[A very extensive necrotizing fasciitis]. / Une fasciite nécrosante très extensive.

Necrotizing fasciitis is a severe skin infection. Fluidized bed may be indicated to improve healing. We report a 36-year-old woman case, who developed an important skin emphysema on a fluidized bed that may have worsen the situation.

Severe large bowel obstruction secondary to infection with Actinomyces israelii.

Abdomino-pelvic actinomycosis is a rare disease, which usually follows a chronic course. However, bowel obstruction may reveal an acute clinical picture. We report on a 38-y-old female with abdomino-pelvic actinomycosis, characterized by a 10 cm long filiform stenosis of the sigmoid colon and bilateral ovarian abscesses. She developed acute ileus that required emergency surgery.

[Parasigmoid abscess revealed by anaerobic osteomyelitis]. / Abcès périsigmoïdien révélé par une ostéomyélite à germes anaérobies.

We report the case of a 66 year-old-patient, who profited by a laminectomy T4 to T7 for spinal cord compression due to an osteomyelitis. Bacteriological samples showed positives gram cocci and Bacteroides fragilis by the culture. The systematic research of a primitive source permitted to find a parasigmoidis abscess, which was treated by a sigmoidectomy with a colorectal anastomosis.

A successfully treated case of multiple liver abscesses accompanied by portal venous gas.

A case with multiple liver abscess accompanied by massive portal venous gas is reported. A 61-yr-old male was admitted because of left lower abdominal pain, fever, and diarrhea. Abdominal x-ray examination demonstrated multiple branching lucencies in the liver. Computed tomography revealed multiple liver abscesses and massive gas in the portal system as well as a thickened wall of the sigmoid colon. Enema study using contrast medium revealed a perforation of the sigmoid colon with diverticulitis. The outcome was favorable after sigmoid colectomy in addition to intensive treatment with antibiotics. Bacteroides fragilis, which produces gas (H2 and NH3) by fermentation, was isolated not only from the resected specimen but also from blood samples. Although the presence of portal venous gas is a sign of poor prognosis in patients with intestinal infectious diseases, the sensitive detection of hepatic portal venous gas by computed tomography and the appropriate treatment may improve the patient's prognosis.

Rectal stricture: a complication of tuberculosis.

Tuberculosis of the rectum is rarely reported, even from areas where tuberculosis, and gastrointestinal tuberculosis in particular, is prevalent. The authors report a case of long tubercular stricture of the rectum and distal part of the sigmoid colon in a 12-year-old girl. Because of nonspecific symptoms and noncharacteristic radiological and endoscopic features, the diagnosis of this rare entity rests mainly on histological evidence of the classical tubercle in a surgical biopsy specimen.

Abdominal actinomycosis.

PURPOSE: Actinomyces israelii are normal inhabitants in the oral cavity and upper intestinal tract of humans. They rarely cause disease and are seldom reported as pathogens. As a pathogen it causes fistulas, sinuses, and may appear as an abdominal mass and/or abscess. The abdominal mass can masquerade as a malignant process that is very difficult to differentiate, often requiring surgical intervention with resection. Because of difficulty in making a preoperative diagnosis, we undertook this review to determine if all patients require surgical intervention and whether other adjunctive modalities may improve preoperative diagnosis. METHODS: We report two patients with abdominal actinomycosis, one affecting the sigmoid colon and the other the retroperitoneum, iliac crest region. Both simulated a malignant process and required operations for diagnosis and treatment. RESULTS: As reported, actinomycotic abdominal masses and strictures can be treated by penicillin alone. Long-term medical treatment seems to be very successful and avoids surgical resection. The difficulty is obtaining a definitive diagnosis. CONCLUSION: The computed tomographic scan is the most helpful diagnostic modality. Appearance of abdominal actinomycosis is usually a contrast enhancing multicystic lesion as was found in these two patients. Needle aspiration cytology can be fairly accurate in obtaining the diagnosis and is recommended for suspicious lesions.

Isolated sigmoid tuberculosis. Report of a case.

PURPOSE: To heighten awareness of colonic tuberculosis (TB) as a once rare disease that is undergoing a resurgence in the United States. METHODS: Report of a case of isolated sigmoid tuberculosis with a brief literature review of the topic. RESULTS: TB can no longer be considered a rare disease in the United States because, in part, of the acquired immunodeficiency syndrome epidemic and because, in part, of increased immigration and lack of containment. The signs and symptoms of colonic TB are nonspecific; therefore, a high index of suspicion must be maintained. Only 20 percent of patients will have associated active pulmonary TB. Colonoscopy with multiple biopsies at ulcer margins should be performed for diagnosis. Tissue should be sent for routine histology and culture and smeared for direct visualization of acid-fast bacilli. If colonic TB is suspected, empiric treatment is warranted, despite negative histology, smear, and culture results. Patients will usually show a dramatic response in one to two weeks. Treatment is solely medical, and all patients should receive a full course of antituberculous chemotherapy. Exploratory laparotomy is necessary if diagnosis is in doubt, when there is concern about a neoplasm, or for complications including perforation, obstruction, hemorrhage, or fistulization. CONCLUSION: An increased awareness of intestinal TB coupled with familiarity of the pathophysiology, diagnostic methods, and treatment should increase the number of cases correctly diagnosed preoperatively and, therefore, improve the outcome of patients with this disease.

Effect of peritoneal fluid pH on outcome of aminoglycoside treatment of intraabdominal infections.

Netilmicin and clindamycin were administered to 47 patients with an intraabdominal infection who underwent emergency laparotomy. Thirty-one patients were cured, seven were improved, and therapy failed in nine patients despite the fact that all aerobic bacteria isolated from these patients were sensitive to netilmicin as determined by standard in vitro susceptibility tests. The pH of peritoneal and drainage fluid collected intraoperatively and during follow-up correlated with clinical outcome. Acidic pH was found in 21 of 33 (64%) specimens sampled from patients with therapeutic failure compared to 17 of 80 (21%) obtained from the categories "cured" and "improved" (p < 0.001). Netilmicin concentrations in serum or peritoneal/drainage fluid did not correlate with clinical outcome. Netilmicin levels were above the minimal inhibitory concentration of the pathogens in 59 of 64 (92%) drainage fluid specimens in which aerobic bacteria were isolated. Aerobic bacteria were isolated in 91% of drainage fluid specimens if the pH was less than 7.0, compared to 37% if pH was more than 7.0 (p < 0.001). Reduction of pH antagonized aminoglycoside activity in vitro against clinical isolates of Escherichia coli. Surgical reexploration should be considered in cases of deterioration following a laparotomy associated with detection of acidic drainage fluid.