Video assisted thoracic surgery in a second trimester pregnant woman with thoracic empyema: a case report.

BACKGROUND: An empyema is an infection of the pleural space that occurs most frequently secondary to the progression of pneumonia. The stages of empyema are based on pleural characteristics and reflect the risks of the condition for morbidity and mortality. Pregnancy is a risk factor for major complications of pneumonia, including empyema. CASE: A pregnant woman at 25 weeks' gestation with a community-acquired Streptococcus pneumoniae pneumonia underwent video-assisted thoracotomy decortication and debridement of a large loculated, gelatinous empyema after conservative medical therapy failed. CONCLUSION: Conservative medical therapy with antibiotics alone may not be adequate for advanced bacterial empyema in pregnancy.

Staged open, endovascular, and hybrid repair of concomitant mycotic aneurysms.

Primary mycotic aneurysms of the aorta are a rare but life-threatening condition. A 59-year-old woman developed a back abscess secondary to an insect bite. A computed tomography scan revealed 3 concomitant mycotic aneurysms, including a rupture. Staged repair was undertaken: immediate open repair for contained rupture of a type IV thoracoabdominal aortic aneurysm, followed by endovascular repair of a descending thoracic aneurysm 3 weeks later and finally an aortic arch hybrid repair of a left subclavian artery aneurysm 16 months later. She remains well postoperatively. There is currently no consensus on the timing of repair or modality of treatment of mycotic aneurysms. Each patient should be treated individually based on aneurysm location, rupture, and comorbidities, as shown by this case.

Late neurological recovery of paraplegia after endovascular repair of an infected thoracic aortic aneurysm.

Spinal cord ischemia is a potentially devastating complication after thoracic endovascular aorta repair (TEVAR). Patients with spinal cord ischemia after TEVAR often develop paraplegia, which is considered irreversible, and have significant increased postoperative morbidity and mortality. We report the case of a patient with unusual late complete neurologic recovery of acute-onset paraplegia after TEVAR for an infected thoracic aortic aneurysm.

Endocarditis of Amplatzer occluder devices after percutaneous closure of a mitral paravalvular leak.

Symptomatic paravalvular leaks (PVL) are a relatively uncommon, but potentially significant postoperative complication of valve replacement surgery. Percutaneous repair of PVLs has become an increasingly utilized approach in patients whose comorbidities obviate surgical repair. We present an interesting case of a gentleman who underwent successful repair of a mitral PVL with Amplatzer devices following initial aortic and mitral valve replacements for bacterial endocarditis. He later developed fungal endocarditis that ultimately required re-operation to remove the devices and replace his mitral and aortic valves. This complication of closure devices, although reportedly rare, should be considered when contemplating a percutaneous approach. © 2012 Wiley Periodicals, Inc.

Hybrid repair of simultaneous multiple mycotic aortic aneurysms.

Simultaneous mycotic aortic aneurysms are a rare but life-threatening complication. We describe the technique of one stage hybrid open debranching and endovascular repair using three thoracic stent-graft devices deployed to cover the whole aorta to exclude multiple mycotic aneurysms.

[V. A. C. INSTILL® therapy - new option in septic thoracic surgery]. / V. A. C.-INSTILL®-Therapie - neue Wege in der septischen Thoraxchirurgie.

BACKGROUND: The V. A. C. INSTILL® therapy is an innovative process for treating chronic wounds that are not optimally accessible to a systemic antibiotic therapy or infected with multi-resistant pathogens. We report on our first experience and applications of V. A. C. INSTILL® therapy in the field of septic thoracic surgery. MATERIALS AND METHODS: V. A. C. INSTILL therapy was used in 11 cases between 11/2009 and 01/2012. Three patients had sternum osteomyelitis (2 MRSA, 1 Finegoldia magna). In 3 patients chronic pleural empyema after lobectomy (1 Streptococcus viridans, 1 mixed infection with MRSA among others) and after pneumectomy (1 MRSA) were detected. In 2 cases there was an acute pleural empyema with extensive phlegmona in the region of the thoracic soft tissues (2 streptococci). In 1 patient a chronic pleural empyema with MRSA infection was treated. Septic arthritis of the sternoclavicular joint with joint destruction and extensive phlegmona in the region of the cervical soft tissues (1 Streptococcus pneumoniae, 1 Staphylococcus aureus) was treated in 2 patients. In all cases instillation of the wound was performed with Lavasept 0.2 %. Swabs of the wound were taken before starting and after ending V. A. C. INSTILL® therapy as well as before wound closure. RESULTS: Mean patient age was 48.8 ± 18.9 years. V. A. C. INSTILL® therapy was performed for 6.5 ± 1.7 days. Instillation time amounted to 21.7 ± 5.7 s. The duration of action was standardised at 18 min in all cases. In 2 cases (1 MESA, 1 finegoldia) the V. A. C. INSTILL® therapy was repeated. In 10 patients a sterile wound status was achieved before secondary wound closure. All wounds underwent secondary closure without recurrence. CONCLUSIONS: Chronic osteomyelitis with MRSA infections as well as chronically infected residual cavities after empyema surgery and extensive phlegmona are possible indications for V. A. C. INSTILL® therapy in order to help eradicating the infection as quickly and as completely as possible.

Infectious native aortic aneurysm with negative blood cultures: do not forget the pneumococcal urinary antigen test!

Infectious native aortic aneurysm (INAA) are rare but life-threatening infections. Early microbiological identification is crucial to initiate adequate therapy and decrease the peri-operative risk, but can be challenging when blood cultures remain negative. We describe two cases of pneumococcal INAA with negative blood cultures, diagnosed in the with the pneumococcal urinary antigen test.

Serial PCR genetic load determination in the surgical management of pneumococcal intracranial sepsis.

PURPOSE: Aspirated intracranial fluid, in the surgical management of intracranial sepsis, may not culture an organism due to the previous administration of antibiotics. We have sought to utilise polymerase chain reaction (PCR) to determine the cause of culture-negative sepsis and in monitoring response to therapy. METHODS: This was a retrospective review of five cases of Streptococcus pneumoniae intracranial sepsis. Samples were analysed using real-time quantitative PCR targeting the pneumococcal lytA gene and the number of genome copies per microlitre of sample determined. RESULTS: Streptococcus pneumoniae sepsis was diagnosed by PCR in five culture-negative cases comprising: ventriculitis (×3), subdural empyema and meningitis. Serial serum inflammatory markers (CRP and WBC) and number of genome copies were graphically plotted over the duration of inpatient stay for cases requiring surgical drainage of recurrent collections or external ventricular drainage. A correlation was demonstrated between change in bacterial genomic load and serum inflammatory markers, reflecting similar changes in clinical state. CONCLUSIONS: This is the first report of the use of serial quantitative PCR in monitoring the course of intracranial sepsis secondary to S. pneumoniae. Further work is required to determine the precise relationship between serum inflammatory markers, clinical state and bacterial load: do changes in one precede the other? Furthermore, a threshold value for number of genome copies in cerebrospinal fluid/aspirate samples has yet to be defined.

Purulent pericarditis in children: is pericardiotomy needed?

OBJECTIVES: This study aimed to describe our experience with pediatric bacterial pericarditis and review the optimal therapy for this entity. METHODS: This is a retrospective study in a pediatric intensive care unit in a university hospital. Three children were diagnosed with purulent pericarditis. They were all treated with antibiotics, echocardiography-guided pericardial fluid drainage, and placement of a pericardial catheter, with no need for thoracotomy or pericardial window. RESULTS: All 3 children fully recovered, and none developed constrictive pericarditis. CONCLUSIONS: Children with purulent pericarditis usually can be treated with antibiotics and drainage of pericardial effusion, with no need for thoracotomy or pericardial window.

Eckardt keratoprosthesis for combined pars plana vitrectomy and therapeutic keratoplasty in a patient with endophthalmitis and suppurative keratitis.

This is a case report on the use of Eckardt keratoprosthesis for pars plana vitrectomy in a patient with endophthalmitis and suppurative keratitis that developed after cataract surgery. A 79-year-old woman developed acute-onset infectious endophthalmitis and suppurative keratitis after cataract surgery that failed to respond to treatment with antibiotic eyedrops and intravitreal antibiotic injection. Using a temporary keratoprosthesis that enabled sufficient visualization, vitrectomy was performed, followed by therapeutic keratoplasty using a cryopreserved donor cornea. The patient's vision was improved from light perception to counting fingers at 30 cm, 3 months postoperatively. There was no recurrence of infection or other significant complications.

Acute-onset endophthalmitis after cataract surgery: success of initial therapy, visual outcomes, and related factors.

PURPOSE: To evaluate the success of initial treatment and the factors influencing the outcome in acute-onset endophthalmitis after cataract surgery. METHODS: We retrospectively reviewed the medical records of all patients with acute postoperative endophthalmitis between 2000 and 2007. We performed pars plana vitrectomy (PPV) to all eyes with initial visual acuity of light perception. Eyes with visual acuity of hand motions or better underwent either intraocular antibiotic injection (IOAI) or PPV. Eyes that did not give a good clinical response to initial therapy within 60 hours underwent a second procedure. The main outcome measure was the rate of early reintervention after PPV and IOAI. RESULTS: We evaluated 88 eyes of 88 patients. Thirty-seven patients underwent PPV and 51 patients underwent IOAI alone. Six of 37 (16.2%) patients required 1 or more procedures within 60 hours of the initial procedure in the PPV group. Twenty-eight of 51 eyes (54.9%) in the IOAI group underwent PPV within 60 hours. The rate of response to primary PPV was significantly higher than to primary IOAI (P < 0.001). Gram-negative organisms composed 35.1% of the isolates. CONCLUSION: Pars plana vitrectomy may be preferable to IOAI in postoperative endophthalmitis since the rate of early reintervention is lower with initial PPV.

[Acute mastoiditis in children: can mastoidectomy be avoided?]. / Mastoïdite aiguë extériorisée chez l'enfant: la mastoïdectomie peut-elle être évitée?

OBJECTIVE: Mastoidectomy is the standard management for exteriorized mastoiditis. The objective of this study was to assess the results of conservative management of acute mastoiditis and to study the types of bacteria isolated and their sensitivity to antibiotics. METHODS: A retrospective study including children admitted with acute mastoiditis was conducted between 1994 and 2007. Intravenous antibiotics were systematic. Since 2002, mastoidectomy has been replaced by retroauricular puncture and grommet tube insertion. RESULTS: Forty-four children had acute mastoiditis. All but one (temporozygomatic swelling) had postauricular swelling. The culture was positive in 78% of cases. Streptococcus pneumoniae was the most common bacteria identified. Twenty-six subperiosteal abscesses were found on the CT scan. Mastoidectomy was performed in 17 cases, 16 of which took place before 2002. The hospital stay has been decreased by six days with retroauricular puncture and grommet tube insertion management. CONCLUSION: In the absence of intracranial complications and suspicion of Fusobacterium necrophorum, a retroauricular puncture and grommet tube insertion associated with antibiotic therapy is an effective alternative to mastoidectomy in the treatment of acute mastoiditis with subperiosteal abscess.

Bartholin's gland abscess caused by Streptococcus pneumoniae in a sexually active young woman.

Gynaecological infections are frequent in women, particularly in young women during their reproductive time. Anatomophysiologically, Bartholin's gland is greatly susceptible to infections and is characterised by an inherent polymicrobial population. In fact, gynaecological microbiota has a set of agents coming from the perianal region that colonise the vagina and, in particular, Bartholin's gland. Taking this into account, infections caused by agents that do not belong to the genital microbiota are less frequent. Here, we describe a case of a 23-year-old young woman with an abscess in Bartholin's gland caused by Streptococcus pneumoniae.

Mowat-Wilson Syndrome Presenting With Purpura Fulminans.

Purpura fulminans is a rapidly progressive syndrome of intravascular thrombosis and hemorrhagic infarction of the skin. The most common infectious etiology is Neisseria meningitidis sepsis, and less commonly it has been documented as a complication of invasive Streptococcus pneumoniae In children who are otherwise healthy, splenic dysfunction is a significant predisposing factor for invasive pneumococcal infection. We present the case of a 10-month-old girl with a history of developmental delay, who developed an overwhelming infection complicated by purpura fulminans and was found to have previously undiagnosed Mowat-Wilson syndrome with anatomic asplenia. We propose screening patients with clinical features suggestive of Mowat-Wilson syndrome for asplenia to evaluate the need for additional preventive care.

A diagnosis of pneumococcal peritonitis secondary to pyo-salpinx in a young healthy female by culturing peritoneal pus.

Pneumococcal intra-abdominal infections of female genital tract origin are rare. A 33-year-old woman with peritonitis due to Streptococcus pneumoniae serotype 3 was reported. The patient did not have any of the known predisposing conditions for intra-abdominal pneumococcal infection. The clinical presentation included signs of multiorgan failure. Peritoneal toilette, bilateral salpingectomy and antibiotic treatment were promptly administered. The patient remained febrile, developed respiratory failure and required a repeated laparotomy and a prolonged antimicrobial treatment. Penicillin susceptible S. pneumoniae was isolated from the pus collected at surgery. Thus, culturing of intra-operative specimens should never be neglected to establish the correct microbiologic diagnosis.

[Pneumococcal endocarditis in children]. / Endocarditis por Streptococcus pneumoniae en un escolar sano.

Endocarditis caused by Streptococcus pneumoniae in children is an infrecuent disease, corresponding to 3-7 % of all cases reported. Pneumococcal endocarditis is a serious condition with a rapidly destructive nature and high fatality rate, demanding prompt medical and surgical treatment. We report a case an infant eleven years old who was admitted with endocarditis by S. pneumoniae, who presented with hearth failure and required surgery. A review of the literature of endocarditis caused by S. pneumoniae is presented.