Treating congenital hypothyroidism: maximum age limit up to which a socially compatible child is expected

Salmonella osteomyelitis is an uncommon disease, usually associated with sickle cell anemia and other hemoglobinopathies, as well as with other disease states. In this case, osteomyelites was apparently caused by hematogenous spread of an enteric infection by Salmonella enteritidis. Bone involvement, in vertebral bodies, was resolved after prolonged clinical treatment with antibiotics. We discuss the pathogeny and compare the findings of four case with others related in literature.     

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.     

A case of split notochord syndrome: presence of dorsal enteric diverticulum adjacent to the dorsal enteric fistula

Like umblical enteric remnants (eg, umblical sinus and omphalomesenteric fistula), enteric remnants can be seen on the dorsal aspect of the body (dorsal enteric sinus, dorsal enteric fistula IDEF], dorsal enteric diverticulum) in conjunction with complete cleft of the vertebral column. Complete cleft of the vertebral column associated with gastrointestinal tract and central nervous system anomalies is known as "split notochord syndrome" (SNS). The authors present an unreported variant of SNS having dorsal enteric diverticulum adjacent to the DEF. The patient died 17 days after surgical repair.     

A secondary aortoenteric fistula, successfully treated with proper preoperative diagnosis

A rare case, presented as a secondary aortoenteric fistula after an abdominal aortic aneurysmectomy with Y-graft replacement 9 months earlier, is reported. The course was clinically very unique, in that the first manifestation of the aorto enteric fistula occurred while the patient had already been hospitalized after the orthopaedic surgical treatment for the pyogenic vertebral spondylitis. After the episode of gastrointestinal bleeding, radiological studies were promptly collected, and with the proper diagnosis, a successful surgical treatment was given under the stable hemodynamic condition, and the patient recovered uneventfully. Retrospectively considered, there are several findings that would suggest that seemingly a secondary aorto enteric fistula could have resulted from an early process of the primary aorto enteric fistula having been under progress without any detectable manifestations before the previous aneurysmectomy. The diagnostic values of computed tomography and the scintigraphy for this rare clinical entity is also underlined.     

Orbital venous anomalies. A long-standing dilemma

Chronic pancreas transplant rejection with enteric exocrine drainage can lead to significant long-term complications. We report a case of a 47-year-old male insulin-dependent diabetic who survived the complications of peripancreatic abscess, enterocutaneous fistula, and arterioenteric fistula related to pancreas transplantation. To avoid these long-term complications, we now recommend elective removal of nonfunctioning, enterically drained pancreas allografts.     

Vertebral body osteomyelitis: spectrum and natural history. A retrospective analysis of 37 cases

There has been a definite change in the natural history of vertebral osteomyelitis. At the turn of the century the disease was most often seen in younger people, accompanied by a high incidence of abscess formation and associated with a high mortality rate. Today the disease is more commonly seen in the older age groups and is only occasionally characterized by abscess formation. In addition it tends to be of a lower grade inflammatory reaction and has a better prognosis. A urinary tract infection is a common pre-existing condition. Diagnosis may be difficult particularly before the onset of destructive changes radiologically at 8 to 12 weeks. Biopsy by either open or closed methods might be necessary to establishe the diagnosis and isolate the causative organism which is usually Staphylococcus aureus. Epidural infection is the most devastating complication, particularly if neglected. The duration of treatment is determined by following the clinical symptoms, sedimentation rate, temperature curve and interval radiological changes. The prognosis is good and most patients will recover within one year.     

Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine

STUDY DESIGN: A retrospective clinical study of patients with vertebral osteomyelitis of the lumbar spine necessitating surgical treatment. All patients underwent sequential (same-day) or simultaneous anterior decompression and posterior stabilization of the involved vertebrae. OBJECTIVE: To evaluate the efficacy and clinical out-come of sequential or simultaneous anterior and posterior surgical approaches in the management of vertebral osteomyelitis of the lumbar spine. SUMMARY OF BACKGROUND DATA: Anterior approach alone and staged anterior decompression and posterior stabilization have been advocated as the surgical treatment methods of choice for patients with vertebral osteomyelitis of the lumbar spine. The drawbacks of the latter management plan are the necessity to use external support or the delayed patient mobilization and the need for additional anesthesia and surgical trauma. Sequential (same-day) anterior and posterior approaches are used regularly in the surgical management of scoliosis and other spinal deformities. It would appear advantageous to also use the same strategy (i.e., combined same-day double approaches) in the management of vertebral osteomyelitis of the lumbar spine. METHODS: Ten consecutive patients who had a diagnosis of vertebral osteomyelitis of the lumbar spine underwent combined (same-day) anterior and posterior approaches either in a sequential or simultaneous manner. Indications for surgery included neurologic deficit, abscess formation, instability with localized kyphosis formation, and failure of nonoperative treatment. Patients were evaluated clinically and radiographically after surgery. RESULTS: All 10 patients had uneventful surgery. Only one patient required a second surgical procedure because of expulsion of the anterior bone graft and pull-out of instrumentation. All patients were mobilized within the 2 days immediately after surgery. At the mean follow-up examination 30 months after surgery, all patients had regained their motor function and prior ambulatory status. CONCLUSIONS: Patients with lumbar osteomyelitis necessitating surgery can undergo combined, same-day surgery either in a sequential or simultaneous manner. This is a safe and efficient way to control the infection and stabilize the affected segments, allowing for early mobilization of these sick elderly patients.     

Percutaneous drainage of subperiosteal abscess: a potential treatment for osteomyelitis

OBJECTIVE: Intravenous antibiotics and surgical drainage are the accepted methods of treating osteomyelitis complicated by abscess formation. The objective of this study was to determine whether percutaneous drainage of subperiosteal abscess is a potential treatment for osteomyelitis. MATERIALS AND METHODS: Three pediatric patients with subperiosteal abscesses from acute osteomyelitis had percutaneous drainage with sonographic and fluoroscopic guidance using a Seldinger technique and an 8-F catheter. RESULTS: Two patients required no further intervention and had the drainage catheter removed after 72 h. After completing a course of antibiotics they healed completely. One patient, after a week of purulent drainage, required open drainage including a bone debridement of an area of septic necrosis. CONCLUSION: Percutaneous drainage of subperiosteal abscess may be an alternative to surgical drainage when medical therapy alone is inadequate. Development of intraosseous abscess, necrosis or persistent drainage suggests further intervention may be necessary.     

Vertebral sarcoidosis in adolescents

Two cases of vertebral sarcoidosis in pediatric patients are presented. All such patients reported have been black, 13-15 years old, and have a history of back pain. Radiographs of the involved vertebrae show primarily lytic destruction with sclerotic borders in some of the lesions. Fungal infections, tuberculosis, pyogenic osteomyelitis, Hodgkin's disease and metastatic disease must be considered in every patient with vertebral sarcoidosis.     

High-performance liquid chromatographic determination of a new oral thrombin inhibitor in the blood of rats and dogs

Donovanosis is a genital ulcer disease that occasionally has extragenital manifestations. This report describes a case of disseminated donovanosis in a 54-year-old woman from northern Australia who had subsequent thoracic vertebral osteomyelitis and spinal cord compression. Malignancy and vertebral tuberculosis were the major differential diagnoses. The patient had no genital lesions at the time of diagnosis of extragenital donovanosis but had undergone a hysterectomy, thus raising the possibility of prior disease of the uterine cervix (most previous cases have been associated with primary cervical disease). Despite treatment with doxycycline, she had no significant neurological improvement. Donovanosis disseminated to bone has been reported in 18 cases in the last 55 years. Awareness of donovanosis in the differential diagnosis of osteomyelitis and prompt pelvic examinations enabling early diagnosis of occult cervical disease are the most important measures in preventing morbidity and mortality due to disseminated donovanosis.     

Symmetrical Brodie's abscess

Chronic recurrent multifocal osteomyelitis is often confused with symmetrical Brodie's abscess as it has a similar pathogenesis. We report an otherwise healthy 17-year-old boy presenting with a true symmetrical Brodie's abscess. We conclude that a symmetrical Brodie's abscess presenting in an otherwise healthy patient is a separate clinical condition with a different management protocol.     

Mutations in the mineralocorticoid receptor gene cause autosomal dominant pseudohypoaldosteronism type I

We report intractable meningitis and intracranial abscess in a diabetic patient, arising from sphenoid sinusitis and osteomyelitis caused by Candida species. Magnetic resonance images (MRI) revealed the sinusitis and osteomyelitis with direct invasion of the sellar region and clivus, subsequently intracranial abscess.     

Dominantly inherited proximal myotonic myopathy and leukoencephalopathy in a family with an incidental CLCN1 mutation

OBJECTIVE: To examine the spectrum of urological complications associated with bladder drainage of pancreatic allografts. PATIENTS AND METHOD: Between July 1991 and October 1996, 140 consecutive bladder-drained pancreatic allografts were performed and were reviewed retrospectively to determine the spectrum of post-operative urological complications. Ninety-five patients (68%) underwent simultaneous pancreas-kidney transplantation, 35 (25%) had the pancreas transplanted after the kidney, while 10 (7%) had a pancreas transplant alone. The mean follow-up was 35 months. RESULTS: Seventy patients (50%) had urological complications necessitating intervention: 17 (12%) had retained foreign bodies, bladder tumours occurred in three, 14 had bladder calculi and 15 (11%) had cystoscopic evidence of duodenitis. One patient developed an arteriovenous fistula and one had a necrotic duodenal allograft. Reflux pancreatitis occurred in six patients. Other complications included urethral stricture (three), urethral erosion (three), epididymitis (three), acute prostatitis (one) and prostatic abscess (one). One patient developed a urethrocutaneous fistula and another developed a vesicocutaneous fistula. In the series, 30 of the 140 patients (21%) required eventual conversion to enteric drainage of their allograft as definitive therapy. CONCLUSIONS: Pancreatic transplantation with bladder drainage is associated with a wide range of significant urological problems. Although appropriate treatment can resolve most of the complications, this often entails additional operative intervention, which may increase the long-term morbidity or jeopardize graft function. As a result of the severity of these urological complications, some centres use primary enteric drainage as the method of choice for pancreatic transplantation.     

Possible salmonella osteomyelitis of spine following laser disc decompression

We report a case of chronic discitis and vertebral osteomyelitis that we believe was caused by Salmonella typhimurium following laser decompression of the L4/5 disc for symptomatic disc protrusion in a 50-year-old Asian man. The infection was successfully treated with intravenous ceftriaxone combined with oral ciprofloxacin. We believe this to be the only report of such a complication following this procedure, which is generally without infective complications.     

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.     

Short-term maternal oxygen administration in fetuses with absence or reversal of end-diastolic velocity in umbilical artery: pathophysiological and clinical considerations

This case report describes our experience in treatment of a child with Crohn's disease involvement of ileocecal and sigmoid regions complicated with a severe abdominal wall abscess. A combined therapeutic approach of the acute episode was based on intestinal diversion, abscess drainage, antibiotherapy, nutritional support and post-operative immunosuppression with azathioprine. The definitive treatment of the ileocolonic involvement occurred 6 months after the acute episode and consisted of limited resection, multiple strictureplasties, primar" closure of ileosigmod fistula and undiversion. This operative procedure was followed by a short period of total parenteral nutrition and progressive re-establishment ofenteric nutritional support and immunosuppression. At 18 months follow-up, under low dose azathioprine revealed, a normal growth with a 20 Kg weight gain and 10 cm height gain, no evidence of fistula recurrence or restenosis and suggests the safety of strictureplasty in paediatric patients as a way to conserve as much small bowel as possible.     

Unusual aetiology of persistent back pain in a patient with multiple myeloma: infectious discitis

A 47 year old man with multiple myeloma presented with persistent back pain caused by infectious discitis. Aspiration of the affected vertebral disc space was carried out, guided by computed tomography, and microbiological examination of the aspirate revealed Staphylococcus aureus and Mycobacterium tuberculosis. Antituberculous and antistaphylococcal antibiotic treatment resulted in a dramatic clinical response with complete resolution of the vertebral abscess. Detailed radiological and microbiological investigations are necessary to diagnose unusual causes of chronic bone pain such as discitis or infectious bone disease in patients with multiple myeloma.     

Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience

A retrospective study was carried out of patients from a single institution over a 30-year period. Thirty-one patients presented with 33 fistulas, four non-enteric and 27 enteric. In 25 of 27 patients with a prosthesis-related enteric fistula gastrointestinal bleeding was present. Angiography revealed the fistula in five patients endoscopy in three, and barium studies, echography and computed tomography each revealed one fistula. Six patients died before and five died during operation. In 20 patients various techniques were used for treatment. In-hospital mortality decreased from six of eight patients before 1970, to seven of ten between 1971 and 1980, and to four of 13 after 1981. In the long term, patients treated with an extra-anatomic reconstruction had a poorer prognosis than those treated by in situ reconstruction. This experience shows that diagnostic tests often fail to reveal a prosthesis-related fistula and that mortality can be substantially reduced by early exploration in patients with negative diagnostic studies.     

Microbial flora in spinal hematogenous osteomyelitis

The analysis of microbic flora of the pus and granulations of 155 patients, operated on hematogenic osteomyelitis of vertebral column. The microbic agents were detected in 81.2% of the patients in subacute stage of the disease, in 48.5% of the patients with chronic stage and duration of the disease less than one year, and in 74.3% of the patients with the duration of the disease exceeding one year. In all cases monoculture was detected with the domination of Staphilococcus (69.2%-83.0%). A comparative analyses of the rate of penetration of the infective agents into the spongeous bone of a damaged vertebra. In case of resection of one third of the height of a vertebra the frequency of detection of an infective agent in subacute stage of a disease decreases 2 times, and in chronic stage-in 4 times. These data provides an opportunity of verification of indications for the surgery.