Septic emboli from pyomyositis.

Pyomyositis commonly presents with fever, muscle pain and abscess formation involving deep soft-tissue compartments. Staphylococcus aureus is the main causative organism and diagnosis is usually established clinically, supported by imaging, but confirmation may be achieved by histopathological examination. Broad-spectrum antibiotic therapy and surgical debridement are the cornerstone of treatment. Its prognosis is good but, as in all soft-tissue infections, it depends on early intervention, directed antibiotics and, if indicated, prompt surgery. In this paper, we describe a case of pelvic pyomyositis complicated with bacteraemia and bilateral septic pulmonary emboli in a young man in Colombia.

Actinomycotic Endometritis.

Seven cases of actinomycotic endometritis were identified among 28,906 endometrial biopsies performed in the last 10 yr. The patients' ages ranged from 44 to 85 yr old. An intrauterine device was in place from 7 to 44 yr. The reasons to perform the biopsies included abnormal uterine bleeding, malodor, prolapse, pelvic inflammatory disease, and suspicion of metastatic uterine sarcoma. Definitive identification of Actinomyces israelii by culture was obtained in 1 case only. Gram, Gomori methenamine silver, and Fite stains were useful in the differential diagnosis with pseudoactinomycotic granules, Nocardia, fungi, and other bacteria. The Actinomyces-like organisms were surrounded by extensive suppurative reaction in all cases. The tissues showed florid neutrophilic and plasmacytic inflammation. The treatment consisted of intrauterine device removal and 10 to 30 d of antibiotics in 4 patients. The Actinomyces-like organisms persisted for 6 wk in spite of antibiotic therapy when the intrauterine device removal was delayed in one of those cases. Two patients had hysterectomy and salpingo-oophorectomy due to tubo-ovarian abscess and hysterectomy, salpingo-oophorectomy, and rectosigmoid excision due to pelvic abscess and septic emboli, both followed by 30 to 45 d of antibiotic therapy. One patient had hysterectomy not followed by antibiotics due to prolapse. No other pelvic abscesses were identified on follow-up, which ranged from 4 to 101 mo (median, 20 mo; mean, 44 mo).

Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help?

AIM: Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these multi-visceral resections leads to fluid accumulation and translocation of bowel within the pelvic cavity, which may increase the risk of pelvic abscess, perineal fluid discharge with perineal wound dehiscence and prolonged ileus. This study describes a novel technique using degradable synthetic mesh with overlying omentum to preclude small bowel and fill the empty space after total pelvic exenteration, and aimed to investigate the rate of pelvic abscess and perineal wound-related complications in this group. METHOD: Ten patients who underwent total pelvic exenteration followed by implantation of degradable synthetic mesh at a quaternary referral centre were identified and included. The mesh was moulded to the contours of the bony pelvis at the level of the pubic symphysis anteriorly and inferior to the sacral promontory posteriorly. The data on the number of postoperative perineal wound-related complications including pelvic abscesses were collected. RESULTS: There was no perioperative mortality. Five patients (50%) developed postoperative complications. One patient developed an abscess inferior to the mesh that required surgical drainage and another had a pre-sacral collection that was successfully managed conservatively. Two patients developed intra-abdominal collections requiring percutaneous drainage. Median length of stay was 20 days (range 16-35). No perineal hernia or entero-perineal fistula was detected in any patient either clinically or radiologically at a median follow-up of 7 months. CONCLUSION: Degradable synthetic mesh reconstruction following exenterative surgery may reduce postoperative complications related to the perineal wound.

Scrub typhus: radiological and clinical findings in abdominopelvic involvement.

PURPOSE: To describe the clinical and radiological findings of abdominopelvic involvement in scrub typhus. MATERIALS AND METHODS: Abdominopelvic computed tomography (CT) of 78 patients with scrub typhus were evaluated by two readers. The presence of gallbladder wall thickening, arterial inhomogeneous enhancement of the liver, periportal edema, splenic infarction, hepatomegaly, splenomegaly, ascites, pleural effusion, and sites of lymphadenopathy were evaluated. Patients were divided into four clinical subgroups according to laboratory findings. Association between imaging findings and subgroups was analyzed by Chi squared test or Fisher's exact test. RESULTS: The most common CT finding was hepatomegaly (74.4%), followed by splenomegaly (66.7%). The majority of patients had at least three areas of abdominopelvic lymphadenopathy (71.8%). Pelvic lymphadenopathy was most commonly seen when eschar was found in the ipsilateral lower extremity (left, n = 5/7; right, n = 8/13). Significant association between hepatic dysfunction and perigastric lymphadenopathy was documented (p = 0.03). CONCLUSION: Scrub typhus has a spectrum of variable clinical and radiological findings mimicking those of acute hepatitis. Diffuse abdominopelvic lymphadenopathy involving the retroperitoneum and pelvic area may aid in early diagnosis of scrub typhus. Perigastric lymphadenopathy could be a sign of severe scrub typhus combined with hepatic dysfunction.

Intra-abdominal bacterial contamination in TAMIS total mesorectal excision for rectal carcinoma: a prospective study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is currently gaining a lot of attention. NOTES is expected to further reduce surgical trauma and improve patient care due to eliminating abdominal incisions. The interest in transrectal NOTES has grown slowly, because of concerns of bacterial contamination due to transection of the rectum at the start of the procedure. However, different studies already demonstrated that transanal TME (TaTME) can be performed without major complications. This prospective study focuses on the presence and clinical significance of peritoneal bacterial contamination after TaTME for rectal cancer. METHODS: Three bacterial cultures were taken at standardized locations from the pelvic area after completion of the TaTME procedure and before closure of the incisional wounds. The cultures were evaluated for bacterial count and species identification. Furthermore, C-reactive protein and white blood cell count were measured perioperatively, and postoperative complications were recorded. RESULTS: Twenty-three consecutive patients were included between July 2013 and December 2014. Thirty-nine percent (9/23) of the cultures showed gastrointestinal flora. Four of these patients (44 %) developed presacral abscesses. The remaining 61 % (14/23) of the cultures were negative. None of these patients developed infectious complications. CONCLUSION: Transanal TME procedures are associated with positive cultures in more than one-third of the patients. In these patients, postoperative locoregional infectious complications are more common.

Medial approach for drainage of the obturator musculature in children.

BACKGROUND: In a recent study designed to determine the anatomic location of infection in children presenting with acute hip pain, fever, and elevated inflammatory markers, we demonstrated the incidence of infection of the musculature surrounding the hip to be greater than twice that of septic arthritis. Importantly, the obturator musculature was infected in >60% of cases. Situated deep in the pelvis, surrounding the obturator foramen, debridement of these muscles and placement of a drain traditionally requires an extensive ilioinguinal or Pfannenstiel approach, placing significant risk to the surrounding neurovascular structures. We hypothesized that the obturator internus and externus could be successfully debrided using a limited medial approach. METHODS: An IRB-approved prospective study of children (0 to 18 y) evaluated in the pediatric emergency department by an orthopaedic surgeon to rule out septic hip arthritis at a tertiary care children's hospital (July 1, 2010 to June 30, 2012) was conducted. Infected obturator musculature was identified and confirmed using magnetic resonance imaging. Cadaveric dissection was performed comparing the ilioinguinal, Pfannenstiel, and proposed minimally invasive medial approach. The proposed approach was utilized to debride and place drains in 7 consecutive patients. RESULTS: Anatomic information gained from magnetic resonance images of patients with abscess within the obturator musculature, and from the results of cadaveric studies, allowed for planning of a novel surgical approach. We found that through the surgical approach used to perform an osteotomy of the ischium (Tonnis) the obturator externus could be debrided through the adductor brevis and the obturator internus could be debrided through the obturator foramen. Using our medial approach, resolution of symptoms in all children who underwent surgical drainage resulted without complication. CONCLUSIONS: Our medial approach can safely access the obturator musculature for abscess decompression and drain placement with successful results. Advantages to this approach include: lower risk to neurovascular structures within the pelvis, less soft tissue trauma, and similarity to current techniques used for adductor lengthening, medial reduction of the dislocated hip, and osteotomy of the ischium. LEVEL OF EVIDENCE: Level II.

Abdominopelvic actinomycosis mimicking disseminated peritoneal carcinomatosis.

We present a case of a 38-year-old woman who presented with symptoms suggestive of intra-abdominal or pelvic malignancy: marked weight loss, abdominal pain, altered bowel habit, anorexia and fatigue. The findings of multiple peritoneal deposits, adnexal and presacral masses on CT imaging and appearances on diagnostic laparotomy also suggested malignancy. However, the histological analysis was inconsistent with malignancy and revealed an infection with Actinomyces israelii. The patient started a course of intravenous antibiotics and complete resolution is expected. An intrauterine contraceptive device was identified as the likely source of the infection.

Recurrence of pelvic abscess from Panton-Valentine leukocidin-positive community-acquired ST30 methicillin-resistant Staphylococcus aureus.

A 17-year-old female patient (a basketball player) suffered from recurrent pelvic abscesses from methicillin-resistant Staphylococcus aureus (MRSA). The first episode, from strain NN12, occurred in October 2004. Her cutaneous abscesses complicated into systemic progression to osteomyelitis and multifocal pelvic abscesses, adjacent to the sacroiliac joint. The second episode, abscesses at tissues adjacent to the sacroiliac joint from strain NN31A, occurred late in February 2005. The third episode, from strain NN31B, occurred on July 30, 2005, repeating the second episode. Three MRSA strains were identical in terms of genotypes (belonging to Panton-Valentine leukocidin [PVL]-positive ST30 community-acquired MRSA, CA-MRSA), pulsed-field gel electrophoresis patterns, and peptide cytolysin gene (psmα) expression levels. The three MRSA strains exhibited superior THP-1 cell invasion ability over hospital-acquired MRSA (New York/Japan clone). The data suggest that PVL-positive ST30 CA-MRSA, with high levels of cell invasion and peptide cytolysins, causes recurrence of pelvic abscesses in a healthy adolescent.

An unexpected cause of multiple intra-abdominal abscesses in an HIV-positive patient.

This case report describes a female HIV-positive patient diagnosed with pelvic actinomycosis using 16S rRNA gene sequence analysis. Actinomycosis is notoriously difficult to diagnose by microbiological culture. 16S rRNA gene sequence analysis allows rapid definitive diagnosis of actinomycosis and is potentially of great value in a clinical setting. This is the first report of pelvic actinomycosis in an HIV-1 infected patient.

Pelvic tuberculosis mimicking advanced ovarian malignancy.

We sought to identify the characteristic features of pelvic tuberculosis (TB) in women with symptoms and sonogaphic findings which were otherwise consistent with an ovarian malignancy. This study is a retrospective analysis of 138 women who underwent an operation and had a preoperative diagnosis of ovarian malignancy at the Government Medical College Hospital, Chandigarh, from January 2004 to January 2008. Among these 138 women, seven cases (5.7%) of pelvic TB were identified. Abdominal pain and distension were the most common presenting symptoms. All patients had a pelvic mass, six had ascites (85%) and five had a fever (71%). The mean cancer antigen (CA) 125 level was 295 IU (13-529). Pelvic TB can present with symptoms and signs which mimic ovarian malignancy. Therefore, a high-index of clinical suspicion should be maintained when treating patients in countries with a high prevalence of TB.

Primary pyomyositis of the pelvis in children: a retrospective review of 8 cases.

Primary pyomyositis of the pelvic musculature is a condition rarely seen in temperate climates, although its frequency has been increasing in the United States. The condition should be considered in the initial differential diagnosis of an adolescent presenting with fever, difficulty ambulating, and hip pain. This is a retrospective review of 8 cases of primary pelvic pyomyositis in patients aged 18 years or younger who were treated at the Children's Medical Center in Augusta, Georgia. The site of infection was the obturator internus in the majority of the cases (5). The site was the gluteus, iliopsoas, and iliacus in 1 case each. Four patients who were diagnosed early responded to intravenous antibiotics with no need for further intervention. Two patients required incision and drainage of an abscess combined with antibiotics. Two patients had prolonged hospital courses requiring intensive unit care and mechanical ventilation. Blood cultures were positive in 87.5% of patients, and all patients presented with elevated acute phase reactants. One of the most difficult diagnostic aspects of presentation is an inconclusive symptom profile. It is noteworthy that patients with pelvic pyomyositis may present with limited range of motion in a specific plane (the motion placing the infected muscle on stretch) vs global limited range of motion of the joint as is commonly seen in septic arthritis. Early diagnosis is essential to prevent systemic illness and complications associated with this condition. Magnetic resonance imaging with gadolinium is helpful to diagnose and guide treatment.

Abdominal-pelvic actinomycosis mimicking malignant neoplasm.

Abdominal-pelvic actinomycosis is often mistaken for other conditions, presenting a preoperative diagnostic challenge. In a 46-year-old female, computed tomography showed an abdominal-pelvic retroperitoneal mass extending from the lower pole of the right kidney to the lower pelvis. The patient had a 3-year history of intrauterine device. The mass appeared to involve the ascending colon, cecum, distal ileum, right Fallopian tube and ovary, and ureter anteriorly and the psoas muscle posteriorly. The resection of retroperitoneal mass, distal ileum appendicectomy, right hemicolectomy, and right salpingo-oophorectomy was performed. The postoperative period was uneventful. Penicillin therapy was given for six months without any complication. The retroperitoneal mass measured 4.5 × 3.5 × 3 cm, surrounded adjacent organs and histologically showed inflammatory granulomatous tissue, agglomeration of filaments, and sulfur granules of Actinomyces, with positive reaction with periodic acid Schiff. Right tubo-ovarian abscess was present. Abdominalpelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intrauterine device.

Abdominal and pelvic coccidioidomycosis.

Coccidioidomycosis is a fungal infection endemic to the Southwestern United States that has a clinical presentation resembling community-acquired pneumonia. Disease occurs after inhalation of airborne arthroconidia. Dissemination to a variety of organ systems via hematogenous spread from a primary pulmonary focus may then occur. Coccidioidomycosis rarely involves the abdominal cavity. The authors review the spectrum of abdominal and pelvic presentations of coccidioidomycosis and report 6 unusual cases, including acute appendicitis, hepatitis and adnexal masses. Pathologists played a critical role in the diagnosis of these presentations by recognizing spherules in tissue. In only 2 of the cases were Coccidioides species cultured.

Diagnosis of pelvic tuberculosis in a patient with tubal infertility.

OBJECTIVE: To describe a case of pelvic tuberculosis presenting as primary infertility and discuss the various diagnostic modalities. DESIGN: Case report. SETTING: Academic reproductive medicine center. PATIENT(S): A 28-year-old nulliparous Indian immigrant presenting with primary infertility and known tubal pathology. INTERVENTION(S): Laparoscopic bilateral salpingectomy and adhesiolysis and diagnostic endometrial sampling. MAIN OUTCOME MEASURE(S): Acid-fast bacilli were obtained on polymerase chain reaction and culture of endometrial sample. RESULT(S): The patient was diagnosed with pelvic tuberculosis and treated with a directly observed multidrug regimen. CONCLUSION(S): Tuberculosis is an important cause of gynecologic morbidity and should be considered in the appropriate patients.