An unusual presentation of a nasal septal abscess

Nasal septal abscess is a rare complication of septal haematoma. Nasal obstruction and, less frequently, pain are the usual presenting features. We report a case of a nasal septal abscess in a 21-year-old female patient who developed a naso-oral fistula. To our knowledge this is the first report of such an unusual presentation of a septal abscess. The aetiology, pathogenesis and management of septal abscesses are discussed.     

Primary sternal osteomyelitis presenting as a pleural-based mass

Osteomyelitis in uncommon locations can present unusual diagnostic difficulties. A patient with primary sternal osteomyelitis who presented with pain over the right supraclavicular area and a radiologic picture of a pleural-based right upper lung mass is discussed. A triple-phase bone scan was consistent with the diagnosis, and a needle aspiration of the mass revealed a staphylococcal abscess. Percutaneous drainage of the contiguous abscess and a prolonged course of antibiotic therapy cured the infection.     

Alignment of the umbilical axis: an effective maneuver for laparoscopic entry in the obese patient

BACKGROUND: In obese patients, a panniculus may cause a caudal deviation in the vertical axis of the umbilicus and make laparoscopic entry difficult. TECHNIQUE: First, the presence or absence of caudal deviation of the umbilical axis is ascertained by measuring the distance between the external umbilical orifice and the anterior superior iliac spines along the length of the patient. Second, the caudally deviated umbilicus is displaced cranially by manual pressure on the panniculus so that the external umbilical orifice rests approximately 8 cm above the level of the anterior superior iliac spines. Third, open laparoscopy is performed through the base of the umbilicus by elevating it with clamps and incising skin, fascia, and peritoneum in a vertical axis. EXPERIENCE: In an 18-month period, 67 consecutive obese women (weight range 99-213 kg) underwent surgery by the authors for gynecologic conditions requiring primary intraperitoneal evaluation or treatment. All of these patients were scheduled for laparoscopy and underwent the assessment, alignment, and entry technique described above to commence the operations. Laparoscopic entry by this technique was successful and rapid in all 67 cases and was not complicated by preperitoneal insufflation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. CONCLUSION: Umbilical axis assessment and alignment safely facilitates laparoscopy in obese patients.     

Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair

BACKGROUND: A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair. METHODS: One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1.5 mg/kg, (2) bupivacaine 1.5 mg/kg with 1 in 200000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation. Results: At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0.71) or the number of doses of either morphine (at 24 h, P = 0.73) or oral analgesia (at 24 h, P = 0.89). There was also no significant difference in the time to return to normal activity or work between the groups. CONCLUSION: This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.     

Radiographic assessment of changes in marginal bone around endosseous implants supporting mandibular overdentures

We report a case of primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage. A 56-year-old man presented at our hospital with lumbago, right-sided back pain, fever (temperature 38.5 degrees C) and chills. On physical examination, we found dark red skin, swelling, and tenderness localized at the right side at the back of his waist. Laboratory examination showed leukocytosis (white blood cell count 9700/mm3) with a leftward shift and elevated C-reactive protein (5.2 mg/dl). Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging revealed a hypodense lesion in the right iliopsoas muscle extending to the subcutaneous tissue. About 50 ml of thick yellow pus was obtained by ultrasonographically guided aspiration drainage. A drain catheter was inserted in the abscess cavity. Laboratory findings improved and clinical symptoms abated rapidly after drainage. On the twenty-first day after drainage, US and CT showed that the abscess was no longer present. The patient was discharged after 32 days of hospitalization. As possible primary diseases causing iliopsoas abscess, such as digestive tract disease, tuberculosis, and osteomyelitis, were not found, we diagnosed the disease as primary iliopsoas abscess. Although surgical drainage has been performed in most reported cases of iliopsoas abscess, this case report shows that ultrasonographically guided percutaneous drainage is also effective for treating primary iliopsoas abscess if it is diagnosed early enough.     

Germline mutations in PTEN are an infrequent cause of genetic predisposition to breast cancer

Spinal extradural abscess is an infrequent, but serious complication to extradural catheters. Early diagnosis is essential for successful treatment. An extradural abscess may develop slowly over days to several weeks and symptoms may be vague and unspecific, delaying correct diagnosis. Meticulous supervision of the patients is required and must continue as long as an epidural catheter is in place and for some time after the catheter has been withdrawn. This case report describes a patient undergoing extensive reconstructive plastic surgery after a leg trauma. For postoperative pain treatment a continuous epidural infusion of bupivacaine was given. After 10-14 days an extradural abscess developed with increasing low back pain but without any neurologic symptoms. With antibiotics a complete resolution of the extradural abscess occurred, documented by computerized tomography (CT).     

Phorbol ester-induced contractions of mouse detrusor muscle are inhibited by nifedipine

BACKGROUND: There are many conditions related to brain abscess. Brain abscesses resulting from nasopharyngeal carcinoma is rare. It is unusual for an intracranial abscess to appear as the initial clinical presentation of nasopharyngeal carcinoma. CASE REPORT: A 43-year-old male patient suffering from nasopharyngeal carcinoma with the initial manifestation of an intracranial abscess without symptoms and signs suggestive of the primary nasopharyngeal carcinoma is reported. The diagnosis was particularly elusive and was not made until the third admission. CONCLUSION: Although it is rare, intracranial abscess should be considered as one of the possible manifestations of nasopharyngeal carcinoma.     

Normal lung function in subjects heterozygous for surfactant protein-B deficiency

OBJECTIVE AND IMPORTANCE: We present a case report of a patient with a left frontal brain abscess. Cultures obtained from the abscess at the time of surgery were identified as dental flora known to establish a synergistic relationship in polymicrobial infections. This type of synergistic relationship makes the clearance of an infection more difficult for an intact immune system. A serum immunoglobulin (Ig) Type A deficiency was identified postoperatively. This immunodeficiency may have contributed to the development of the abscess. CLINICAL PRESENTATION: The patient presented with headaches and photophobia. Computed tomography of the head performed with intravenously administered contrast demonstrated a left frontal brain abscess. INTERVENTION: The patient was operated on through a left frontal approach, carefully avoiding the frontal sinus. The abscess was aspirated, and the patient was treated with intravenous antibiotics for several weeks. Postoperatively, the patient did well. There were no signs of enhancement on follow-up computed tomographic scans at 7 and 12 months postoperatively. CONCLUSION: Through a comprehensive immunological workup, an IgA deficiency was identified postoperatively. Although the deficiency of a single type of Ig may be asymptomatic, complications from recurrent or chronic bacterial infections may occur. The deficiency of IgA, combined with a synergistic polymicrobial infection, contributed to the development of an intracranial abscess. A patient presenting with a brain abscess without any predisposing medical history should be evaluated for an underlying immune deficiency.     

Inhibitors of mitochondrial energy production prevent DNA internucleosomal fragmentation in thymocytes

We describe a case of multiple hepatic pyogenic abscesses with an unusual presentation. The typical signs and symptoms of fever and pain in the right upper quadrant were absent. Instead, the chief complaint was muscle weakness and myalgias accompanied by weight loss. Findings from an ultrasonogram of the abdomen revealed multiple hepatic lesions consistent with metastases. Hence, the initial presumptive diagnosis was metastatic malignancy with unknown primary tumor. It was only when purulent material was unexpectedly encountered when a needle biopsy was performed that the true diagnosis of pyogenic liver abscess was recognized. While liver abscess is rare, it should not be forgotten in the differential diagnosis for multiple hepatic lesions seen on imaging studies.     

Umbilical metastasis of an endometrial adenocarcinoma: "Sister (Mary) Joseph's nodule". Review of the literature

In the beginning of the XXth century, Sir Hamilton Bailey proposed the name "Sister Joseph's nodule" for the umbilical metastasis of an abdominal cancer. This unusual pathology has multiple primitive etiologies. We report here the 27th case of an umbilical metastasis of an endometrial adenocarcinoma. In case of a malignant umbilical tumor, 75% correspond to a "Sister Joseph's nodule". Their clinical manifestations are quite similar. This secondary localisation could appear before, during or after the diagnosis of the primitive tumor. Adenocarcinoma is the frequently diagnosed histological type. The endometrial origin represents only 1.4% of the cases. Multiple routes of spread exist. Prognosis remains poor. Medico-surgical treatment, in a curative target, will be aggressive and should be adapted at every case. Our case-report recalls a new patho-physiological approach. The extended follow-up of this patient, without further medical treatment, is an additional argument.     

Retropharyngeal abscess after blunt trauma in an adolescent

Retropharyngeal abscess is an unusual infection in teenagers, and it is rarely associated with blunt trauma. We present the case of 17-year-old male who developed signs and symptoms of retropharyngeal abscess soon after being struck by a car. The case illustrates that retropharyngeal abscess should be considered, even in an adolescent, if the patient has fever, neck stiffness, and sore throat with symptoms out of proportion to the oropharyngeal findings.     

An office approach to the diagnosis of chronic cough

BACKGROUND: Some cancer patients require invasive techniques for control of chronic cancer pain. Many patients have benefited from local administration of opioids and anesthetics through an epidural catheter. However, epidural abscess and meningitis are side effects of epidural catheters that have serious morbidity and mortality. METHODS: In a retrospective study, the charts of all patients who received an epidural catheter for the management of chronic cancer pain in a 3-year period (1993-1996) were reviewed. Patients with nervous system infections were identified and pertinent clinical, radiologic (magnetic resonance imaging), and bacteriologic data were analyzed. RESULTS: Ninety-one patients received 137 epidural catheters for a total of 4326 catheter days. All but four patients had died at the time of the final analysis. The median survival after placement of the first epidural catheter was 38 days (range, 1 day--> 1000 days). Seventy-two patients received a percutaneous port whereas 19 patients were treated with an implanted subcutaneous port. Adequate pain relief was obtained in 76% of the 58 patients with nociceptive pain and in 73% of 33 patients with neuropathic pain. All neuropathic pain was associated with active tumor and could be classified as nociceptive nerve pain. Technical complications and superficial infections occurred in as many as 43% of patients. Deep infections occurred in 12 patients, 11 of whom had a spinal epidural abscess. CONCLUSIONS: Deep infection is a frequent complication of epidural analgesia and is associated with a high morbidity and mortality. Only cancer patients with a short life expectancy (< or =3 months) should be treated with epidural analgesia.     

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.     

Plasma cell leukemia 3 months after autologous blood cell transplantation for multiple myeloma

A case of an amebic liver abscess with unusual clinical manifestations is presented. A middle-aged male with an abscess in both lobes of the liver presented with obstructive jaundice due to pressure on the porta hepatis with stasis of the bile in the intrahepatic biliary radicals. The patient did not respond to repeated needle aspirations and thus required open drainage. Subsequently, the patient developed a biliary leak through the drainage sites, and an injection of contrast dye into the cavity revealed a communication between the abscess cavities and the biliary tree. The biliary leak stopped spontaneously, and the large cavities also closed completely during the followup period.     

Splenic sepsis in sickle cell disease

We describe two patients with sickle cell disease (SCD) who developed infections situated in the spleen. One patient had a splenic abscess and there was strong clinical evidence for an infected splenic infarct in the second patient. SCD predisposes to splenic infection because of functional hyposplenism, defective phagocyte function and splenic infarction. Splenic infections can occur in patients who might be considered to have an absent spleen and the diagnosis of splenic abscess should be considered in individuals with SCD who present with fever and abdominal pain.     

Rupture of an amebic liver abscess into the pericardium. Presentation of a case and review of current management

An unusual case of amebic liver abscess that ruptured into the pericardial cavity is presented. This complication of amebic disease is extremely rare, and fatal. Chest X-ray and CT scan were performed for diagnosis. Pericardectomy with surgical drainage was performed; unfortunately, the patient died of massive pulmonary emboli.     

Pseudomyxoma extraperitonei: a lethal complication of mucinous adenocarcinoma of the appendix

We report the unusual case of a 56-yr-old man who presented with an appendix abscess. This abscess failed to respond to standard treatment, and recurred despite operative intervention. A colocutaneous fistula developed, which initially discharged frank pus, then began discharging mucus via two cutaneous sinuses. No evidence of malignancy was detected from either repeat curettings or a diagnostic laparotomy. One and a half years after the initial presentation, histologic examination finally revealed mucinous adenocarcinoma of the appendix. We postulate that this malignancy in a retrocecal appendix resulted in a mucocele, which ruptured into the retroperitoneal space and drained via cutaneous sinuses, so-called pseudomyxoma extraperitonei. The patient declined further surgical intervention, and despite initial control by radiotherapy, the tumor spread locally to involve the entire right lower quadrant of the abdomen. The patient eventually died 39 months after the initial presentation.     

Laparoscopic herniorrhaphy. A preperitoneal tension-free approach

At the present time laparoscopic herniorrhaphy appears to be successfully performed by utilizing a preperitoneal approach. The major indications are bilaterals hernia and the recurrent hernia. Other routine hernias may be done at the decision of the surgeon and patient depending upon the necessity of rapid return to work and desire to minimize pain. Utilizing this approach, the recurrence rate at the present time is less than 1%, which compares favorably with all other types of repair.     

Quantitative cytomegalovirus (CMV) antigenaemia during antiviral treatment of AIDS-related CMV disease

Self-inflicted dermatoses are associated with personality disorders and psychoses, including monosymptomatic hypochondriacal psychosis (MHP), which is characterized by a delusion involving a particular hypochondriacal concern. We report an unusual case of MHP with severe mutilation of the skin complicated by a skull defect and brain abscess. The patient was a 66-year-old uneducated man who damaged his forehead repeatedly because he believed that a 'toxic root' in the forehead was the source of his general ailment. He admitted that the lesions were self-inflicted. There was no other evidence of psychosis or primary skin disease and MHP was diagnosed. Despite initial favourable response to pimozide, the patient was lost to follow-up for 4 years, during which he continued to damage his forehead and applied corrosive agents. He was then referred with a personality change and a 6 x 4 cm bony defect in the skull, complicated by herniation and abscess of the left frontal lobe. This case represents one of the most severe examples of self-mutilation ever reported. The differential diagnosis of dermatitis artefacta and the principles of treating MHP are discussed.     

An unusual cause of sciatica. A case report

STUDY DESIGN: This case report illustrates the need to be aware of extraspinal causes of sciatica. A patient with a strangulated sciatic hernia showed the clinical features of sciatic leg pain, intestinal obstruction, and a left gluteal abscess. OBJECTIVE: To highlight the need to examine the course of the sciatic nerve for local pathology when the cause of sciatica is not obvious. SUMMARY OF BACKGROUND DATA: Sciatic herniae are rare. The coexistence of sciatica and a gluteal abscess, caused by a strangulated sciatic hernia, does not appear to have been reported previously. METHODS: A 66-year-old woman with preexisting low back pain and left leg pain was admitted to the hospital with intestinal obstruction and a left gluteal mass. Results of needle aspiration suggested the diagnosis, which was confirmed by laparotomy. The sciatic hernia was repaired via a transabdominal approach. RESULTS: The symptoms of sciatic nerve compression and intestinal obstruction resolved fully after surgery. CONCLUSION: The possibility of local pathology causing sciatic nerve compression should be considered when a patient reports sciatic leg pain, particularly if the presentation is atypical. Intestinal obstruction or the presence of a gluteal mass should suggest the possibility of a sciatic hernia.