James A. Majeski

Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis

Thirty patients with necrotizing fasciitis were analyzed. The first 20 patients were reviewed from the patient records of the University of Cincinnati Medical Center (Group A). An additional 10 patients from the University of Cincinnati Medical Center and the Medical University of South Carolina were more recently treated (Group B). The 20 patients in Group A had a mortality rate of 50 percent, whereas no deaths occurred in Group B. The age range and race and sex ratios were essentially identical between the groups. The most common site of infection in both groups was the leg or perirectal-perioneal area. Hemolytic streptococcus, Escherichia coli, and Staphylococcus aureus were the most frequently isolated organisms in Group B patients. The most common organisms isolated from patients in Group A were identical to those found in Group B, with the addition of Bacteriodes. The clinical manifestations in Group A patients were most commonly fever, edema, crepitus, gangrene, cellulitis, and pus in the involved area. In Group B patients clinical signs of fever, crepitus, skin anesthesia, and roentgenographic evidence of gas were the most common clinical manifestations. Ninety percent of patients in Group B were found to have roentgenographic evidence of soft tissue gas. Diabetes and atherosclerotic vascular disease occurred in more than 75 percent of all patients in both groups. Patients in Groups A and B were identical in nutritional status at the time of admission to the hospital. The improvement in the rate of survival in patients in Group B can be attributed to earlier diagnosis and referral, immediate and extensive debridement of all involved tissue, and aggressive protein replacement.

Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: Association with chronic breast lymphedema

The authors report a rare case of cutaneous angiosarcoma arising more than 5 years after excision of a 1.5 cm invasive ductal cancer of the breast. All lymph nodes were negative for metastatic breast cancer in this 68‐year‐old female. The patient had postoperative therapy consisting of 5040 cGy over a 5 week period using a 6 Megavolt linear accelerator. After radiation therapy to the breast and axillae, the patient developed chronic hard, taut edema of the irradiated right breast. Tamoxifen was administered for 5 years and then stopped. Three months after the cessation of tamoxifen, cutaneous angiosarcoma was found by skin biopsy. A complete mastectomy removed all tumor with clear margins. There are less than 60 cases of radiation associated breast angiosarcoma found in the literature. The presence of chronic lymphedema in the breast after radiation therapy possibly contributes to the development and is an early warning sign for later development of secondary angiosarcoma. The characteristic purple nodules and discoloration of the irradiated skin is the hallmark to suspect the diagnosis. The authors recommend long‐term clinical surveillance for this tumor for all patients who have received breast conservative surgical therapy with concomitant radiation therapy for primary breast cancer. J. Surg. Oncol. 2000;74:208–213.

Action of venom from the brown recluse spider (Loxosceles reclusa) on human neutrophils.

Abstract Loxosceles reclusa venom has an inhibitory effect in vitro on human neutrophil chemotaxis toward complement-derived chemotaxins. Inhibition could be due either to interference with complement activation by endotoxin or a direct effect on neutrophils. The same levels of toxin had no effect on the uptake and killing of bacteria by neutrophils. Therefore, any direct inhibitory effect on the neutrophils is not a general paralysis, but limited to the chemotactic response.

Bilateral breast masses as initial presentation of widely metastatic melanoma.

Malignant melanoma is the most rapidly increasing cancer in the world. Metastatic disease occurs in 20% of patients. Metastatic cancer to the breast is rare, but primary breast cancer is one of the leading causes of death in women. In the present study, a large personal series of breast biopsies is reviewed, and 2 cases of metastatic malignant melanoma to both breasts are reported.

The steroid effect on the in vitro human neutrophil chemotactic response

Abstract Chemotaxis of the polymorphonuclear neutrophilic leukocyte was examined in vitro in the presence of the following steroids: medroxyprogesterone acetate, hydrocortisone sodium succinate, methylprednisolone sodium succinate, cortisone acetate, and prednisone acetate. Results indicate that high concentrations (1 mg/ml) of methyl-prednisolone sodium succinate inhibited the in vitro chemotactic response of human neutrophils. Results also indicate a mild inhibition of the neutrophil chemotactic response by hydrocortisone sodium succinate and prednisone acetate. Medroxyprogesterone acetate and cortisone acetate produced a mild stimulation of neutrophil chemotaxis. These results were discussed with emphasis on the quantitative differences found between in vivo and in vitro effect of steroids on the chemotactic response.

Diverticulum of the vermiform appendix is associated with chronic abdominal pain

BACKGROUND Diverticulum of the vermiform appendix is rarely encountered. Previous reports in the literature indicate that appendiceal diverticulum without inflammations are asymptomatic. METHODS During the past 10 years, 217 patients have been evaluated in our office for chronic lower abdominal pain. Six patients in this group were unusual in that no diagnosis could be made after a complete history, physical examination, and multiple imaging and laboratory studies. Each patient had a normal computed tomography scan of the abdomen, upper endoscopy, colonoscopy, barium enema, and small bowel enteroclysis. Each of the 6 patients underwent an exploratory laparoscopy and appendectomy. RESULTS All 6 patients in this series had acquired diverticulum of the appendix with inspissated intraluminal secretions without histological evidence of inflammation. The age range was 37 to 57 years. Most patients were male, and most had a single diverticulum projecting into the mesoappendix. All 6 patients had complete resolution of their chronic abdominal pain after the laparoscopic appendectomy. CONCLUSIONS An unusual cause of mild chronic abdominal pain can be the presence of appendiceal diverticulum with inspissated intraluminal secretions. The evaluation of these patients is usually normal. Exploratory laparoscopy with appendectomy should be the final evaluation for patients with mild chronic abdominal pain.

Scar endometriosis developing after an umbilical hernia repair with mesh.

A 44-year-old female was initially evaluated for a 3-cm umbilical hernia, which developed after a laparoscopic myomectomy performed seven years prior. The umbilical hernia was repaired using a synthetic mesh. Eight months after the umbilical hernia repair, the patient returned with chronic pain in a 3-cm raised mass originating from the umbilical hernia repair incision. The mass and mesh were surgically removed. The umbilical fascial defect was repaired with a primary fascia-to-fascia closure and the umbilicus was reconstructed from adjacent skin. The mass was found histologically to be endometriosis and fascial scarring with a foreign body reaction to synthetic mesh. Umbilical endometriosis developed either from peritoneal endometrial seeding from a laparoscopic myomectomy or from metaplasia of multipotential cells, which developed into endometriosis due to inflammatory stimulation by the synthetic mesh. Synthetic mesh probably should be avoided in the surgical repair of a laparoscopically caused umbilical hernia in a premenopausal female especially if there is a history of pelvic endometriosis.

Repair of a Subvalvular Left Ventricular Aneurysm Following Mitral Valve Replacement

Left ventricular aneurysms are a frequent complication of myocardial infarction. Some aneurysms occur secondary to trauma, previous operation, or infection. This report presents the case of a patient with a posterior submitral left ventricular aneurysm, which occurred following mitral valve replacement. The complete obliteration of the pericardial sac due to previous cardiac operation and the posterior location made external dissection of the aneurysmal wall technically impossible. Closure of the defect through the valve orifice by placing a patch over the neck of the aneurysm was found to be a relatively simple and safe technique combined with replacement of the prosthetic valve. The possibility of injury to the circumflex coronary artery was reduced using this surgical approach.

Elastofibroma: a subscapular mass.

A large mass protruded from beneath the inferior angle of each scapula of a 69-year-old man when he adducted and elevated either arm 90 degrees at the shoulder. The tumor is situated under the inferior angle of the scapula when the arm and scapula are in the neutral position. A chest computed tomography scan with contrast showed bilateral soft-tissue opacities below each scapula. The radiologic diagnosis of a typical subscapular elastofibroma was confirmed by core-needle biopsy of each mass. The radiologic and clinical diagnosis and surgical treatment of this benign soft-tissue tumor are discussed.