Late-Onset Mesh Infection Manifesting as Preperitoneal Abscess and Cutaneous Fistula Post-TEP Inguinal Hernia Repair: A Case Report.

BACKGROUND Endoscopic inguinal hernia repair has become the preferred technique currently. The use of mesh to facilitate a tension-free reinforcement has become the standard of care during endoscopic totally extraperitoneal (TEP), laparoscopic transabdominal pre-peritoneal, and open inguinal hernia repair. Although uncommon, late-developing mesh infections, defined as those occurring in the surgical site months or years after the procedure, can lead to severe complications. To achieve the best possible outcome for the patient, prompt imaging and a multidisciplinary approach to management, including complete surgical removal of the contaminated mesh and proper antibiotic therapy, are crucial. CASE REPORT A 39-year-old woman presented with a 1-month history of intermittent fever, progressive lower abdominal pain and fullness, and purulent discharge from the abdominal wall. Her medical history was significant for an endoscopic right TEP inguinal hernia repair performed 3 years earlier, which involved the use of an anatomic mesh and titanium screws. Physical examination and ultrasound findings revealed a large preperitoneal abscess with cutaneous fistulization, secondary to a deep-seated mesh infection. Pseudomonas aeruginosa was identified as the causative pathogen. She underwent a 2-step surgical procedure, including an initial fistulectomy followed by endoscopic abscess drainage and surgical excision of the infected mesh, combined with antimicrobial therapy, resulting in an excellent clinical response and complete resolution. This strategy also allowed for an effective assessment of the abdominal wall integrity. CONCLUSIONS This case underscores the importance of considering late-developing mesh infections in patients presenting with abdominal symptoms who have previously undergone TEP hernia repair, even years after the initial surgery.

Staged surgical treatment for infection of total disc arthroplasty: three cases and a narrative review of the literature.

Although total disc arthroplasty (TDA) is a common procedure for selected cases of degenerative disc disease, until today there are only two cases of TDA infections reported in the literature. We report three cases of postoperative TDA infections, two developed cutaneous fistulas. To eradicate the infectious site, a staged removal of the device, resolute debridement, and stabilization plus fusion is proposed. Surgeons are challenged by (1) major retroperitoneal vessels adherent to the device, (2) surrounding scar tissue, (3) accompanying retroperitoneal abscess, and (4) technical issues when removing and replacing the implant. A staged multidisciplinary team approach involving vascular and plastic surgery as well as spine specialists is mandatory to achieve good results.

Clinical, microbiological, immunological and imaging characteristics of tunnels and fistulas in hidradenitis suppurativa and Crohn's disease.

Hidradenitis suppurativa (HS) tunnels and Crohn's disease (CD) fistulas are a challenge to treat. Although pathogenic similarities have been described between HS and CD, recent studies indicate that clinical, microbiological, immunological and imaging characteristics differ between these diseases. This review highlights the differences between HS tunnels and CD fistulas. Next-generation sequencing studies demonstrate a microbiome in HS tunnels dominated by Porphyromonas spp., Prevotella spp. whereas no specific bacteria have been associated with cutaneous CD. Immunologically, TNF has been found upregulated in HS tunnels along with various interleukins (IL-8, IL-16, IL-1α and IL-1ß). In CD fistulas, Th1, Th17, IL-17, IFN-ɤ, TNF and IL-23 are increased. US imaging is an important tool in HS. US of HS tunnels depict hypoechoic band-like structure across skin layers in the dermis and/or hypodermis connected to the base of a widened hair follicle. In CD, MR imaging of simple perianal fistulas illustrates a linear, non-branching inflammatory tract relating to an internal opening in the anus or low rectum and an external opening to the skin surface. An increased awareness of the immediate potential differences between HS tunnels and CD fistulas may optimize treatment regimens of these intractable skin manifestations.

Primary and secondary arterial fistulas during chronic Q fever.

OBJECTIVE: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.

Healing of spongiosus-cutaneous fistula with Hyperbaric Oxygen Therapy (HBOT): a case report.

INTRODUCTION: We present a case of a spongiosus-cutaneous fistula in a 39-year-old man with recurrent episodes of cutaneous abscess in dorsal middle third penis (5 × 3 cm) treated with Hyperbaric Oxygen Therapy (HBOT). CASE REPORT: After emptying nodular abscess, the patient was noncompliant for further surgery. Therefore, it was suggested the association between HBOT and antibiotic therapy. HBOT is carried out in a hyperbaric room, where the internal pressure is increased (compression phase) by entering compressed air up to 283.71 kPa in about 10 minutes. Every HBOT cycle lasted 24 days in which the patient had been taking Amoxicillin/Clavulanic Acid 875 mg/125 mg 3 tabs/day and Sulfamethoxazole/Trimethoprim 160 mg/800 mg 2 tabs/day for 2 weeks. At the end of the treatment, a penile magnetic resonance imaging and an ultrasonography were executed and they evidenced a complete remission of the lesion. In the subsequent 22 months, there was no recurrence. CONCLUSIONS: Our results suggest that HBOT is an effective treatment for chronic wounds, including a spongiosus-cutaneous fistula of unknown cause, when used in combination with conventional standard therapy or further interventions. At present time, the gold standard remains surgery; nevertheless, our experience with HBOT may stimulate its use in clinical trials.

Arteriocutaneous Fistula Associated with Bilateral Femoral Pseudoaneurysms Caused by Bacillus Calmette-Guérin. Apropos of a Case and Review of Literature.

Vascular complications of intravesical instillation of bacillus Calmette-Guérin (BCG) are rare. BCG is an attenuated strain of Mycobacterium bovis that was initially developed for vaccination against tuberculosis, but it has also been used as an adjuvant treatment for bladder transitional carcinoma. We report a patient with a history of instillation of BCG 2 years before, who underwent surgical treatment of 2 pseudoaneurysms. The first, located in the left superficial femoral artery (SFA), was resected, and the artery was ligated because he had a history of femoropopliteal occlusion. After 4 weeks, he presented another one associated with hemorrhage by cutaneous fistula, in the right common femoral artery. In this case, revascularization was performed by means a common-to-deep femoral artery bypass with polytetrafluorethylene graft and reimplantation of SFA. Initially, bacterial cultures were negative, but bacilli cultures identified M. bovis after 3 weeks. Antituberculosis therapy was administered. After 13 months, the patient was asymptomatic and duplex ultrasound showed no signs of recurrent infection. This exposure should be considered if presentation of the false aneurysm is spontaneous and there is a history of bladder carcinoma.

Sternal wound infections following open heart surgery - a review.

Surgical site infections (SSIs) are common complications after open heart surgery. Fortunately, most are superficial and respond to minor wound debridement and antibiotics. However, 1-3% of patients develop deep sternal wound infections that can be fatal. Late infections with sternocutaneous fistulas, are encountered less often, but represent a complex surgical problem. This evidence-based review covers etiology, risk factors, prevention and treatment of sternal SSIs following open heart surgery with special focus on advances in treatment, especially negative-pressure wound therapy.

Fístula cutánea: un caso clínico / Cutaneous fistula: a clinical case

Objetivo: diagnosticar y tratar la presencia de una fístula cutánea. Caso clínico: un paciente de sexo masculino, de 9 años de edad, consultó por una lesión cutánea en la zona mandibular del lado izquierdo. Concusiones: una fístula cutánea requiere un diagnóstico diferencial preciso, a fin de determinar su etiología y planificar el procedimiento endodóntico correcto. Como consecuencia de una mortificación pulpar, la presencia de bacterias dentro del conducto radicular puede generar una periodontitis perirradicular crónica de origen endodóntico.

[Multiple sites extrapodal actinomycetoma: Favorable outcome to treatment with a combination of cotrimoxazole and NSAI]. / Mycétome actinomycosique extrapodal plurifocal : bonne réponse au traitement par l'association cotrimoxazole et AINS.

Mycetoma is a bacteriological or fungal infectious disease affecting the skin and/or soft tissues, which can be complicated by bone involvement. The most common feature is a tumor of the foot, but extrapodal localizations have been described. We report one case of a 47-year-old man who presented with tumefaction of a leg with multiple skin fistulae. Histopathological examination permitted to confirm the diagnosis of actinomycetoma and TDM showed the degree of bone and soft tissues involvement. Our case was characterized by the very inflammatory aspect of the tumor, its localization to the leg without foot involvement, the modest functional signs compared to the importance of radiological bone involvements, the deep destruction of the fibula while the tibia was apparently intact and the good response to treatment. In spite of its characteristic features, diagnosis of mycetoma is still late in our country, often with bone and/or articular spread. Priority may be given to measures for reduction of mycetoma diagnosis lateness.

Supraclavicular artery island flap for reconstruction of complex parotidectomy, lateral skull base, and total auriculectomy defects.

IMPORTANCE: There are limited data on the use of the supraclavicular artery island flap (SCAIF) for parotid and lateral skull base (LSB) surgery. This flap can be an important reconstructive tool for these procedures. OBJECTIVE: To describe the use of the SCAIF for parotid and LSB surgery and its success, as well as important technique modifications for successful use of the flap in this setting. DESIGN, SETTING, AND PARTICIPANTS: Retrospective single-institution review from July 1, 2011, to September 30, 2013, of patients in a tertiary care referral center. A prospectively collected institutional database was reviewed to identify patients who received SCAIF reconstruction for parotid and/or LSB surgery. Forty-six SCAIF reconstructions were identified; 16 were performed for the indication of parotidectomy or LSB surgery. INTERVENTIONS: The SCAIF reconstruction for parotid and/or LSB surgery. MAIN OUTCOMES AND MEASURES: Indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication. RESULTS: Resection was performed for advanced cutaneous malignant tumor in 10 patients, primary salivary gland malignant tumor in 4 patients, and chronic infection and mastoid cutaneous fistula in 2 patients. All defects were complex, involving multiple subsites; 5 patients underwent facial nerve resection and 4 had previous radiation therapy. No complete flap loss occurred. One partial flap loss occurred. The average flap island size was 7 × 10 cm. No major complications occurred. Two minor reconstruction site complications and 3 donor site seromas occurred. CONCLUSIONS AND RELEVANCE: The SCAIF can be successfully and reliably used for complex defects following parotid and LSB surgery. There are 3 important technique modifications to help facilitate rotation and coverage of this region.

[Pulmonary actinomycosis with chest wall fistula formation in a child]. / Actinomycose pulmonaire fistulisée à la paroi thoracique chez un enfant.

INTRODUCTION: Actinomycosis is a suppurative infection caused by bacteria of the Actinomyces genus. It is a rare cause of pulmonary infection and can be difficult to diagnose because its presentation may mimic tuberculosis or cancer. In the absence of treatment of pulmonary lesions fistulae can develop. We report a case of thoracic actinomycosis with chest wall involvement in a child, managed in the pediatric department at Moulay Youssef University Hospital in Rabat, Morocco. CASE REPORT: We report the case of a 13-year-old boy with a history of trauma to the right chest 1 year earlier, admitted with right-sided chest wall swelling with cutaneous fistulae. Physical examination identified a parietal mass with fistulization to the skin. Laboratory tests showed an inflammatory syndrome. The chest x-ray revealed moderate right pleural effusion. The thoracic computed tomography scan showed a right parietal pleural mass and the percutaneous biopsy confirmed the diagnosis of actinomycosis. The patient underwent antibiotic therapy with favorable evolution. CONCLUSION: The diagnosis, the clinical, radiological and histological pattern, and the therapeutic features are described in this report.

Intracardiac abscess with cutaneous fistula secondary to ventricular septal defect repair simulating sternal wound infection.

Cutaneous fistula as a clinical presentation of intracardiac abscess of the right side is such an unusual occurrence that it has not until now been reported in the English-language medical literature. We present a rare case of right-sided infective endocarditis caused by Achromobacter xylosoxidans in which recurrent infection presented as sternal wound discharge. The infection was found to have an intracardiac origin and was successfully managed by radical débridement on cardiopulmonary bypass.

Orofacial tubercular lesions.

AIM: The aim of this study was to evaluate the clinical characteristics of orofacial lesions like ulcer, swelling, discharge (with or without fistulae), nodules (tubercles), granulomatous growth, induration, diffuse inflammation, and extraction socket involvement in an Indian population through the case reports and review of literature. MATERIAL AND METHODS: Four case reports are presented of patients who had orofacial lesions which turned out to be tuberculous. The diagnosis of tuberculosis was possible because it was kept high on the list of differential diagnosis of orofacial lesions. In our study, we used the following clinical criteria: 1) Suspicious lymph nodes should be biopsied. 2) Excision of non-healing, fistulous, or non-responsive lesions should be considered for biopsy. 3) Histopathological evidence of granulomatous inflammation with epithelioid cells and Langhan's giant cells or acid-fast bacilli should on Ziehl-Neelsen staining. 4) The patients' medical records were reviewed for details relating to presenting signs and symptoms, site and appearance of the lesions, chest x-ray findings, and sputum smear and tuberculosis culture results. RESULTS: In all cases, the patients were prescribed antituberculosis therapy (ATT) by the physician. Strict follow-up was done to ensure completion of intensive phase therapy and both oral as well as pulmonary lesions were resolved. CONCLUSION: Dentists and physicians treating orofacial lesions should be alert to the possibility of orofacial tuberculosis. Medical history should be taken very carefully and lymph node biopsy as well as other radiological and microbiological investigations should be carried out to rule out oral tuberculosis. Antituberculous therapy leads to successful resolution of the orofacial lesions.

An analysis of complex, life-threatening infectious complications of hip and knee joint arthroplasty based on departmental data.

BACKGROUND: The growing popularity of arthroplasty results in an increase in the number of infectious complications. The clinical course of inflammation, silent initial symptoms of the disease and non-medical factors, such as poor public awareness and difficulty in finding specialist care, lead patients to postpone the decision about surgical intervention. This results in a state of imminent threat to health or life by endangering other organs of the body. The purpose of this study was to analyze extreme cases of vital organ damage due to infections following hip and knee replacement procedures. MATERIAL AND METHODS: Retrospective analysis of selected cases of life-threatening infectious complications resulting in vital organ damage (urinary tract, large vessels, cardiorespiratory system, etc.) treated at the Department of Orthopedics at the Center of Postgraduate Medical Education (CPME) over the past 12 years. RESULTS: Establishment of an early diagnosis, and above all, confirmation of periprosthetic infection are extremely important. This allows for a biologically reasonable, early and radical management with the best possible treatment options and prevents the risk of life-threatening complications. CONCLUSIONS: Universal access to antibiotics, suppression rather than treatment of infections, silent and unusual course of septic joint loosening and the lack of sufficient awareness of the problem among physicians, contribute to the reoccurrence of such cases and cause significant treatment challenge. They require management at multidisciplinary centers specializing in such cases and rarely end successfully.

Stump infections after major lower-limb amputation: a 10-year retrospective study.

BACKGROUND AND PURPOSE: There is little published data on the diagnostic and therapeutic management of lower-limb stump infections (excluding toe and forefoot amputations). PATIENTS AND METHODS: We made a retrospective observational study of 72 patients having undergone a major lower-limb amputation for a vascular or traumatic reason, complicated by post-surgical stump infection, between January 1, 2000 and December 31, 2009. RESULTS: Stump infection was diagnosed more than 6weeks after amputation in half of the patients. Staphylococcus was the most frequently isolated bacterium. Ultrasonography and CT scan combined with fistulography were useful to confirm the diagnosis and to determine the extension of infection. Thirty-two patients (44%) needed surgical revision in addition to antibiotic treatment. Patients diagnosed with bone infection more frequently required complementary surgery than those with soft tissue infection (P<0.001). CONCLUSION: The optimal management of this type of infection requires obtaining reliable bacteriological documentation (abscess aspiration in case of soft tissue infection or bone biopsy in case of osteomyelitis) to adapt to the antibiotic treatment. The management should be multidisciplinary (orthopedic or vascular surgeons, rehabilitation specialists, and infectious diseases physicians). Most patients may use prosthesis once the infection is treated.

Open window thoracostomy for the treatment of bronchopleural cutaneous fistula -- case report.

Pleural empyema and bronchopleural fistula (the communication between the pleural space and the airways) are early or late complications of various diseases. We present the case of a 29-year-old patient operated for cavitary pulmonary tuberculosis and giant caseoma at the age of seven, who also had fibrocavitary pulmonary tuberculosis positive for mycobacterium tuberculosis at the age of 19. The patient presented with low grade fever, chills, sweating, cough with mucopurulentsputum, dyspnea on mild exertion, perioral cyanosis, cyanosis of the limbs at exertion, anorexia, weight loss and skin suppuration on the left side of thorax. The diagnosis of chronic pulmonary suppuration, the failure of conservative therapy (multiple antibiotic treatments in the last three years), the presence and size of the bronchopleural cutaneous fistula, thepatient's surgical history (presence of "lifesaving"sutures), as well as his immunocompromised state required that conservative medical treatment (antibiotics, antimycotics and supportive medication for six months) be associated with surgery. An open window thoracostomy was selected over segmentectomy or lobectomy due to their associated risks caused by anatomic changes in the large vessels. The open window thoracostomy should not be forgotten or abandoned as it may be the only approach that ensures patient survival and the effective management of the residual cavity and chronicsuppuration in selected cases.

Cutaneous fistula due to pulmonary actinomycosis in a Mapuche girl.

Actinomycosis is a chronic granulomatous disease caused by Gram-positive anaerobic bacteria of the genus Actinomyces. Pulmonary actinomycosis is a rare infection in children, and its extension into the chest wall is infrequently reported. We report a case of pulmonary actinomycosis in a 14-year-old girl of Mapuche descent who presented with chronic respiratory symptoms and multiple discharging skin sinuses on her right lower chest wall. The diagnosis was made by skin biopsy, which showed sulfur granules with actinomyces colonies. She was successfully treated with intravenous ceftriaxone and penicillin G for 6 weeks, followed by oral amoxicillin for 6 months.

[Cryptococcal osteomyelitis in a patient with a lymphocytic leukemia treated with fludarabine-cyclophosphamide-rituximab]. / Cryptococcose osseuse chez une patiente porteuse d'une leucémie lymphocytique traitée par fludarabine-cyclophosphamide-rituximab.

INTRODUCTION: Cryptococcosis is a serious invasive fungal infection mostly described in patients with cell-mediated immunosuppression. Cryptococcus neoformans osteomyelitis is a rare infection that occurs mainly during disseminated forms. OBSERVATION: A 72-year-old diabetic patient, treated with fludarabine-cyclophosphamide-rituximab (since 10 months) for lymphocytic leukemia presented with osteolysis of the fourth left hand metacarpien the histological examination of which revealed C. neoformans. This bone involvement was associated with costal osteolytis and pulmonary cryptococcosis but central nervous system (CNS) was spared. Fluconazole was administered intravenously for 15 days, then switched to oral route for 6 months with favorable clinical course. This case describes an unusual clinical presentation of disseminated cryptococcosis without CNS involvement with multiple osseous metastases. A review of cryptococcal osteomyelitis cases reported in adult from 2000 to 2011 is also discussed. CONCLUSION: Cryptococcosis is a rare infection that should be discussed in seriously immunocompromized patients presenting with osteomyelitis even in the absence of CNS involvement.

Post-sternotomy chronic osteomyelitis: is sternal resection always necessary?

OBJECTIVES: The goal of this study was to investigate alternative strategies to the sternal resection in the treatment of post-sternotomy osteomyelitis. We report our experience in the treatment of chronic infection of median sternotomy following open heart surgery without sternal resection. METHODS: A 4-year retrospective study was performed, consisting of 70 patients affected by post-sternotomy sternocutaneous fistulas due to chronic osteomyelitis: 45 patients underwent only medical treatment and 25 underwent steel wire removal and surgical debridement (conservative surgery). Of the 25, 7 patients underwent an additional vacuum assisted closure (VAC) therapy due to widespread infected subcutaneous tissue. The diagnosis of osteomyelitis was supported via 3D CT scan images. RESULTS: Complete wound healing was achieved in 67 patients including a patient who achieved healing after being affected by a fistula for over 24 years before coming under our observation, another, affected by mycobacteria other than tuberculosis osteomyelitis, who needed antimicrobial treatment for a period of 30 months and 2 who were affected by Aspergillus infection and needed radical cartilage removal. Fistula relapses were observed in 6 patients of the total 70, possibly due to the too short-term antibiotic therapy used in the presence of coagulase-negative Staphylococcus (CoNS) with multiple resistances and in the presence of Corynebacterium species. CONCLUSIONS: Post-sternotomy chronic osteomyelitis can be successfully treated mainly by systemic antimicrobial therapy alone, without mandatory surgical treatments, provided that accurate microbiological and radiological studies are performed. The presence of CoNS and Corynebacterium species seemed to be associated with a need for a prolonged combined antimicrobial therapy with a minimum of 6 months up to a maximum of 18 months. The CT scan and the 3D reconstruction of the sternum proved to be a good method to evaluate the status of the sternum and support the treatments. The VAC therapy was not useful in treating osteomyelitis, although, if used appropriately in the postoperative deep sternal wound infection with the sponge fitted between the sternal edges, it seems to be an effective method to eradicate the infection in the sternum and to prevent chronic osteomyelitis.

Cutaneo-pericardial fistula after transapical aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) represents a therapeutic option of increasing impact for the treatment of high-risk patients with symptomatic, severe aortic valve stenosis. We report here the case of an 86-year old patient with a cutaneo-pericardial fistula after a transapical TAVI procedure.