Brucella aortitis managed with debridement, extra-anatomical bypass, and long-term antimicrobial therapy

Objectives This report aims to review the management and outcomes of Brucella-associated mycotic aortic aneurysms. Methods This is a retrospective chart review at a tertiary-level healthcare system. IRB approval was waived per policy. Results We describe a case of Brucella aortitis acquired from habitual contact with wild hogs. Clinical presentation included lower back pain and elevated white blood cell count. Diagnosis was confirmed with imaging showing an infrarenal abdominal aortic aneurysm and serology revealing elevated Brucella antibodies titers. The patient was initially managed with endovascular aortic repair and combined oral and intravenous antibiotics therapy. He then underwent explanation and extra-anatomical bypass due to symptomatic periaortic infection and interval development of type I endoleak. The patient was asymptomatic after his final operation at 24 months of follow-up and remained on suppressive oral antibiotic therapy. Conclusions An aortic aneurysm secondary to Brucella is a rare entity. A detailed history of long-term exposure to animals may be a clue to obtain serologic testing. Operative debridement and re-establishing of reliable blood flow combined with long-term antibiotic suppression are the mainstay of treatment.

Pavement Burns in New Mexico: Our Experiences, Treatments, and Outcomes

Introduction This study focused on patients treated at the University of New Mexico Burn Center who sustained burn injuries from contact with environmentally heated pavement. We report on our patient demographics and outcomes as well as describe our institutional staged surgical approach to treatment. We provide a comparison of our results with other case reports as well as other findings. Methods A retrospective review of patients admitted to the University of New Mexico Burn Center with injuries suffered from contact with hot pavement was performed. Patients were stratified on the presence or absence of altered mental status (AMS) and additional inciting factors. A total of 6 patients were reviewed from 2018 to 2019. We looked at patient demographics and comorbidities, time of contact with hot pavement, inciting factors, total body surface area (TBSA) burned, location of areas burned, depth of burn injury at the time of presentation and at the time of initial operative debridement, percentage of autograft take, complications, length of stay (LOS), and final disposition. Results The patients in our study had a mean TBSA of 9.82% corresponding to pressure points of the body. All patients had nearly 100% conversion to full-thickness burns at the time of initial operative debridement. With staged excision and split-thickness autografting, our patients had nearly 100% take of their skin grafts with minimal graft loss or related complications. At the time of presentation, 100% of patients had AMS and 66% (4/6) had a drug or alcohol related inciting event. Finally, the average LOS was 19.5 days in comparison to 7-9-days for uncomplicated burns of equivalent size at our burn centre. Conclusion Despite an initial appearance of a partial-thickness burn, pavement burns had a high propensity to convert to full-thickness burns. Patients with AMS contributed to our patient population being found with pavement burns. Patients with pavement burns had a distinct anatomic pattern corresponding to pressure points of the body which were often areas at high risk for skin and wound breakdown and complications. Staged excision and split-thickness autografting in the treatment of pavement burns yielded excellent results. Finally, our data showed that providers must be prepared for an extended LOS for patients with pavement burns.

A rare case of retained sabot after close-range shotgun injury

Background Shotgun injuries are a relatively uncommon type of trauma, and therefore may present a challenge in management for trauma surgeons. This is particularly true in the case of surgeons unfamiliar with the unique characteristics of shotgun wounds and the mechanics of shotguns. In many cases, the shot pellets are the primary source of injury. However, a broad understanding of shotgun mechanics is important in recognizing alternative presentations. This article details a case of sabot (a stabilization device used with certain projectiles) retention after a close-range shotgun injury, reviews underlying shotgun mechanics, and discusses strategies for the detection and mitigation of these injuries. The aim of this case report is to increase awareness of and reduce the potential morbidity of close-range shotgun injuries. Case presentation A middle-aged female presented to the Emergency Department with wounds to her right hip and flank after suffering a shotgun injury. A contrast computed tomography scan demonstrated no evidence of hollow viscous or vascular injury, but was otherwise severely limited by scatter artifact from the numerous embedded pellets. The patient was admitted for wound care and discharged 2 days later with a clean wound bed and no evidence of tissue necrosis. Six days after injury, she reported an “unusual” smell associated with severe pain in her right hip wound. She was evaluated in clinic where examination revealed a retained foreign body, identified to be a shotgun shell sabot, which was removed in clinic. She presented again several days before scheduled follow-up with a persistent foul smell from her wound and was noted to have necrotic tissue at the base and margins of the wound that required hospital readmission for operative debridement and closure with negative pressure wound therapy. The patient had an uncomplicated recovery after surgical debridement. Conclusions Although shotgun sabot penetration and retention are rare, they are associated with significant morbidity. Sabot penetration should be considered if injury narrative, physical examination, or radiographic characteristics indicate a distance from shotgun to patient of less than 2 m. A high degree of suspicion is indicated at less than 1 m.

High-Pressure Injection Injuries to the Foot: A Case Report of 2 Patients

Background: High-pressure injections injuries to the extremities can result in significant disability, including amputation of the affected limb. Proprietary mixtures associated with drill mud and hydraulic fracking leads to frequent encounters with varied materials. The physician needs to be aware of the effect of these materials when inadvertent exposure occurs. Injected toxic materials cause extensive soft tissue inflammation and destruction. This puts the foot at risk not only to the cleaning fluid used, generally water, but any contaminant on the boot at the time of injury. This case report is the first known case report involving injection with drill mud contaminant and describes 2 oil field injuries resulting in the gross deep contamination of the foot from a high-pressure washer injury. Case Report: Two patients, a 46-year-old man (patient 1) and a 29-year-old man (patient 2) sustained high-pressure injection injuries to the foot. These patients underwent treatment with immediate broad-spectrum antibiotics and emergent irrigation and debridement on arrival to the treating facility. Neither patient underwent amputation of the affected extremity as a result of their injuries and achieved a full recovery and return to work. Conclusion: High-pressure injection injuries are operative emergencies. Treatment should include tetanus prophylaxis, neurovascular monitoring, broad-spectrum antibiotic coverage, emergent operative debridement for toxic materials. Despite the toxic nature of the injection injuries, aggressive treatment can improve the chance of salvage in these industrial injuries.

An atypical case of necrotizing fasciitis secondary to perforated cecal cancer

Necrotizing fasciitis is an aggressive, life threatening soft tissue infection that requires high index of suspicion for diagnosis. Diagnosis is clinical with management including broad spectrum antibiotics and emergent operative debridement. The majority of cases are secondary to underlying medical processes, local tissue damage, abscess, or inciting procedure, with a paucity of data correlating causation with colon cancer. We describe the case of an 84-year-old man presenting with sepsis of unknown origin who was diagnosed with an atypical presentation of necrotizing fasciitis secondary to a perforated cecal malignancy. His case is unique in that a less virulent polymicrobial infection was likely involved as he initially improved with conservative management alone. He ultimately declined and expired secondary to overwhelming sepsis from his infection. This case highlights the importance of maintaining a high index of suspicion for necrotizing infection and considerations for alternative etiologies of infection including perforated malignancies.

Leclercia adecarboxylata causing necrotising soft tissue infection in an immunocompetent adult

A 72-year-old woman presented with concern for a necrotising soft tissue infection (NSTI) 6 days after a tree branch impaled her left lower extremity while hiking in Hawaii. The wound was irrigated and closed at a local clinic in Hawaii. She completed a 5-day course of clindamycin. She presented to our emergency department 1 day after completion of antibiotics due to worsening erythema and malodorous drainage. Local wound exploration revealed bullae and easy dissection of fascial planes. CT scan revealed complex heterogeneous fluid and inflammatory stranding in the posterior calf. Clinical and radiographic findings raised concern for NSTI prompting initiation of broad spectrum antibiotics and urgent operative debridement. Wound cultures and deep tissues cultures returned positive for pansusceptible Leclercia adecarboxylata. She underwent two additional operative debridements and transitioned to negative pressure wound therapy during her hospitalisation. She was discharged home on oral amoxicillin/clavulanate on hospital day 6.

Fournier Gangrene in Men and Women: Appearance on CT, Ultrasound, and MRI and What the Surgeon Wants to Know

Fournier gangrene (FG) is a genitourinary necrotizing fasciitis that can be lethal if not promptly diagnosed and surgically debrided. The diagnosis is often made by physical examination paired with an appropriate clinical suspicion and supporting laboratory values. Imaging, particularly computed tomography (CT), plays a role in delineating involved fascial planes for operative debridement and occasionally in diagnosing FG. Less commonly, the imaging manifestations of FG may also be seen on ultrasound, radiographs, and magnetic resonance imaging. With the ubiquitous use and availability of CT, radiologists have a growing role in recognizing FG. This can be challenging in the absence of fascial gas, but a CT scoring system for necrotizing fasciitis can be helpful in making the diagnosis. Recent series suggest that this predominantly male disease has a rising incidence in women. Women with FG are more likely to be morbidly obese and have vulvar or labial involvement compared to men. Imaging mimics include ulcerative and necrotic tumors, traumatic or iatrogenic fascial gas, and vaginitis emphysematosa. The purpose of this pictorial review is to illustrate the imaging manifestations of FG and its mimics, with emphases on necrotizing fasciitis CT scoring systems and FG in women.

Factors Influencing Infection Rates after Open Hand Fractures

Introduction Open hand fractures are anecdotally reported to have lower infection rates than open long bone fractures. Although a 3-hour rule for antibiotic administration and a 6-hour rule for operative debridement have historically been upheld as ideal management for open fractures, other factors may be more influential in the development of infection. The purpose of this study was to investigate factors associated with open hand fracture infections. Materials and Methods We retrospectively reviewed 67 patients with 107 open hand fractures between 2012 and 2017. Time from injury to antibiotic administration and operative debridement, modified Gustilo–Anderson classification, and patient characteristics including age, smoking status, and presence of chronic disease were examined for each patient. Outcome parameters were the development of infection and fracture union. Results The overall rate of infection was 9% (6 of 67 patients). No type 1 or type 2 fractures developed infection in contrast to 12.2% of type 3 fractures. Patients who received antibiotics in less than 3 hours and underwent debridement in less than 6 hours did not have lower infection or nonunion rates than those who did not. The association between the modified Gustilo–Anderson classification and the development of infection or nonunion was statistically significant. Conclusion Factors including time to antibiotics, time to operative debridement, smoking status, and chronic disease comorbidities were not predictive of either infection or nonunion in open hand fractures. Fracture type as defined by a modified Gustilo–Anderson classification was the factor most strongly related to the development of infection or nonunion in these fractures.