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BackgroundNecrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency.MethodsThe medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively.ResultsThe paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4).ConclusionsEarly operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.Level of EvidencePrognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Background Group A Streptococcus (GAS) causes acute tonsillopharyngitis in children, and approximately 20% of this population are chronic carriers of GAS. Antibacterial therapy has previously been shown to be insufficient at clearing GAS carriage. Bacterial biofilms are a surface-attached bacterial community that is encased in a matrix of extracellular polymeric substances. Biofilms have been shown to provide a protective niche against the immune response and antibiotic treatments, and are often associated with recurrent or chronic bacterial infections. The objective of this study was to test the hypothesis that GAS is present within tonsil tissue at the time of tonsillectomy. Methods Blinded immunofluorescent and histological methods were employed to evaluate palatine tonsils from children undergoing routine tonsillectomy for adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis. Results Immunofluorescence analysis using anti-GAS antibody was positive in 11/30 (37%) children who had tonsillectomy for adenotonsillar hypertrophy and in 10/30 (33%) children who had tonsillectomy for recurrent GAS pharyngitis. Fluorescent microscopy with anti-GAS and anti-cytokeratin 8 & 18 antibodies revealed GAS was localized to the tonsillar reticulated crypts. Scanning electron microscopy identified 3-dimensional communities of cocci similar in size and morphology to GAS. The characteristics of these communities are similar to GAS biofilms from in vivo animal models. Conclusion Our study revealed the presence of GAS within the tonsillar reticulated crypts of approximately one-third of children who underwent tonsillectomy for either adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis at the Wake Forest School of Medicine. Trial Registration The tissue collected was normally discarded tissue and no patient identifiers were collected. Thus, no subjects were formally enrolled.

Objectives This study aimed to explore the diagnostic sensitivity of 3D heavily weighted T2-weighted MRI (T2MRI) and high-resolution computed tomography (HRCT) in patients with cochlear fibrosis associated with Streptococcus suis ( S. suis ) meningitis and the practicality of Cochlear implantation (CI) treatments. Methods Between January 2020 and December 2022, we enrolled four patients with rare cochlear S. suis meningitis with associated hearing loss despite aggressive or non-aggressive follow-up antibiotic treatment. Clinical imaging data, surgical performances and post-surgical-electrode impedance were evaluated. Results Combined with HRCT and T2MRI, the cochlea had varying degrees of fibrosis and ossification in different cases. However, the electrodes were successfully and wholly inserted after intraoperative removal of the ossified and fibrotic foci. Post - surgical electrode impedance values of MP1 + 2 mode were normal in all 4 cases at initial activation. Conclusion In patients with S. suis meningitis and associated cochlear fibrosis, T2MRI examination of the inner ear was more sensitive than HRCT. This research highlights the feasibility of CI treatment in S. suis meningitis patients with severe cochlear fibrosis.

Hip disarticulation is the removal of the entire lower limb through the hip joint by detaching the femur from the acetabulum. This major ablative procedure is rarely performed for infection but may be required in severe necrotising fasciitis. We present a single centre retrospective review of all cases of emergency hip disarticulations in patients with necrotising fasciitis between 2010 and 2020. All five patients included in the review presented with acute lower limb pain and sepsis. Three patients had comorbidities predisposing them to necrotising fasciitis. Three were deemed to be high risk and two were at intermediate risk of developing necrotising fasciitis. There were two deaths in the postoperative period. Of the three survivors, two required revision surgery for a completion hindquarter amputation and one for flap closure. All three survivors had good functional outcomes after discharge from hospital. Despite its associated morbidity, emergency amputation of the entire lower limb is a life-saving treatment in cases of rapidly progressing necrotising fasciitis and should be considered as a first-line option in managing this condition.

The increasing use of transcatheter aortic valve replacement (TAVR) has led to a rise in cases of infectious endocarditis (IE), a serious complication. For patients who can tolerate surgery, transcatheter heart valve (THV) explantation is considered, though it carries risks of injury to adherent tissues. This report presents a method to minimize such risks during THV removal. An 82-year-old man with hypertension, smoking history and dyslipidaemia underwent TAVR with a 29-mm Evolut FX bioprosthetic valve. Six months later, he developed a fever, and blood cultures revealed Streptococcus gordonii, leading to an IE diagnosis. Despite 3 months of antibiotics, a transoesophageal echocardiogram revealed vegetation growth and valve leakage, necessitating surgery. During the operation, the aorta was incised, and a novel technique using a vinyl chloride tube was employed to retract and protect the THV’s stent frame. This approach helped detach adhesions with minimal tissue damage. The infected valve was successfully replaced with a bioprosthetic valve. By reducing adherent tissue injury, this technique could improve patient outcomes and decrease the need for additional procedures. Explantation of THVs with minimal tissue damage reduces the risk of concomitant procedure and results in low mortality.

Background Mitral valve repair has been proved to provide better outcomes when compared with replacement in degenerative disease. However, it is still unclear that benefits of repair still remain in active endocarditis. Patient clinical conditions and severity of tissue destruction might limit successful durable repair. Methods Of all 247 patients who received surgery during active phase of native left-sided endocarditis from Jan 2006 to Dec 2017, 114 had mitral valve procedures due to active infection of mitral valve apparatus (38 repair and 76 replacement). Perioperative data and mid-term outcomes were retrospectively compared. Results Mean age was 46.4 years old. Repair group had significantly less patients with NYHA class IV (18.4% vs 56.6%, p  = 0.001). Both groups had preserved ejection fraction but accompanied by severe pulmonary hypertension. Major organism was streptococci (50%) and timing of surgery was 11 days after diagnosis. Bypass and cross-clamp time were similar but repair group had significantly less combined procedures. Bi-leaflet involvement was common (47.4% vs 57.6%) and valve lesions were comparable. There was 13.2% of postoperative moderate to severe mitral regurgitation in repair group without recurrent endocarditis. Repair group tended to have better 5-year survival estimates (91.6% vs 70.0%, p  = 0.08) with comparable reoperation rate (7.9% vs 2.6%). By logistic regression analysis, mitral valve replacement was more likely to be performed in patients with decompensated heart failure and combined procedures. Conclusions Mitral valve repair during active endocarditis can be safely performed with good mid-term outcomes, especially in selected group of patients without extremely high surgical risk.

Background Brain abscesses continue to pose diagnostic and therapeutic challenges in developed and developing countries. Their aetiology and management remain complex and unclear, making improvement of treatments and outcome difficult. Methods To determine the demographics, management, and the variables that affect the outcome in subjects with brain abscesses treated at a single centre over an 11-year period, we retrospectively analysed data in 60 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision in Shanghai Changzheng Hospital between January 2001 and December 2011. Such variables as age, gender, Glasgow Coma Scale (GCS) score at admission, clinical presentation, location, number of lesions, predisposing factors, mechanism of infection, aetiological agent, and therapy were analysed independently. Results Our analysis demonstrated that patient age and gender were factors that influence the occurrence of brain abscess; female patients and patients greater than 40 years of age were most likely to suffer a brain abscess. We also found that a patient’s GCS score upon admission did not influence outcome. While frequency of successful culturing of the infectious agent was low, positive cultures were obtained in only 8 of the cases (13.33%), in which the most common isolate was Streptococcus milleri. Outcome was favourable in 78.33% of the subjects, while the mortality rate was 20%. The outcome of one patient was poor due to the abscess in the basal ganglia region. Conclusions Stereotactically guided aspiration is an effective treatment for brain abscess with an overall favourable outcome. Mortality due to brain abscess was not directly related to surgery nor surgical technique. Additional studies will continue to reveal patients trends that may improve treatment for brain abscess.

Periprostatic abscess is a rare complication of hydrogel spacers in radiotherapy for prostate cancer. We present the case of a 61-year-old man who developed this condition. Abdominopelvis CT scan revealed a 54×35×75 mm collection in the location of the SpaceOAR, for which ultrasound-guided transperineal percutaneous drainage of the periprostatic abscess was performed. The patient remains well with serial CT scans showing near resolution of the collection.

Background Ankle arthrodesis is the most frequently performed salvage procedure for pyogenic arthritis. However, its failed fusion rate of approximately 15% has been considered problematic. Herein, we present a case of pyogenic ankle arthritis successfully treated via a two-stage surgical procedure on the basis of the induced membrane technique. Case presentation A 43-year-old Japanese male patient with alcoholic liver disease was referred to our institution. He complained of persistent ankle pain and local heat following osteosynthesis for a closed pilon fracture. Radiological examinations revealed massive destruction of the ankle joint. Cultures of samples obtained from the joint isolated Streptococcus viridans. On the basis of these findings, he was diagnosed with pyogenic ankle arthritis with osteomyelitis of the distal tibia and talus. We performed the two-stage procedure per the induced membrane technique. In the first stage, the necrotic and infected tissue was debrided, and a polymethylmethacrylate spacer was inserted into the bone defect. Intravenous antibiotics were administered for 1 week thereafter. In the second stage, which was performed 5 weeks after the first stage, the induced membrane was identified around the polymethylmethacrylate spacer and cut to remove the latter. Ankle arthrodesis was performed with three double-thread screws. Finally, the autologous cancellous bone graft harvested from the ipsilateral iliac crest was used to fill the bone defect. During the postoperative period, antibiotics were administered intravenously for 2 weeks. Blood examinations normalized 3 weeks after the second stage. The immobilization splint was maintained for 6 weeks, after which partial weight bearing was started, and 6 months after surgery, the patient returned to full weight bearing and walked confidently without ankle pain. Radiological evaluations performed 2 years after the second stage revealed complete consolidation, and he reported no pain while walking. Conclusion Ankle arthrodesis performed via the induced membrane technique not only successfully controlled infection, but also achieved complete bone union, enabling the preservation of ankle joint. This technique demonstrates its potential as a highly effective approach for treating pyogenic ankle arthritis.