Excision of a giant anterior chest wall neurofibroma and chest wall reconstruction with methlymethacrylate and vertical rectus abdominis musculocutaneous flap: case report.

INTRODUCTION: Plexiformneurofibromas (PNFs) are benign nerve tumours resulting from aberrant growth of cells of nerve sheath. PNFs are generally painless, slow growing neoplasms. Although most neoplasms are asymptomatic, they can be particularly debilitating due to their potential to grow to very large sizes. They have potential for transformation into highly malignant peripheral nerve sheath tumours which occur in approximately 5% of patients. They can affect most parts of the body. When they occur in the chest wall, they are amenable to excision. Following excision, a surgeon is faced with a large skeletal and soft tissue defects which pose functional and cosmetic challenges. CASE PRESENTATION: We present a 24-year-old farmer that presented with a giant anterior chest wall plexiformneurofibroma that was noticed since childhood. He had excision of the mass and skeletal reconstruction with methylmethacrylate sandwiched in prolene mesh and softtissue coverage with vertical rectus abdominismusculocutaneous flap. CONCLUSION: We conclude that the use of methylmethacrylate and myocutaneous flaps give both good functional and cosmetic outcome following excision of large chest wall tumours.

Severe burn trauma from deliberate self-harm: the Sokoto experience.

BACKGROUND: Burn injury is one of the most severe forms of trauma that can afflict mankind. Although several forms of suicide and para suicide have been reported worldwide, severe burn injuries from deliberate self-harm have been poorly documented in Africa. AIM: To evaluate the pattern of deliberate self-harm by burning in our environment. METHOD: This is a 5-year retrospective analysis of all patients who sustained burns from deliberate self-harm (DSH) seen at the Usmanu Danfodiyo University Teaching Hospital, Sokoto from June 1998 to May 2003. The patients' data and other necessary information were extracted from the case notes. RESULTS: Seven patients were seen over the study period. There were six females and one male, giving a female to male ratio of 6:1. All the injuries occurred at home from kerosene flame burns. In all cases, the intent was to take the patient's own life. The triggering factors were mainly psychosocio-economic. Six patients had up to secondary education while one patient had a degree certificate. None of the patients was gainfully employed at the time of incidence. Two patients had previously attempted suicide. Only one patient had a history of psychiatric illness. All sustained severe flame burns ranging from 45% - 98% body surface area (BSA). Compliance to treatment was generally poor. All patients were managed at the intensive care unit (ICU) of the hospital.. Five patients died, while the remaining two signed against medical advice (SAMA) during the course of management. The duration of hospital stay ranged from 2 - 10 days. CONCLUSION: Severe burn injury from DSH, although previously poorly documented in Africa, is not uncommon in our environment. The morbidity and mortality are high, not only because of the nature of injury, but probably because of poor compliance to treatment. We advocate community based studies and routine screening of adolescents to identify those at risk. The need for the establishment suicide information, intervention and prevention centre in Nigeria cannot be overemphasised.

Cutaneous manifestations of malignant disease: a review.

BACKGROUND: The skin is the largest and most accessible organ in the body. Internal malignancies can produce a wide range of cutaneous manifestations that are often neglected by clinicians. This review aims to increase the awareness of clinicians by highlighting the various cutaneous manifestations of common internal malignancies. METHOD: A review composed via Medline Internet search, literature search and contributions from our experiences as well as shared experiences from colleagues over the years. RESULTS: The skin can be involved in systemic malignancy in a variety of ways: secondary spread; as part of a genetic or acquired syndrome; as a consequence of immunosupression or as paraneoplastic phenomena. The cutaneous markers of malignancy may occur before, at the same time as, or after the diagnosis of the tumour. While in some instances the skin lesion abates with the treatment of the primary tumour, relapse of a previously treated cutaneous disease can herald recurrence of the tumour. CONCLUSION: Systemic malignancies could, and do, produce a wide range of skin manifestations that are easily seen but often neglected by clinicians. A good understanding of these features will aid prompt and appropriate diagnosis, upon which the necessary treatment could be anchored.

Bacterial isolates from necrotizing fasciitis: a clinico-pathological perspective.

BACKGROUND: Necrotizing fasciitis (NF) is a progressive, polymicrobial, potentially fatal soft tissue infection that can affect both sexes, all age groups and any anatomical region of the body. Identification of the offending microorganisms is important, since the eventual outcome of treatment is dependent on aggressive surgical, chemotherapeutic and supportive therapy. AIM: To determine the spectrum of aerobic bacterial organisms responsible for NF in Sokoto, Northwestern Nigeria, and to establish a baseline for which further studies can be conducted. PATIENTS AND METHODS: A 5-year prospective study of aerobic bacteria isolated from all consecutive patients with NF seen at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from January 2001 to December 2005. All necessary information from each patient was fed into the computer for analysis. RESULTS: There were 62 patients, of which 33 (53.2%) were males while the remaining 29 (46.8%) were females. The ages ranged from six days to 70 years (mean = 21.4 years). One or more precipitating factors were identified in 32 (51.6%) patients, while 40 (64.5%) patients had identifiable pre-morbid pathology. The body surface area (BSA) involved ranged from 1 31% (mean = 5.2%). The commonest anatomical region involved was the trunk in 23 (37.1%) patients; this was followed by the lower limbs, upper limbs, head and neck, perineum and buttocks in that order. From the 62 patients, 176 aerobic cultures were carried out. Of this, 147 cultures (83.5%) were positive, while the remaining 29 (16.5%) grew no organisms after 48 hours of incubation. The commonest offending organisms were Staphylococcus aureus and Pseudomonas aeruginosa. Infection was polymicrobial in 64% of patients. Cephalosporins, quinolones and aminoglycosides were the most sensitive antibiotics. Multiple wound debridements were required in nearly half of the patients. The duration of hospital stay ranged from 3 132 days (mean=39 days). The overall mortality was 14.5%. CONCLUSION: NF is essentially polymicrobial, deriving significant contributions from both gram-negative and gram-positive bacteria. The cultural characteristics of the disease, and sensitivity to antibiotics, require periodic assessments.

Spontaneous liver rupture in pre-eclampsia.

Spontaneous liver rupture is a rare complication of pre-eclampsia. A booked, 30-year old woman with pre-eclampsia and twin gestation developed severe abdominal pains 10 hours after a supervised, vaginal delivery. On examination she was in hypovolemic shock with abdominal distension from hemoperitoneum. Uterine rupture was suspected and she had a laparotomy after resuscitation. But at surgery the uterus was intact and instead liver rupture was found which was managed by omental packing after evacuating the clots. Postoperatively, the patient developed acute renal failure that responded well to treatment. The mother and her babies were discharged in good health after 15 days of multidisciplinary management.

Malignant peripheral nerve sheath tumour associated with von Recklinghausen's disease: case report.

Only a few cases of malignant peripheral nerve sheath tumour (MPNST) associated with Von Recklinghausen's disease or type I neurofibromatosis (NF-1) have so far been reported worldwide, yet the primary disease (NF-I ) does not seem rare even in Africa. We present a case of a 40 year old woman with MPNST of the left thigh associated with NF-1. The diagnosis was based on clinical, radiological and histopathological evidence. She presented with a 25 year history of painless, multiple, generalized skin nodules and hyperpigmented spots. She also noticed a gradually progressive, painless, redundant mass on the left side of the forehead 16 years prior to presentation. Four months before presentation, she noticed another mass at the back of the left thigh, which increased rapidly in size. Examination revealed a middle aged woman with generalized subcutaneous nodules of various sizes (3mm - 2.5cm), multiple café-au-lait spots (2cm-4.5cm), a plexiform neurofibroma on the left side of the forehead measuring 6cm x 5cm x 5cm. There was a firm, non-pulsatile and non-tender mass (11.5cm x 9cm x 5cm) on the posterior aspect of the left upper thigh. The mass was more mobile longitudinally than transversely and was attached to the overlying skin at the summit, the regional Iymph nodes were not enlarged. Most investigations were essentially normal except a plain radiograph, which revealed a soft tissue mass on the left thigh without bony involvement. At surgery, a well localized soft tissue tumour, abutting on the sciatic nerve was widely resected without neural damage to the nerve. Histologic sections of a tru cut as well as the surgical specimens showed a tumour consisting of closely packed serpentine cells arranged in palisades; marked nuclear and cellular pleomorphism and hyperchromatism, many bizarre tumour giant cells, mitotic figures and foci of necroses. The patient received six courses of cytotoxic therapy and is well eleven months after surgery. It is presented to highlight the clinical and pathological features of NF-1 complicated with malignant transformation.

Arteriovenous fistula for patients on long term haemodialysis in jos, Nigeria.

BACKGROUND: The introduction of haemodialysis has prolonged the lives of patients with end-stage-renal disease (ESRD). To maintain them on long-term dialysis, vascular access procedures are required. OBJECTIVES: To describe the experience with arteriovenous fistula (AVF) from a developing country. METHODS: Eighty-two AVF were created in 74 patients on maintenance haemodialysis. They all had side-to-end AVF using prolene 7/0 monofilament suture for anastomoses. RESULTS: There were 55 males and 19 females with a male: female ratio of 2.9:1. The ages ranged from 18 to 70 years with a mean of 43.4 "12.1 years. Most of the AVF created were on the left upper limbs with the radio-cephalic and brachio-cephalic accounting for more than 70% . Eight patients developed thrombosis of the veins used for the AVF and one developed a pseudo aneurysm. CONCLUSIONS: Arteriovenous fistula makes long-term haemodialysis feasible. It can be created easily and has a low rate of complications.

Managing scalp defects in sub-Saharan Africa.

OBJECTIVES: To determine the common aetiological factors of scalp defects, and outcome of management. DESIGN: A two year prospective study. SETTING: Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. SUBJECTS: All consecutive patients with scalp defect from January 2001 to December 2002. MAIN OUTCOME MEASURES: Size of defect, associated bone loss, osteomyelitis, type of surgery, duration of hospital stay and complications of surgery. INTERVENTIONS: Patients went through a simple management protocol involving history, clinical examination, relevant tests and appropriate treatment, including surgery. RESULTS: A total of 27 patients were studied out of which 15 were males and 12 females, giving a male to female ratio of 1.25:1. The age range was seven months-42 years (mean = 13.9 years). Road Traffic Accidents (RTAs) was the commonest cause of scalp defects (81.5%). The temporo-parietal area was involved in over 50% of patients. Chronicity and osteomyelitis were common complications of the defects. Over 50% of the patients had local flap reconstruction. CONCLUSIONS: Management of scalp defects remains a major challenge in our environment. The importance of continuing education of colleagues and other health workers in peripheral health units on the importance of proper initial wound debridement and early referral cannot be overemphasised.

Chronic osteomyelitis in patients with sickle cell disease.

OBJECTIVE: To determine the baseline pattern and audit management modalities of chronic osteomyelitis in patients with sickle cell disease. DESIGN: A retrospective study. SETTING: Jos University Teaching Hospital, Jos, Nigeria from August 1993 to July 1997. PATIENTS: Twenty four patients with concomitant chronic sickle cell disease. INTERVENTIONS: Fifteen patients had operations; eleven had sequestrectomy and curettage while four had incision and drainage. Eight patients were treated with antibiotics alone and one patient refused surgery. MAIN OUTCOME MEASURES: The demographic data of patients, aetiological agents, culture and sensitivity patterns, aetiopathogenesis, treatment modalities and outcome were analysed. RESULTS: Twenty four (36.9%) out of 65 patients who had chronic osteomyelitis also had sickle cell disease. Male:female ratio was 1.2:1. The peak age incidence (37.5%) was in the first decade of life. Seventy five per cent of infections were haematogenous. The most frequently isolated organism was Staphylococcus aureus (58.8%) while the rest were Gram negative organisms. There was no case of Salmonella osteomyelitis. The most sensitive antibiotics were gentamicin and the third generation cephalosporins. Twelve patients (50%) had good results while eight (33.3%) were still undergoing treatment. Complications recorded were persistent discharging sinuses in two cases, recurrence of symptoms in one and pathological fracture with non-union in one patient. CONCLUSION: Though the incidence of Gram negative organisms in causation of chronic osteomyelitis in patients who have sickle cell disease is high (41.2%), Salmonella osteomyelitis may be related to endemicity of the organism in a given locality.

Testicular torsion on the Jos Plateau.

In order to determine the pattern and the factors that influenced outcome, we retrospectively studied fifty-seven patients with torsion of the testis admitted to the Jos University Teaching hospital between August 1993 and July 2001. The age ranged from 2 to 55 years with a mean of 22.7 years. Majority (79%) of the patients were in the second and third decades of life. The main suspected precipitating factors in this study were cold weather and scrotal trauma: in 28% of the cases no cause could be ascertained. Eight (14%) patients presented within 4 hours and 35 (61%) presented after 24 hours of the onset of symptoms. Both sides were equally affected. Testicular pain, retraction and scrotal swelling were the most common presenting complaints. The highest incidence 65%) occurred between November and February when the weather on the Jos plateau is coldest. At surgery, 34 (60%) patients were found to have associated congenital anomalies; in 22 (39%) patients, the testis was non-viable. There was no mortality in this series and the complications were superficial wound infection (14%), testicular atrophy (7%) and sub-fertility (16%). High index of suspicion in a patient with acute scrotum, prompt and effective surgery will improve testicular salvage.

Adult intussusception: the Jos experience.

Twenty two consecutive cases of adult intussusception managed between January 1990 and December 1998 at Jos University Teaching Hospital formed the basis of this study. Thirteen (59.1%) of the patients were males and 9(40.9%) females, with a male to female ratio of 1:4:1 and a mean age of 49.6 years. Most patients were referred late to our service as a result of poor index of suspicion and misdiagnosis. Laparotomy was done in all the cases and in 5(22.7%) patients no cause could be found, but in the remaining 17(77.3%) definite causes were identified which were mainly polyps in 7(31.8%) patients and colonic malignancies in 4(18%). The ileocolic intussusception was the commonest variety. Sixteen (72.7%) patients had bowel resection for colonic carcinoma, gangrenous bowel and irreducibility of the intussusception while manual reduction was successful in the other 6(27.3%) patients. The morbidity rate was 22.7% and the complications were wound infection and adhesive intestinal obstruction. Two deaths were recorded with a mortality rate of 9.1%. The pattern of adult intussusception as seen in the western world was observed in this tropical highland.

Open haemorrhoidectomy revisited.

The open method of haemorrhoidectomy has been criticized because of slow wound healing, severe pain and prolonged post operative care. This has led to a shift of interest to other methods of haemorrhoidectomy. These grounds of criticism need to be re-appraised for a rational conclusion and recommendation. Thirty nine consecutive patients who had open haemorrhoidectomy between 2nd and 3rd degree haemorrhoids from May, 1998 to April, 1999 were prospectively assessed for wound healing rate and complication rate. There were 26 males and 13 females (ratio 2:1). The average length of hospital stay was 3 days. Post operative pain and acute retention of urine were the commonest complications. The mean wound healing rate was 5 weeks, with a peak (30.8%) in the 5th post operative week. The mean cost of management was thirty eight U.S. Dollars ($38.00) or four thousand, five hundred and ninety three Naira. (N4,593.00). Open haemorrhoidectomy remains a safe and simple surgical technique that should not be discarded in complete preference to newer innovative methods.

Palatal avulsion injury by a foreign body in a child.

A 6-year-old girl who claimed to have fallen while playing with metal rod that resulted in palatal avulsion injuries was presented. Neither of the parents was around when the incidence happened. She was brought to the hospital because of pain, bleeding from the mouth, drooling of saliva mixed with blood and inability to feed or phonate appropriately. Examinations of the oral cavity revealed a triangular area of avulsion in the posterior aspect of the hard palate extending to the soft palate. She had examination under anaesthesia and wound repaired with 3-0 vicryl interrupted sutures after thorough wound debridement. She did well and was discharged from the clinic.

Abdominal Wall Reconstruction Using De-epithelialized Dermal Flap: A New Technique.

BACKGROUND: Although autogenous materials have been used in abdominal wall hernioplasty for a long time, the introduction of prosthetic materials diminished their popularity. However, these materials may be expensive, inappropriate or unavailable. The aim of this study is to determine the place of de-epithelialized dermal flap in the reconstruction of abdominal wall hernias. MATERIALS AND METHODS: A five-year prospective, descriptive analysis of eligible patients with difficult abdominal wall hernias closed with de-epithelialized dermal flap in a Nigerian Tertiary Health Institution, from January 2001 to December 2005. RESULTS: Over the five-year period, 37 patients were recruited into the study. There were 11 males and 26 females, giving a male: female ratio of 1: 2.4. The ages ranged from 8 months to 47 years (mean = 12.6 years). The defects consisted of 15 incisional hernias, 12 intermuscular/inferior lumbar hernias, nine healed exomphalos major and two giant umbilical hernias. The size of the hernia defects ranged from 4.5 cm to13cm (mean = 6.4 cm). Three patients had bowel resection and end-to-end anastomosis, in addition to the flap reconstruction. Morbidity was minimal and included skin dimpling in 11 patients, seroma in three, and wound infection in two patients. Neither recurrence of herniation nor mortality was recorded during the period of follow-up, which ranged from three months to 4.5 years (mean = nine months). CONCLUSION: The results suggest that this is a useful technique that can easily be applied in many centers with minimal resources. It is cheap, effective and associated with minimal morbidity.

Mature sacrococcygeal teratoma: case report.

BACKGROUND: Mature sacrococcygeal teratomas (SCT) are uncommon neoplasms comprised of mixed elements derived from the three germ cell layers. They attract attention because of their gross appearance and bizarre histology. AIM: To demonstrate the clinical presentation and management of mature SCT in a neonate. PATIENT AND METHOD: A case report of a neonate with mature SCT is hereby presented. RESULTS: A 10-day old baby boy presented with a mature SCT comprising well- developed lower limb, rudimentary external genitalia and teeth. He had complete surgical excision (including coccygectomy) with primary wound closure and uneventful postoperative recovery. Follow-up at three years using clinical, biochemical and radiological assessment revealed no evidence of recurrence. CONCLUSION: Mature SCT appear to be entirely benign during the neonatal period. Complete surgical excision remains the mainstay of treatment.

Necrotising fasciitis: experience with 32 children.

BACKGROUND: Necrotising fasciitis (NF) in children is rare, rapidly progressive and potentially fatal. A satisfactory outcome depends on early diagnosis and aggressive surgical debridement, along with appropriate antibiotic therapy. AIM: The aim was to describe the various presentations of NF and evaluate outcome of treatment. PATIENTS AND METHODS: This was a 4-year prospective, descriptive study of all consecutive cases of NF aged 15 years and under treated at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from January 2001 to December 2004. RESULTS: Thirty-two children were treated during the study period. The male:female ratio was 1.7:1. Ages ranged from 6 days to 12 years (mean 2 yrs). The commonest predisposing factors were malnutrition (40.6%), boils (37.5%) and intravenous canulation (9.4%). Duration of symptoms ranged from 3 to 19 days (mean 6.4) and the total body surface areas involved ranged from 2% to 16% (mean 5.9%). Half of the patients presented with involvement of the trunk, followed by head/neck (28.1%), upper limbs (21.9%), lower limbs (6.3%) and perineum (6.3%). Most patients had polymicrobial infection, but the organism most commonly isolated was Staphylococcus aureus (71.9%). All patients were resuscitated and had surgical wound debridement, antibiotics and wound care. Final wound resurfacing was by secondary intention (46.9%), direct suturing (6.3%), split thickness skin grafting (21.9%) and local flap reconstruction (12.5%). Septicaemia was the commonest complication (71.9%). The mortality rate was 9.4%. Duration of hospital stay ranged from 14 to 96 days (mean 27.6). Follow-up ranged from 3 weeks to 6 months (mean 52.4 days). CONCLUSION: NF in children is not uncommon in Nigeria. It is associated with significant morbidity, but mortality can be reduced remarkably by early diagnosis and aggressive treatment.

Childhood intussusception: a 9-year review.

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.