RESUMO
An 87-year old Caucasian male with past medical history of rheumatoid arthritis (RA) and chronic kidney disease presents with left hand erythema, pain, tenderness, induration and edema. Clinically, these hand findings began proximal to the metacarpo-phalangeal joints and extended to the distal wrist. He was noted to have ipsilateral axillary lymph node enlargement but denied any constitutional signs or symptoms. Laboratory markers of inflammation were poor prognostic indicators due to relatively active RA, the use of chronic daily glucocorticoids and weekly adalimumab use. Oral antibiotics were administered with limited success leading to a skin biopsy which reported a hematogenously disseminated fungal panniculitis; cultures grew Cryptococcus neoformans, however, serum cryptococcal antigen was negative. With initial fluconazole treatment, skin findings and lymphadenopathy improved gradually over the next six months. However, the patient's improvement stagnated and his condition reverted back to the state of initial presentation.
RESUMO
OBJECTIVE: Vacuum-assisted closure (VAC) therapy without muscle flap coverage is our primary approach for graft preservation in early, deep groin infections with and without exposed grafts; however, concerns exist regarding its safety. We report our experience in a consecutive series of patients with early groin infections managed without muscle flap closure. METHODS: All patients with early (<30 day), deep vascular groin infections without (Szilagyi II) or with (Szilagyi III) exposed vascular graft or suture line between January 2004 and December 2008 were reviewed. Graft preservation followed by local wound care with VAC was attempted in all with intact anastomoses, patent grafts, and absence of systemic sepsis. Szilagyi classification, microorganism cultured, duration of VAC use, time to healing, additional interventions, and follow-up data (limb salvage, survival) were analyzed. RESULTS: Twenty-two patients (26 groins, mean age 69.1 +/- 9.5 years [range, 44-86 years]) presented with deep groin infections 16 +/- 5 days (range, 7-28 days) after the index procedure (bypass-polytetrafluoroethylene [n = 11], autologous vein [n = 3], endarterectomy/patch [n = 6], extra-anatomic bypass [n = 5], percutaneous closure device [n = 1]). Grafts were exposed in 12 groins (Szilagyi III, nine with suture lines). VAC was started one to six days (median, three) after operative debridement. All had positive wound cultures and received culture-directed antibiotic therapy for 47 +/- 45 days (range, 14-180 days). Length of stay was significantly more in Szilagyi III, whereas mean VAC use and time-to-healing were similar. Mean follow-up was 33.4 +/- 19.5 months (range, 2-72 months). All wounds healed (mean, 49 +/- 21 days). Two treatment failures occurred in the Szilagyi III group (17%). One patient had bleeding from the anastomotic heel eight days after debridement, had graft removal/in situ replacement and one presented with reinfection on day 117 and had partial graft removal/extra-anatomic bypass. There was no perioperative mortality or limb loss, but six late unrelated mortalities and one amputation at 46 months unrelated to the groin infection. CONCLUSIONS: Management of early, deep groin wound infections with debridement, antibiotics, and VAC treatment is safe and enables graft preservation in the majority of patients with minimal morbidity, no perioperative limb loss, or mortality.
