Cutaneous botryomycosis - Case report

Botryomycosis is a chronic, granulomatous, suppurative bacterial infection involving the skin and subcutaneous tissues. The skin lesion is characterized by multiple fistulae draining purulent secretion with white-yellowish grains PAS positive. The main etiologic agent is Staphylococcus aureus and other less frequent pathogens are Pseudomonas aeruginosa and Escherichia coli, isolated or associated. The authors report a case of this disease with exuberant lesions on the right leg and increased limb volume, fibrous consistency and multiple fistula orifices draining white-yellowish grains. Resolution was achieved with sulphamethoxazole-trimethoprim.

Accuracy of intraoperative cultures in primary total hip arthroplasty

The aim of this investigation was to assess the diagnostic accuracy of intraoperative cultures for the early identification of patients who are at risk of infection after primary total hip arthroplasty. Four or six swabs were obtained immediately before the wound closure in 263 primary total hip replacements. Patients with a maximum of one positive culture were denoted as patients with a normal profile and did not receive any treatment. Patients with two or more positive cultures, with the same organism identified, were denoted as patients with a risk profile and received treatment with a specific antibiotic as determined by the antibiogram for six weeks. The follow-up ranged from a minimum of one year to five years and eleven months, concentrating on the presence or absence of infection, which was defined as discharge of pus through the surgical wound or as a fistula at any time after surgery. The accuracy of this procedure ( number of cases correctly identified in relation to the total number of cases) in the group of 152 arthroplasties in which 4 swabs per patient were collected was 96%. In the group of 111 arthroplasties in which 6 swabs per patient were collected the accuracy was 95.5%. We conclude that the collection of swabs under the conditions described is a method of high accuracy ( above 95%) for the evaluation of risk of infection after primary total hip arthroplasty.

Short-Term Effects of Duodenocecostomy on Body Weight, Glucose Absorption, Serum Components, and Intestinal Histopathology in Four Normal Horses

The objective of this study was to evaluate duodenocecostomy in horses performed through a ventral midline laparotomy and report its influence oil body weight, glucose absorption, serum components, and characteristics of jejunum, cecum, and large colon histology. Four horses were submitted to the duodenocecostomy technique through a ventral midline laparotomy with animals in dorsal recumbency under inhalation anesthesia, followed by abdominal exploration. A side-to-side anastomosis was performed between the duodenojejunal flexure and the base of the cecum with two simple continuous suture lines of the serosal and muscular layers. The size of the opening created was approximately 2 cm in diameter. The mucosa layer was not Sutured. After 30 days, animals were submitted to a second laparotomy to check the patency of the duodenocaecal fistula. During both laparotomy procedures, excisional biopsies of different segments of the gastrointestinal tract were performed. Information on physical examination findings, results of hematologic and histopathologic evaluations, and oral glucose absorption test were recorded. The horses did not have significant weight loss from baseline, and absorption curve of glucose did not significantly vary from baseline. Only triglycerides had significant alterations. Histologic evaluation of jejunum, cecum, and large colon did not show alterations of intestinal structure and morphology. We concluded that the proposed technique, principally in relation to the fistula size and not suturing the mucosa layer, allowed partial or total Occlusion of the fistulae without the necessity of a second surgery and avoided the permanent bypass of ingesta and weight loss.

Accumulative copper poisoning in buffaloes

The main objective of this study was to evaluate the clinical and hematological alterations, and the hepatic concentration of Cu in buffaloes with chronic copper poisoning (CCP). Ten buffalo yearling steers were randomly distributed into two groups: one copper supplemented (BUFCu; n = 6) and another control group (BUF; n = 4). The group BUFCu received, by ruminal fistula, 2 mg Cu/kgBW (as CuSO4.5H2O) daily during one week; after which 2 mg Cu/kgBW was added during each additional week, until the end or the experiment (105(th) day). Three liver biopsies were realized during the experiment (day zero, 45(th), and 105(th) day) to determine the degree of copper accumulation. Alterations in body weight, clinical examination, and hematological values were monitored every 15 days. Two buffaloes supplemented with copper demonstrated clinical manifestations consistent with CCP, and died. Two distinct clinical manifestations were observed, one classical (n = 1) and another atypical (n = 1), characterized by remarkable high levels of liver copper, progressive hyporexia followed by anorexia, dehydration, severe apathy, decreased rumen movements, oliguria, and death. Some animals were resistant to CCP although high copper intake. In buffalos with clinical picture similar to the one described as atypical, CCP should be considered as a possible diagnostic even without presence of macroscopic hemoglobinuria.

Chronic maxillary sinusitis associated with dental impression material

A 62-year-old man was referred for routine treatment of hyperplasia of the mucosa in the anterior lower jaw. An oroantral fistula was detected in the right superior alveolar ridge. The patient had no complaints. Plain radiographs showed a radiopaque foreign body in the posterior region associated with opacification of the maxillary sinus. Computed tomography showed the same hyperdense foreign body located in the posterior lower part of the sinus and an abnormal soft tissue mass in the entire right maxillary sinus. When asked about sinusitis, the patient mentioned occasional episodes of pus taste and intermittent crises of headache lasting for one week. The patient has been edentulous for 20 years. Sinus debridement was performed and the oroantral fistula was closed. The clinical suspicion of the presence of zinc oxide-eugenol paste was confirmed by microscopical and chemical analysis. After 6 months of follow-up, the fistula continued to be closed and sinusitis did not recur. This clinical case of maxillary chronic sinusitis illustrates a different odontogenic origin.

Replantation of an avulsed maxillary primary central incisor and management of dilaceration as a sequel on the permanent successor

This case report outlines the sequel and possible management of a permanent tooth traumatized through the predecessor, a maxillary right primary central incisor that was avulsed and replanted by a dentist 1 h after the trauma in a 3-year-old girl. Three years later, discoloration and fistula were present, so the primary tooth was extracted. The patient did not come to the scheduled follow-ups to perform a clinical and radiographic control of the succeeding permanent incisor, and only returned when she was 10 years old. At that moment, the impaction and dilaceration of the maxillary right permanent central incisor were observed through radiographic examination. The dilacerated permanent tooth was then surgically removed, and an esthetic fixed appliance was constructed with the crown of the extracted tooth. Positive psychological influence of the treatment on this patient was also observed.

Diagnosis and treatment of odontogenic cutaneous sinus tracts of endodontic origin: three case studies

To describe three cases of extraoral sinus tracts, related to infected teeth, which were initially misdiagnosed as skin lesions and inappropriately treated. The extraoral sinus tracts were initially misdiagnosed as skin lesions. Dermatological surgery was performed and antibiotics prescribed but the lesions did not resolve. Then, a dental cause was sought, and identified. Endodontic intervention resulted in resolution of the problem, confirming the initial misdiagnosis. center dot Dermatologists and other medical practitioners should be aware that dental extraoral sinus tracts can be confused with skin lesions. center dot A dental aetiology, as part of a differential diagnosis, should be kept in mind with oro-facial skin lesions. center dot If an extraoral sinus tract is of endodontic origin, then elimination of infection through effective endodontic treatment will lead to resolution of the sinus tract. center dot Early correct diagnosis can prevent unnecessary and ineffective antibiotic therapy and/or surgical intervention.

Safety and efficacy of low anterior en bloc resection as part of cytoreductive surgery for patients with ovarian cancer

Objective. To examine the feasibility and safety of a low anterior resection of the rectosigmoid plus adjacent pelvic tumour as part of primary cytoreduction for ovarian cancer. Methods. This study included 65 consecutive patients with primary ovarian cancer who had debulking surgery from 1996 through 2000. All patients underwent an en bloc resection of ovarian cancer and a rectosigmoid resection followed by an end-to-end anastomosis. Parameters for safety and efficacy were considered as primary statistical endpoints for the aim of this analysis. Results. Postoperative residual tumour was nil, 1 cm in 14, 34, and 14 patients, respectively. The median postoperative hospital stay was 11 days (range, 6 to 50 days). Intraoperative complications included an injury to the urinary bladder in one patient. Postoperative complications included wound complications (n=14, 21.5%), septicemia (n=9, 13.8%), cardiac complications (n=7, 10.8%), thromboembolic complications (n=5, 7.7%) ileus (n=2, 3.1%) anastomotic leak (n=2, 3.1%) and fistula (n=1, 1.5%). Reasons for a reoperation during the same admission included repair of an anastomotic leak (n=1), postoperative hemorrhage (n=1), and wound debridement (n=1). Wound complications, septicemia, and anastomotic leak formation were more frequent in patients who had a serum albumin level of less than or equal to 30 g/L preoperatively. There was one surgically related mortality in a patient who died from a cerebral vascular accident 2 days postoperatively. Conclusions. An en bloc resection as part of primary cytoreductive surgery for ovarian cancer is effective and its morbidity is acceptably low. (C) 2001 Academic Press.

Permanent vascular access in patients with end-stage renal disease, Brazil

OBJECTIVE: To assess factors associated with the establishment of permanent vascular access for patients with end-stage renal disease. METHODS: Cross-sectional study conducted in a nationally representative sample of Brazilian end-stage renal disease patients in dialysis and transplant centers during 2007. The sample comprised only patients who received hemodialysis as a primary therapy modality and reported the type of vascular access for their primary hemodialysis treatment (N=2,276). Data were from the TRS Project - "Economic and Epidemiologic Evaluation of Modalities of Renal Replacement Therapy in Brazil". Multiple logistic regression analysis was used to assess factors associated with the establishment of permanent vascular access in these patients. RESULTS: About 30% of the patients studied had an arteriovenous vascular access. The following factors were associated with a lower likelihood of having an arteriovenous vascular access as a primary type of access: time of hemodialysis start since the diagnosis of chronic renal failure < 1 year; shorter dialysis therapy; having no private health insurance; living in the central-western, northeastern and southeastern regions of Brazil; and living in the northern region plus having no private health insurance. In the final model there was found a positive association between the outcome and pre-dialysis care and no were association with socioeconomic and comorbidity variables. CONCLUSIONS: The study results showed that the focus should on pre-dialysis care to increase the establishment of an arteriovenous vascular access before starting hemodialysis in Brazil.

Non-colorectal intestinal tract carcinomas in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (II)

Patients with inflammatory bowel diseases (IBD) have an excess risk of certain gastrointestinal cancers. Much work has focused on colon cancer in IBD patients, but comparatively less is known about other more rare cancers. The European Crohn's and Colitis Organization established a pathogenesis workshop to review what is known about these cancers and formulate proposals for future studies to address the most important knowledge gaps. This article reviews the current state of knowledge about small bowel adenocarcinoma, ileo-anal pouch and rectal cuff cancer, and anal/perianal fistula cancers in IBD patients.

Síndrome de Churg-Strauss, Aneurismas Femorais Venosos e Tromboembolismo Pulmonar

OBJECTIVE: Venous aneurysms of the lower limbs are rare. When they involve the deep venous system, they can be associated with deep venous thrombosis and pulmonary embolism. The authors report the case of a 63-year-old women evaluated by duplex imaging and venography, in the context of a pulmonary embolism, and detected bilateral large aneurysms of the femoral veins (5 cm in the right femoral vein and 4 cm in the left femoral vein). The aneurysms were located at the bifurcation of the common femoral vein with the superficial and profound veins. METHOD: The right aneurysm was partially thrombosed. The patient was asymptomatic in the lower-limb extremities. After a period of anticoagulation, the authors proceeded to surgically excise the right aneurysm and replaced the venous system using a polytetrafluoroethylene (PTFE) graft with the construction of an a-v fistula. RESULT: The patient had no complications in the postoperative period and her 8-month follow-up examination revealed no symptoms, not even leg edema. The duplex scan showed patency of the graft. She continued with oral anticoagulation. The histologic examination revealed an eosinophilic inflammatory reaction of the vein wall, compatible with the diagnosis of Churg-Strauss syndrome. CONCLUSION: The authors conclude that they have probably described the first case in the international literature of a venous aneurysm with a Churg-Strauss syndrome and pulmonary embolism.

Cirurgias de Derivação do Ventrículo Pulmonar

Cavopulmonary connections have been extensively used in the palliation of complex forms of congenital heart disease requiring some form of right heart bypass. We examine the mid term outcomes of pulmonary ventricle bypass operations in a single institution and performed by the same surgical team. POPULATION: Between March 1999 and April 2006, 62 patients underwent pulmonary ventricle bypass operations: bidirectional cavopulmonary anastomosis (Glenn procedure), total cavopulmonary connections (Fontan procedure) and one and a half ventricle correction in two cases. Age at operation averaged three years (range: 0.42-25 years) for the Glenn procedure and seven years (range: 3-14 years) for the Fontan procedure. There were 36 male patients (58%) and 26 female patients (42%). The most common indication for surgery was the single ventricle defect, present in 66% of patients. Associated lesions included: transposition of the great arteries in 16 patients (35.6%), bilateral superior vena cava in four patients (8.9%), situs ambigus in five patients (11%), situs inversus in another patient (2.2%), Ebstein disease in one patient (2.2) and coronary fistula in another patient (2.2%). Sub-aortic stenosis was present in one patient (2.2%). Palliative surgery was performed in all, but three patients (5%), before the Fontan procedure. RESULTS: Thirty two patients underwent bidirectional cavopulmonary anastomosis and thirty patients underwent cavopulmonary connections, total or 2nd stage. Mean cardiopulmonary bypass times were 50.6+/-21.9 minutes for the Glenn procedure and 88.5+/-26.3 minutes for the Fontan procedure. There was no intra-operative mortality, but two patients (3.2% (died in the first month after surgery; one due to failure of the Glenn circuit and sepsis and the other due to a low cardiac output syndrome and multi-organ dysfunction. Mean ventilation time was 5.2+/-1.7 hours for the Glenn operation and 6.2+/-3.2 hours for the Fontan operation. The mean length of stay in ICU was 3.4+/-2.8 days for patients undergoing the Glenn operation and 4.6+/-3.1 days for patients undergoing the Fontan operation and the mean length of hospital stay was 10.6+/-5.8 days for the Glenn operation and 19.1+/-12.6 days for the Fontan operation respectively. The mean follow up time was 4+/-2.1 years (minimum 0 years and maximum seven years), most patients being in NYHA class I. Epicardiac pacemakers were implanted in three patients due to arrhythmias. Two re-operations (6.7%) were needed, both in the same patient, after the Fontan procedure, this patient eventually died a few years after surgery. CONCLUSIONS: The immediate and mid term outcomes of pulmonary ventricle bypass operations can have excellent results. From our point of view there has been an improvement, namely in the use of the extracardiac conduit technique in the 2nd stage of the Fontan operation.

Origem Anómala da Artéria Coronária Esquerda a Partir da Artéria Pulmonar

OBJECTIVE: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA). DESIGN OF THE STUDY: Prospective study of case series between March 1991 and December 1994. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS AND METHODS: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed. RESULTS: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram. CONCLUSIONS: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

Fístulas Carótido-Cavernosas. Perspectivas de Diagnóstico e Terapêutica

Even though in clinical practice carotid cavernous fistulas (CCF) are not a frequent pathology, it should be a diagnostic hypothesis in face of a suggestive clinical presentation. We intended to review the diagnosis and the therapeutics, comparing them with the actual perspectives. Files of 25 patients with the diagnostic hypothesis of CCF, confirmed by conventional angiography in the HSAC Neuroradiology Department, were reviewed. In this group of patients, (5 males and 20 females), the fistulous aetiology was spontaneous in 10 and traumatic in 15. Clinically the symptom most often presented was diplopia (23 cases) and the most frequent encountered sign was ophthalmoplegia (20 cases). Of the Neuroradiologic investigation, CT scan (done to all patients) have shown an prominent superior ophthalmic vein as the most frequent abnormality. Angiographic study was based on Lasjaunias et al protocol (Surgical Neuroangiography, Vol. 2, Springer-Verlag). Surgery was the therapeutic approach for the traumatic fistulas; only 2 of the spontaneous were treated by endovascular route. Three patients are still under observation. In all the others cases there was a fistula exclusion.