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Case 1.6
Published in Monica Fawzy, Plastic Surgery Vivas for the FRCS(Plast), 2023
The purpose of decompression is to rescue threatened muscle and nerve, so if these are already necrotic then there is no need to decompress. If anything, this would risk further morbidity – with infection and even death:If the diagnosis or presentation is delayed by more than 10 hours, I would obtain an MRI to evaluate the state of the muscles, as irreversible muscle damage is thought to start to occur at 8 hours. This will provide radiological confirmation regarding the progression of rhabdomyolysis to myonecrosis – with early ischaemic changes seen as a hyperintense signal on MRI, versus irreversible myonecrosis with complete lack of signal enhancement – in which case I would not operate.In addition, I would not operate if the diagnosis were delayed by 3 days, as widespread irreversible myonecrosis would have already occurred – with no need for imaging to confirm this.Lastly, I would not decompress a foot – even if acute – as morbidity of the procedure outweighs that of the sequelae, which is simply clawed toes.
Postpartum infections
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Infection beneath the deep fascia produces myonecrosis. A clostridial infection is the most common cause, although myonecrosis can occur from a neglected necrotizing fasciitis, which invades deep fascia. Clostridial infection may present early in the postpartum period with severe pain disproportionate to the physical findings. A wound or blood culture positive for clostridia should raise the index of suspicion for myonecrosis. Crepitation or clinical deterioration in the presence of an episiotomy infection warrants surgical exploration and radical excision of involved tissues, supplemented with antibiotic therapy. For clostridial infection, high-dose penicillin (4 million units intravenously every 4 hours) is indicated. Polyvalent gas gangrene antitoxin is thought to be ineffective (89). C. perfringens is the most notorious organism associated with myonecrosis. Clostridium sordellii has also been identified in serious episiotomy infections, but presents with massive malignant vulvar edema thought to be caused by toxin production and results in death from cardiovascular collapse (95).
Toxic Shock Syndrome and Other Related Severe Infections
Published in Botros Rizk, A. Mostafa Borahay, Abdel Maguid Ramzy, Clinical Diagnosis and Management of Gynecologic Emergencies, 2020
The most commonly reported resistance is to clindamycin, with resistance rates between 3.2% and 14%, depending on the tested bacterial strain [69, 83]. Although antibiotic regimens differ depending on treatment team for conservative management of clostridial endometritis, various susceptibility testing suggests prominent responses to metronidazole, ampicillin/sulbactam, piperacillin, penicillin, gentamicin, or cefoxitin [83, 84]. Table 11.4 illustrates the optimal antibiotic treatment for invasive infections caused by clostridial species. Despite extensive study, there is little demonstrable role for use of hyperbaric oxygen in treating C. perfringens, although one case report indicated pain relief and infection control with hyperbaric oxygen, when C. perfringens complicated that case requiring chemotherapy for choriocarcinoma [85]. The same report also proposed that presurgical treatment with hyperbaric oxygen could help delineate areas of myonecrosis.
Pyomyositis presenting as myonecrosis secondary to methicillin-resistant Staphylococcus aureus bacteremia in chronic lymphocytic leukemia
Published in Baylor University Medical Center Proceedings, 2022
Shannon Coombs, Albert Bui, Haares S. Mirzan, Kimberly Robelin, Hillary W. Garner, Murli Krishna, Jennifer B. Cowart
In prior case reports, CLL patients with pyomyositis presented with weight loss and abscess formation in late-stage disease.9,12,13 Our patient did not have abscess formation likely due to chemotherapy-induced myelosuppression.14 The presence of infectious myonecrosis or necrotizing myositis in our patient implies a more aggressive and severe infection. Emergent surgery should be considered but can be deferred if mortality risk is high.14–19 Our patient was not deemed to be a surgical candidate due to his CLL, inpatient neutropenic fever, and sepsis. Fortunately, he had a favorable clinical response to antibiotics through improved muscular function. Our patient also had an elevated serum creatine kinase and aldolase, which indicates more aggressive muscle damage and was vital in identifying pyomyositis.20,21 For treatment, we prescribed a longer 6-week duration of vancomycin due to multiorgan involvement and CLL immunocompromise. CLL is categorized by neoplastic B cells that inhibit normal immune cells, change cytokine function, and cause hypogammaglobulinemia.22 The immune dysregulation associated with CLL along with concomitant chemotherapy treatments has been shown to increase rates of infection fourfold through impaired ability to mount an immune response.3,14,22,23 Lastly, port catheter removal was essential in removing the suspected nidus of infection.24
A case report of a fulminant Aeromonas hydrophila soft tissue infection in a patient with acute lymphoblastic leukemia harboring a rare translocation
Published in Current Medical Research and Opinion, 2022
Emmanouil Charakopoulos, Panagiotis T. Diamantopoulos, Konstantinos Zervakis, Nefeli Giannakopoulou, Mina Psichogiou, Nora-Athina Viniou
Data of case reports of Aeromonas SSTIs in hematologic patients were analysed and are summarized in Table 1. The mean age of the adult population was 54.2 years while 76% of reported cases involved male patients. Clinical manifestations ranged from cellulitis to severe myonecrosis and compartment syndrome while in 64% of infections the primary disease was AL. Furthermore, recent cytotoxic chemotherapy and severe neutropenia (<0.5 × 109/L) were present at the time of infection in 54.5% and 81% of patients, respectively. In addition, 66.7% of isolated Aeromonas spp were identified as A. hydrophila and a history of exposure to water was present in 34.8% of cases. In 47.8% of reported cases, there was an infection-related death which in all cases occurred between 2 to 20 days after the first febrile episode. Finally, in concordance with Masuya et al., we also believe that prompt surgical intervention, even amputation, should not be withheld in cases of necrotizing Aeromonas SSTIs accompanied by severe neutropenia, as suggested by five relevant cases where infection-specific mortality was prevented when surgery was conducted14–34.
Statin-induced necrotizing autoimmune myopathy
Published in Baylor University Medical Center Proceedings, 2021
Syed A. Huda, Sanjay Yadava, Sara Kahlown, Muhammad S. Farooqi, Stephanie Bryant, Ronald Russo
SINAM is rare, with an estimated incidence of 2 to 3 per 100,000 people who use statins.3 There is no definitive association with any particular statin.4 There is great variation in statin use duration before symptoms develop,5 and the diagnosis usually lags disease onset, as it is almost exclusively diagnosed in tertiary care centers.6 It is characterized by significant loss of muscle power, pronounced myonecrosis on muscle biopsy, and irritable pattern on electromyography with elevated serum creatine kinase. The exact pathogenesis is not well understood. Statin exposure causes up-regulation of HMG-CoA reductase in statin-exposed muscles. The development of autoantibodies against HMG-CoA reductase suggests a direct role of statin exposure in development of this pathology.6