in situ hybridization for IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, IFN-gamma, RANTES, and TNF-alpha) were assessed in the biopsy specimens. RESULTS: After allergen provocation, an increase in cell number was found for eosinophils and cells expressing mRNA for the chemokines IL-8 and RANTES and for the TH2 cytokines IL-10 and IL-13. Significant correlations were found between eosinophils and RANTES and eosinophils and IFN-gamma in the early phase and between eosinophils and IL-5 and eosinophils and RANTES in the late phase. The increase in eosinophils and IL-10 and IL-13 mRNA-positive cells could still be observed 1 week after allergen provocation. CONCLUSIONS: Nasal allergen provocation induced significant tissue eosinophilia and a significant increase in IL-8, IL-13, and RANTES mRNA-positive cells. A significant increase in eosinophils and IL-10 and IL-13 mRNA-positive cells compared with baseline can still be observed 1 week after a single allergen provocation.