Gastric mucormycosis complicated by a gastropleural fistula: A case report and review of the literature.

RATIONALE: Mucormycosis is a rare opportunistic fungal infection with poor prognosis. The incidence of mucormycosis has been increasing, and it is a threat to immunocompromised hosts. We present a case of gastric mucormycosis complicated by a gastropleural fistula during immunosuppressive treatment for adult-onset Still disease (AOSD). PATIENT CONCERNS: An 82-year-old woman diagnosed with AOSD who developed gastric ulcers during the administration of an immunosuppressive therapy with corticosteroids, cyclosporine, and tocilizumab complained of melena and epigastralgia. Esophagogastroduodenoscopy showed multiple ulcers covered with grayish or greenish exudates. DIAGNOSES: The patient diagnosed with mucormycosis based on culture and biopsy of the ulcers, which showed nonseptate hyphae branching at wide angles. Mucor indicus was identified using polymerase chain reaction. INTERVENTIONS AND OUTCOMES: Although liposomal amphotericin B was administered, gastric mucormycosis was found to be complicated by a gastropleural fistula. The patient died because of pneumonia due to cytomegalovirus infection, and autopsy revealed the presence of Mucorales around the fistula connecting the stomach and diaphragm. LESSONS: Gastric mucormycosis is refractory to treatment and fatal. Surgical resection, if possible, along with antifungal drugs can result in better outcomes.

Marked cachexia in probable invasive pulmonary aspergillosis with bronchopleural fistula.

A 49-year-old man with a medical history of diabetes and heavy smoking was admitted to intensive care with severe bilateral pneumonia associated with marked cachexia. He developed a complex right-sided bronchopleural fistula and was transferred to our tertiary centre for consideration of surgical intervention.Despite escalation of antibiotic therapy, he did not improve and further investigations led to a diagnosis of invasive pulmonary aspergillosis. Definitive treatment plans required a right pneumonectomy; however, given the severity of cachexia, he remained unable to undergo such a large operation. This case demonstrates an atypical presentation of invasive pulmonary aspergillosis in a mildly immunodeficient individual. It highlights the challenges in assessment and management of critically ill patients' nutrition as well as optimal timing for surgical intervention.

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.

External fistulous wound with Pseudomonas aeruginosa infection and massive bleeding following rupture of pulmonary suppuration.

We present a 54-year old man with a pulmonary infectious cavity continuing to a cutaneous fistula. Before he was admitted to our hospital, he had undergone open-window surgery for a left thoracic empyema due to the rupture of pulmonary suppuration of the left upper lobe. He had then undergone thoracoplasty with the plombage of the cavity using left pectoralis major muscle. However, this procedure had failed and the external fistulous wound remained infected by Pseudomonas aeruginosa and occasional massive bleeding from the cavity occurred. He underwent en bloc left upper lobectomy for the external fistulous wound. The pedicled left latissimus dorsi muscle flap was transposed to fill the dead space and reinforce the bronchial stump. He remained in good health and did not experience intrathoracic infection or haemoptysis.

Moraxella catarrhalis: an unrecognized pathogen of the oral cavity?

OBJECTIVE: We investigated the effect of the bacterial flora of the nose and throat on the outcome of the initial repairs of the cleft palate in the presence of prophylactic antibiotics. DESIGN: A retrospective review of 90 procedures in 66 patients who had cleft palate repair between April 2005 and June 2007 was conducted at Booth Hall Children's Hospital, Manchester, U.K. Both isolated cleft palate and cleft lip and palate patients were included. Exclusion criteria included syndromic cases, other medical disorders, and revisions of previous cleft palate repairs. Nose and throat swabs were taken on admission. Benzyl penicillin and flucloxacillin were given perioperatively. The occurrence of oronasal fistulas was correlated with the bacteria grown on culture. RESULTS: The oronasal fistula rate was 15.9%. The highest fistula rate in procedures with positive swabs was seen with Moraxella catarrhalis. CONCLUSIONS: M. catarrhalis has not been previously recognized as a pathogen in cleft palate repairs. This study demonstrates a higher fistula rate in procedures positive for M. catarrhalis. Other factors that may have contributed to the fistula formation include the severity of the initial cleft and technical factors. Further study is required before a definitive link can be established.

[Spontaneous esophago-pleural fistula secondary to candidiasis in a patient with human immunodeficiency virus infection. An infrequent complication of esophageal moniliasis]. / Fistula esófago-pleural espontanea secundaria a candidiasis en paciente con infección por el virus de la inmunodeficiencia humana. Una rara complicación de la moniliasis esofágica.

Several nosologic conditions may affect the esophagus and cause fistulas communicating this organ with the respiratory system. Rarely, infections cause perforation and further fistula to the bronchial tree, lungs or pleural space. We present the rare case of an HIV-infected patient with related spontaneous esophago-pleural fistula related to Candida infection.

Surgery for pulmonary tuberculosis - a 15-year experience.

BACKGROUND: Surgery for pulmonary tuberculosis (TB) has become rather limited. However, it is still required for some sequelae and complications. This is a 15-year retrospective study of cases operated upon for pulmonary TB at a centre. PATIENTS AND METHODS: A total of 2878 cases underwent surgical procedures for various complications of pulmonary TB over a 15-year-long period. After excluding those managed by tube thoracostomy, rib resection and open-window thoracostomy, 1297 cases out of this series were taken up for major thoracic surgical procedures. A total of 98 were operated for persistent sputum-positive status, 740 for recurrent massive haemoptysis or chest infections, 2024 for empyema and 18 for diagnostic reasons. Procedures were 830 lung resections, 12 primary thoracoplasties, 295 space-reducing thoracoplasties, 158 decortications, 744 open-window thoracoplasties and 837 tube thoracotomies alone. RESULTS: There were 18 early deaths and 37 late deaths. The cause of death was haemorrhage in seven cases and respiratory failure in nine cases and septicaemia in two cases. Late deaths were mostly because of progressive tubercular disease. There was significant morbidity in terms of broncho-pleural fistula (BPF) in 95 cases and persistent sinus in 37 cases. Milder complications such as pneumonia, fever and wound sepsis were noticed in some cases but definite records were not available. BPF was managed by tube drainage followed by either window thoracostomy or thoracoplasty. In multi-drug-resistant (MDR) cases, persistent documented sputum negativity was achieved in 64 out of 86 cases. Results were better in haemoptysis and chest infection group where the desired result was achieved in 699 cases. CONCLUSIONS: Surgery in pulmonary TB is still relevant in many cases and yields a very gratifying result. It is a challenging surgery and this series is a very large one.

Staphylococcus aureus transmission through oronasal fistula in children with cleft lip and palate.

OBJECTIVE: To determine the presence of Staphylococcus aureus in a nasal flora and oral environment, the correlation between frequency of transmission of S. aureus and oronasal fistula size, and the pattern of methicillin resistance on S. aureus strains in children with cleft lip and palate (CLP). DESIGN: Thirty-two CLP children with and without oronasal fistulas, ranging in age from 5 to 13 years were examined for oronasal fistula presence and size. Stimulated saliva samples and nasal swab samples were taken and investigated for S. aureus presence. S. aureus presence and counts were correlated with fistula presence and size. RESULTS: Saliva samples showed statistical differences between the groups with and without oronasal fistulas with an area ranging from 0.80 to 28.26 mm2. The S. aureus counts were significantly higher (r = .535, p = .002) in saliva samples from children with larger oronasal fistula. The S. aureus count was not significantly different (r = -.013, p = .942) in nasal samples compared with oronasal fistula size. Methicillin resistance with disk-diffusion method was recorded as sensitive (> or =13 mm) in all S. aureus strains. CONCLUSIONS: The results of this study indicate a positive correlation between fistula size and S. aureus transmission to one oral environment through oronasal fistulae, and a positive correlation between frequency of S. aureus transmission and fistula size. All S. aureus strains were sensitive to methicillin. These results may have implications for preventive treatment of CLP children.

Use of video-assisted thoracoscopy surgery for the treatment of Aspergillus empyema with bronchopleural fistula.

Pulmonary aspergillus empyema with bronchopleural fistula is a rare and severe disease with a poor prognosis. In this report, we describe the successful surgical treatment of this condition in a 34-year-old man who was initially hospitalized due to complications of chronic hepatitis B. While under artificial liver therapy and as a consequence of long-term corticosteroid use, the patient developed invasive pulmonary aspergillosis, which was further complicated by an empyema and a bronchopleural fistula.Video-assisted thoracoscopy surgery was performed following failure of the prescribed antifungal treatment and chest tube drainage, and the empyema resolved completely 3 months postoperatively,with no evidence of recurrence after 5 months' follow-up.

[Endovascular management of a left subclavian artery lesion following thoracoplasty for bronchopleural fistula and empyema secondary to aspergillus fumigatus]. / Manejo endovascular de lesión de arteria subclavia izquierda tras toracoplastia por fístula broncopleural y empiema secundario a Aspergillus fumigatus.

Massive and/or recurrent hemoptysis is a clear indication for surgical treatment of pleuropulmonary aspergilloma, despite the incidence of postoperative morbidity and mortality. Thoracoplasty has been widely used for 20 years and is still indicated in these cases, following lobectomy, even though the procedure is not free of complications. We report the case of a patient who required thoracoplasty to treat a pleuropulmonary aspergilloma invading the chest wall. Subsequent placement of an aortic stent-graft was required due to tearing of the left subclavian artery.

[Thoracic actinomycosis: three cases]. / L'actinomycose thoracique. A propos de trois cas.

Actinomycosis is a rare condition which, in the thoracic localisation, can mimic cancer or tuberculosis. We report a series of three case of thoracic actinomycosis treated in the Ibn Sina University Thoracic Surgery Unit in Rabat, Morocco. CASE N degrees 1: This 45-year-old patient presented a tumefaction on the left anterior aspect of the chest. Physical examination identified a parietal mass with fistulisation to the skin. Radiography demonstrated a left pulmonary mass. Transparietal puncture led to the pathological diagnosis of actinomycosis. The patient was given medical treatment and improved clinically and radiographically. CASE N degrees 2: This 68-year-old patient presented repeated episodes of hemoptysis. The chest x-ray revealed atelectasia of the middle lobe and bronchial fibroscopy demonstrated the presence of a bud in the middle lobar bronchus. Biopsies were negative. The patient underwent surgery and the histology examination of the operative specimen revealed pulmonary actinomycosis. The patient recovered well clinically and radiographically with antibiotic therapy. CASE N degrees 3: This 56-year-old patient presented cough and hemoptysis. Physical examination revealed a left condensation and destruction of the left lung was noted on the chest x-ray. Left pleuropulmonectomy was performed. Histological analysis of the surgical specimen identified associated Aspergillus and Actinomyces. The outcome was favorable with medical treatment. The purpose of this work was to recall the radiological, clinical, histological, therapeutic, outcome aspects of this condition and to relate the problems of differential diagnosis when can suggest other diseases.

Septal perforation secondary to Mycobacterium kansasii infection.

We report the first recorded case of a septal perforation caused by Mycobacterium kansasii. This atypical mycobacterium is finding increasing prevalence with the increasing incidence and longevity of human immunodeficiency (HIV) infections. Cases of chest infection, sinusitis, septic arthritis, osteomyelitis, pericarditis, brain abscess, cutaneous and oral lesions have all now been reported. This discovery represents a rare but important differential in the aetiology of septal perforation.

Hemoptysis following left ventricular aneurysm repair: a misleading clinical sign.

We report on a 66-year-old man with severe hemoptysis following coronary artery bypass grafting and repair of a left ventricular septal defect after acute myocardial infarction. Initial diagnosis was delayed by misleading clinical symptoms and radiologic studies. Due to subfebrile temperature and sputum culture positive for Pseudomonas aeruginosa, he had been treated with antibiotics before reoperation. At reoperation, replacement of all foreign material and reconstruction of the ventricular repair with bovine pericardium resulted in reinfection with the same organism despite prolonged antibiotic therapy after 6 months. Removal of the pericardial tissue with direct suture closure of the ventricles and interposition of omentum led to complete healing of the infection without reoccurrence after 2 years.

[Surgical repair of pharyngocutaneous defects resulting from actinomycosis]. / Actinomycosis talaján kialakult pharyngocutan defektus sebészi kezelése.

The pharyngo-cutan defect is a frequent complication of oropharynx and larynx operations. The not frequent serious actinomycotic inflammation of the neck, and in its treatment the repeated surgical incision was in the background of the defect. The authors review the possibilities of closing these defects, and they describe the method used.