Incidence, clinical spectrum, diagnostic features, treatment and predictors of paradoxical reactions during antibiotic treatment of Mycobacterium ulcerans infections.

BACKGROUND: Paradoxical reactions from antibiotic treatment of Mycobacterium ulcerans have recently been recognized. Data is lacking regarding their incidence, clinical and diagnostic features, treatment, outcomes and risk factors in an Australian population. METHODS: Data was collected prospectively on all confirmed cases of M. ulcerans infection managed at Barwon Health Services, Australia, from 1/1/1998-31/12/2011. Paradoxical reactions were defined on clinical and histological criteria and cases were determined by retrospectively reviewing the clinical history and histology of excised lesions. A Poisson regression model was used to examine associations with paradoxical reactions. RESULTS: Thirty-two of 156 (21%) patients developed paradoxical reactions a median 39 days (IQR 20-73 days) from antibiotic initiation. Forty-two paradoxical episodes occurred with 26 (81%) patients experiencing one and 6 (19%) multiple episodes. Thirty-two (76%) episodes occurred during antibiotic treatment and 10 (24%) episodes occurred a median 37 days after antibiotic treatment. The reaction site involved the original lesion (wound) in 23 (55%), was separate to but within 3 cm of the original lesion (local) in 11 (26%) and was more than 3 cm from the original lesion (distant) in 8 (19%) episodes. Mycobacterial cultures were negative in 33/33 (100%) paradoxical episodes. Post-February 2009 treatment involved more cases with no antibiotic modifications (12/15 compared with 11/27, OR 5.82, 95% CI 1.12-34.07, p = 0.02) and no further surgery (9/15 compared with 2/27, OR 18.75, 95% CI 2.62-172.73, p < 0.001). Six severe cases received prednisone with marked clinical improvement. On multivariable analysis, age ≥ 60 years (RR 2.84, 95% CI 1.12-7.17, p = 0.03), an oedematous lesion (RR 3.44, 95% CI 1.11-10.70, p=0.03) and use of amikacin in the initial antibiotic regimen (RR 6.33, 95% CI 2.09-19.18, p < 0.01) were associated with an increased incidence of paradoxical reactions. CONCLUSIONS: Paradoxical reactions occur frequently during or after antibiotic treatment of M. ulcerans infections in an Australian population and may be increased in older adults, oedematous disease forms, and in those treated with amikacin. Recognition of paradoxical reactions led to changes in management with less surgery, fewer antibiotic modifications and use of prednisolone for severe reactions.

Sutured attachment of the implantable Doppler probe cuff for large or complex pedicles in free tissue transfer.

The Cook-Swartz implantable Doppler probe (Cook Medical(®), Cook Ireland Ltd., Limerick, Ireland) has evolved as a useful option for postoperative free flap monitoring. For placement, the probe either is left unattached around the venous pedicle or is secured. In our experience with over 300 applications, we typically secure the cuff with two small microclips, or use fibrin glue. These techniques require redundant silicone cuff for apposition; however, we have encountered some vessels that are of sufficiently large diameter as to not provide enough cuff to employ these methods. The first technique comprises the application of two interrupted sutures through the cuff ends to mimic the technique of microclips. The sutures can be tightened to the desired tension and can be used in cases where the cuff ends are not in direct apposition. A second technique is to excise a segment of silicone cuff and either clip or suture the excised segment to the cuff ends, effectively elongating the cuff diameter. All four techniques (nonattachment, microclip fixation, suture fixation, silicone cuff elongation) have been used effectively, and none have resulted in any complications. Of note, the technique of nonattachment was associated with an increased rate of false-positive results, as migration away from the vessel was postulated to have occurred. There are a range of techniques for attachment of the implantable Doppler probe, and each contributes to the range of options for cuff attachment in difficult cases, with each technique worthwhile in particular settings.

Surgical correction and reconstruction of the nipple-areola complex: current review of techniques.

Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.

Chronic Synovitis after Open Carpal Tunnel Decompression.

Open carpal tunnel decompression is a common procedure with potential long-term complications such as scar tenderness, pillar pain and neuroma. We present the case of a 65 year-old male with chronic lipomatous hypertrophy of the wrist and chronic flexor tenosynovitis after open carpal tunnel release for its rarity and severity of symptoms that required further surgery.

Mycobacterium ulcerans disease: experience with primary oral medical therapy in an Australian cohort.

BACKGROUND: Mycobacterium ulcerans (MU) is responsible for disfiguring skin lesions and is endemic on the Bellarine peninsula of southeastern Australia. Antibiotics have been shown to be highly effective in sterilizing lesions and preventing disease recurrences when used alone or in combination with surgery. Our practice has evolved to using primarily oral medical therapy. METHODS: From a prospective cohort of MU patients managed at Barwon Health, we describe those treated with primary medical therapy defined as treatment of a M. ulcerans lesion with antimicrobials either alone or in conjunction with limited surgical debridement. RESULTS: From 1/10/2010 through 31/12/11, 43 patients were treated with exclusive medical therapy, of which 5 (12%) also underwent limited surgical debridement. The median patient age was 50.2 years, and 86% had WHO category 1 and 91% ulcerative lesions. Rifampicin was combined with ciprofloxacin in 30 (70%) and clarithromycin in 12 (28%) patients. The median duration of antibiotic therapy was 56 days, with 7 (16%) receiving less than 56 days. Medication side effects requiring cessation of one or more antibiotics occurred in 7 (16%) patients. Forty-two (98%) patients healed without recurrence within 12 months, and 1 patient (2%) experienced a relapse 4 months after completion of 8 weeks of antimicrobial therapy. CONCLUSION: Our experience demonstrates the efficacy and safety of primary oral medical management of MU infection with oral rifampicin-based regimens. Further research is required to determine the optimal and minimum durations of antibiotic therapy, and the most effective antibiotic dosages and formulations for young children.

Sentinel lymph node biopsy for squamous cell carcinoma of the extremities: case report and review of the literature.

BACKGROUND: Lymph node metastases from squamous cell carcinoma (SCC) can reach 20% in some high risk subgroups, and while early detection of metastasis may potentially improve overall and/or disease-specific survival, techniques for early detection have not been established. One such technique is the use of sentinel lymph node biopsy (SLNB), however its role for SCC of the extremities has not been explored. MATERIALS AND METHODS: A case that highlights the utility of SLNB in this setting is described, and a systematic review of the literature was undertaken in order to establish the current evidence for its use. RESULTS: There have been no prospective clinical trials performed to investigate the role of SLNB in this setting. Thirty-two cases utilizing SLNB for peripheral SCCs have been reported, with a 28.1% rate of positive SLN, and low false-positive and false-negative rates. No complications were reported. CONCLUSION: SLNB for SCC of the limbs has been scarcely reported, but those cases reported do collectively demonstrate a high positive predictive value for lymph node metastasis and a low false-positive rate, with poor prognostic variables identified. The efficacy of SLNB in this setting requires further investigation.