Whole genome-based antimicrobial resistance and virulence profiling of Staphylococcus aureus isolates from chronic leg ulcer patients in Kilimanjaro, Tanzania.

BACKGROUND: Chronic leg ulcers are hard to treat and can be a burden, particularly in resource-limited settings where diagnosis is a challenge. Staphylococcus aureus is among the common bacteria isolated from chronic wounds with a great impact on wound healing, particularly in patients with co-morbidities. Antimicrobial resistance genes and virulence factors in Staphylococcus aureus isolates were assessed to support healthcare professionals to make better therapeutic choices, and importantly to curb the development and spread of antibiotic resistance. METHODS: A cross-sectional study involved both inpatients and outpatients with chronic leg ulcers was conducted from August 2022 to April 2023 in 2 health facilities in Kilimanjaro region in Tanzania. Antimicrobial susceptibility testing was done using the disc diffusion method. Further, whole genome sequencing was performed to study the genotypic characteristics of the isolates. RESULTS: A total of 92 participants were recruited in which 9 participants were only positive for 10 Staphylococcus aureus isolates upon culture. Five STs among 9 isolates were identified. Most of them belonged to ST8 (44%), with 1 isolate does not belong to any ST. Additionally, 50% of the isolates were methicillin-resistant Staphylococcus aureus (MRSA). All S. aureus isolates had almost similar virulence factors such as hemolysin, proteases and evasions that promote toxin production, protease production and host immune evasion respectively. Moreover, all mecA positive S. aureus isolates were phenotypically susceptible to cefoxitin. CONCLUSION: Presence of mecA positive S. aureus isolates which are also phenotypically susceptible to cefoxitin implies the possibility of classifying MRSA as MSSA. This may result in the possible emergence of highly cefoxitin - resistant strains in health care and community settings when subsequently exposed to beta-lactam agents. Therefore, combination of whole genome sequencing and conventional methods is important in assessing bacterial resistance and virulence to improve management of patients.

Medieval (arrow) weapon injuries in contemporary surgical practice: Impaled posterior thoracic wall arrowhead leading to haemo-thorax: Management protocols. Case report.

INTRODUCTION AND IMPORTANCE: Arrow injuries are rare in modern surgical practice. However, there are still case reports in tribal and guerrilla conflicts in rural settings were arrows are still used as weapons. Since the discovery of gun powder, guns and explosives have been the preferred effective assault weapons. Most surgeons in metropolitan trauma centers face scarce arrow injuries cases, mostly due to accidents or suicide attempts using the crossbow mechanism. CASE PRESENTATION: We present a case of an 18-year-old boy who sustained penetrating posterior thoracic wall arrow injury leading to haemothorax and review of the management protocols. CLINICAL DISCUSSION: Arrow injuries to the chest can span the entire spectrum of organs in the chest cavity ranging from superficial muscle to vital organs and vessels injury. Immediate death can result from injury to vital organs or vessels with late fatalities due to infection or toxins from dipped arrow heads with "poisons". Pre-operative radiological investigations such as CT scanning with angiography have proved its predictive value of intra-thoracic injuries when compared to post-operative diagnoses. CONCLUSION: Management protocols range from open thoracotomy of unstable patients to simple retrieval under thoracoscopy guide. Several management protocols set date back as early as the 16th Century still hold water to date.

Traumatic left common carotid artery thrombosis with ischemic brain injury: A case report.

INTRODUCTION AND IMPORTANCE: Penetrating neck injuries (PNIs) are common and are associated with arterial injuries in 10-25 % of the cases, with carotid artery twice as frequent as to vertebral arteries. Carotid artery injury constitutes about 22 % of all cervical vascular injuries. CASE PRESENTATION: We present a case of a 44-year-old male who sustained penetrating neck injury in a motor traffic crash. He presented with monoplegia of his right upper limb and an open wound on the left side of his neck which was not actively bleeding hence surgical debridement was done and sutured. CT angiography and CT-scan brain concluded of left common carotid thrombosis secondary to penetrating neck trauma with ischemic brain injury. Patient was successfully managed conservatively. CLINICAL DISCUSSION: The general mortality rate in PNI with associated cervical vascular injury is approximately 66 %. Artery dissection occurs when the intima tears causing intramural hematoma leading to narrowing or occlusion. CT angiography is the best and fastest modality to assess these injuries and management depends on the clinical bases of the patient. CONCLUSION: Neck is vulnerable to external trauma because it is not protected by the skeleton. The neck contains vital structures such as the trachea, esophagus, blood vessels and nervous system organs. Vascular injuries can be life-threatening owing to its prompt clinical assessment and investigation.

Pattern, Management, and Outcomes of Chest Injury At Kilimanjaro Christian Medical Centre.

Background: Chest trauma is a major cause of morbidity and mortality in the region. Lacking data in our environment has been a challenging part of knowing the burden of the problem. Long hospital stays and associated injuries are an essential measure of morbidity. The study results will provide a basis for planning prevention strategies and establishment of treatment protocols. Objectives: To determine the prevalence, pattern, and management outcomes of chest injury patients at Kilimanjaro Christian Medical Center (KCMC), a Tertiary Hospital in Northern zone Tanzania from October 2021 to April 2022. Methodology: A hospital-based cross-sectional study was conducted among patients with chest injuries who were admitted and managed at Tertiary Hospital Northern Zone (Kilimanjaro Christian Medical Center-KCMC) in the Emergency medicine and General Surgery departments. Using a designated data collection tool, details of the mechanism of injury, radiological and laboratory investigations, management, and outcomes were recorded. Results: A total of 114 chest injury patients were studied. Males outnumbered females by a ratio of 7.14:1. Their ages ranged from 2 to 83 years (mean = 36.18 years). The Majority of patients (95.58%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 65.79% of patients. Lung contusion, hemothorax, and rib fractures were the most common type of injuries accounting for 54.4%, 27.2%, and 21.1%, respectively. Associated injuries were noted in 85.7% of patients, and head injury (60.5%) was found in most patients. The Majority of patients (60.5%) were treated successfully with a non-operative approach. Underwater seal drainage was performed at (38.9%). One Patient (0.9%) underwent a thoracotomy. 14% of patients had complications of surgical site infection, and 69% were found in the Majority of patients. The median length of hospital stay was 4.5 days. The mortality rate was 21. Conclusion: Motor traffic crash was the principal cause of chest trauma. Young male patients were most affected by chest trauma and the majority of patients were treated conservatively. Chest X-ray remains to be the main imaging modality for diagnosing thoracic trauma lesions. Associated injuries such as head injuries, were found to contribute to a high mortality rate.

Chest tube thoracostomy: A simple life-saving procedure with potential hazardous risks.

INTRODUCTION AND IMPORTANCE: Chest tube thoracostomy is a simple life-saving procedure with many benefits but comes with significant potential morbidity. Potentially all intra-thoracic organs are at risk of possible injury as well as peritoneal. CASE PRESENTATION: We present four patients who had chest tube thoracostomy with potential complications fortunately were managed promptly and recovered fully. CLINICAL DISCUSSION: Complications related to tube thoracostomy is reported up to 25 % especially when done under emergency conditions. While the procedure is reported safe, it's associated morbidity is not well described. Additionally, clinicians are urged to follow standard operating procedures and address the potential complications with consent to their patients. CONCLUSION: Chest tube thoracostomy is an invasive life-saving procedure performed across various clinical ranks and sub-specialties. It has potential life-threatening risks and complications therefore clinicians should be well trained to identify such complications and address accordingly.

Midgut Atresia: Diagnostic and Management Challenges From Northern Tanzania.

Intestinal obstruction is one of the most common surgical emergencies in the neonatal period. Early diagnosis is vital for proper management and good outcome. Intestinal obstruction can be divided into high, for example, duodenal atresia and jejunal atresia, or low, for example, ileal atresia, colonic atresia, and Meckel's diverticulum. The most common cause of intestinal obstruction in neonates is midgut atresia. Surgical correction is needed and is a challenge in the developing countries where there is lack of pediatric surgeons, anesthesiologists, and intensive care. More research and data is also needed across countries to show the uneven distribution of the available resources.

Acute pancreatitis in SARS-CoV-2 infection: A case report from Tanzania.

The pandemic caused by the severe acute respiratory syndrome coronavirus 2 has mainly affected the respiratory system but has expanded to other systems, including the gastrointestinal system. We present an 80-year-old man with sharp epigastric pain and vomiting. Laboratory investigations revealed elevated pancreatic enzymes, and contrast-enhanced computed tomography of the abdomen suggested acute pancreatitis. He was undergoing treatment for acute pancreatitis when he developed respiratory compromise, leading to the use of oxygen. Computed tomography of the chest revealed bilateral pleural effusion. However, a positive nasopharyngeal swab suggested severe acute respiratory syndrome coronavirus 2 infection. He was treated for the viral infection with various medications until clinically stable before being self-isolated at home. His follow-up visits revealed a favorable outcome, with progressive resolve occurring 4 weeks after the onset. There is no specific conclusion regarding pancreatic involvement in severe acute respiratory syndrome coronavirus 2 infection. There are several confounding factors in the etiology of acute pancreatitis during concomitant severe acute respiratory syndrome coronavirus 2 infection. However, further research is warranted to evaluate whether pancreatic involvement is one of the clinical presentations or subsequent complications of severe acute respiratory syndrome coronavirus 2 infection.

Potential Spectrum of Accompanied Penetrating Abdominal Intraperitoneal Injuries with Bowel Evisceration: Surprises Awaiting the Trauma Surgeon in Resource Limited Settings.

Penetrating abdominal injuries involves violation of the peritoneal cavity and injuries to solid organs and other intraperitoneal viscera such as major blood vessels and hollow organs. Typically such injuries arise from gunshot wounds or stab wounds. With increase in crime rates and motor traffic accidents in urban areas, the trauma surgeon in civilian urban centers faces spectrum of injuries similar to his colleague in war torn areas. Potential spectrum of penetrating abdominal injuries is wide and accurate diagnosis in resource limited centers is challenging. Majority of injuries are concealed and diagnosed intraoperatively and dealt with relatively junior trauma surgeons in emergency settings in remote limited settings. Computed tomography (CT) scans and Magnetic Resonance Imaging (MRI) facilities are scarce in resource limited settings. Haemodynamic states of penetrating abdominal injuries patients presenting in emergency departments necessitate urgent surgical exploration and management with minimal room for full radiological work-up. Evisceration of bowels with unstable haemodynamic states mandate laparotomy due to wide spectrum of accompanied intraperitoneal injuries. Four cases of penetrating abdominal injuries are presented with modes of assault ranging from gunshot injuries to stab wounds with broken bottles to highlight the intra-abdominal spectrum of injuries, challenges in diagnosis and emergency managements done in a resource limited setting.

Esophageal stenosis: A case of delayed dysphagia in an infant from northern Tanzania.

INTRODUCTION AND IMPORTANCE: Congenital stenosis of the esophagus is often overlooked in children with feeding difficulties leading to delayed diagnosis and treatment. This can have detrimental effects on the child's growth and general health, ranging from malnutrition to life-threatening complications such as aspiration pneumonia. CASE PRESENTATION: We present a case diagnosed at the age of 3 years when the child already had developed moderate malnutrition and offer the diagnostic and surgical findings in the hope of helping others suspect and clench the diagnosis early. CLINICAL DISCUSSION: With an incidence of up to 1 in 25,000, congenital stenosis of the esophagus is definitely a congenital malformation worth knowing about, particularly since misdiagnosis often leads to delayed intervention as was in our case. History of feeding difficulty and failure to thrive are often the triggers to seeking medical attention. The confirmation can be easily made with contrast imaging opening up the possibility for surgical and non-surgical management. CONCLUSION: With a high index of suspicion, diagnosis can be made relatively easily, allowing for early intervention, which can prove to be lifesaving.

Jejunoileal Atresia in a Newborn: Our Experience From Northern Tanzania and Literature Review.

Jenunoileal atresia is a congenital defect that causes small bowel obstruction in newborns. They are classified into 5 types and simple abdominal x-ray can aid in the diagnosis and with prompt resuscitation and surgery provides positive outcome. We present a 5-day-old newborn male baby was presented with features of intestinal obstruction since birth. Diagnosis of atresia of the small bowel was made through plain abdominal x-ray and was successfully operated. During the recovery, the baby developed surgical site infection which was managed promptly.

Standard Urine Collection Bag as an Improvised Bogotá Bag as a Temporary Abdominal Closure Method in an Open Abdomen in Preventing Abdominal Compartment Syndrome.

Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.

Clinical profiles of diabetic foot ulcer patients undergoing major limb amputation at a tertiary care center in North-eastern Tanzania.

BACKGROUND: Diabetic foot ulcers complications are the major cause of non-traumatic major limb amputation. We aimed at assessing the clinical profiles of diabetic foot ulcer patients undergoing major limb amputation in the Surgical Department at Kilimanjaro Christian Medical Centre (KCMC), a tertiary care hospital in North-eastern Tanzania. METHODS: A cross-sectional hospital-based study was conducted from September 2018 through March 2019. Demographic data were obtained from structured questionnaires. Diabetic foot ulcers were graded according to the Meggitt-Wagner classification system. Hemoglobin and random blood glucose levels data were retrieved from patients' files. RESULTS: A total of 60 patients were recruited in the study. More than half (31/60; 51.67%) were amputated. Thirty-five (58.33%) were males. Fifty-nine (98.33%) had type II diabetes. Nearly two-thirds (34/60; 56.67%) had duration of diabetes for more than 5 years. The mean age was 60.06 ± 11.33 years (range 30-87). The mean haemoglobin level was 10.20 ± 2.73 g/dl and 9.84 ± 2.69 g/dl among amputees. Nearly two thirds (42/60; 70.00%) had a haemoglobin level below 12 g/dl, with more than a half (23/42; 54.76%) undergoing major limb amputation. Two thirds (23/31; 74.19%) of all patients who underwent major limb amputation had mean hemoglobin level below 12 g/dl. The mean Random Blood Glucose (MRBG) was 13.18 ± 6.17 mmol/L and 14.16 ± 6.10 mmol/L for amputees. Almost two thirds of the study population i.e., 42/60(70.00%) had poor glycemic control with random blood glucose level above 10.0 mmol/L. More than half 23/42 (54.76%) of the patients with poor glycemic control underwent some form of major limb amputation; which is nearly two thirds (23/31; 74.19%) of the total amputees. Twenty-eight (46.67%) had Meggitt-Wagner classification grade 3, of which nearly two thirds (17:60.71%) underwent major limb amputation. CONCLUSION: In this study, the cohort of patients suffering from diabetic foot ulcers treated in a tertiary care center in north-eastern Tanzania, the likelihood of amputation significantly correlated with the initial grade of the Meggit-Wagner ulcer classification. High blood glucose levels and anaemia seem to be also important risk factors but correlation did not reveal statistical significance.

Giant isolated hydatid lung cyst: two case reports.

BACKGROUND: Echinococcosis is a parasitic disease caused by Echinococcus granulosus and causes cystic lesions in the liver and lungs commonly. It is endemic in many parts of the world, and though humans are incidental hosts of the parasite, the disease can have severe consequences. CASE PRESENTATION: We present two patients from pastoralist (Maasai) communities in rural Tanzania with long-standing chest pain accompanied by hemoptysis. Both were managed surgically after diagnosis, but one patient died of the complications following rapture of the cyst during surgery. Histopathological evaluation of the specimens confirmed the diagnosis of giant hydatid cysts. CONCLUSION: Animal-keeping communities such as the Maasai are at risk of echinococcosis because of their close proximity to animals. The diagnosis can be made on the basis of history and radiological as well as laboratory findings. Surgery is a recommended mode of treatment, though it carries a high risk, especially when the cyst ruptures. Primary preventive measures are thus necessary in order to avoid the secondary and tertiary complications of the management of giant hydatid cysts, which is difficult in resource-limited endemic areas.