Sadasivan Jagdish

Role of bone biopsy specimen culture in the management of diabetic foot osteomyelitis.

INTRODUCTION There has been increasing evidence in favor of conservative management of diabetic foot osteomyelitis which requires targeted antibiotic therapy to the causative pathogen. But the method of reliable microbiological isolation is controversial. AIMS AND OBJECTIVES To study the concordance of superficial swab culture with bone biopsy specimen culture in patients with diabetic foot osteomyelitis. MATERIALS AND METHODS A prospective study was conducted from July 2008 to July 2010. All consecutive patients with suspected diabetic foot osteomyelitis were included in the study. Superficial swab and Percutaneous bone biopsy specimens were obtained for culture. The culture results in these two groups were compared for concordance. RESULTS A total of 144 patients were included in the study. 134 cases of bone biopsy specimen and 140 cases of superficial swab showed positive culture results. Mean number of isolate per sample was similar. Staphylococcus aureus was the commonest organism grown in both cultures. The bone pathogen was identified in the corresponding swab culture in only 55 cases (38.2%). Staphylococcus aureus had the highest concordance percentage of 46.5% which was not statistically significant. CONCLUSION Superficial swab culture may not be accurate in identifying all the organisms causing diabetic foot osteomyelitis. Bone biopsy specimen taken simultaneously would increase the accuracy of detecting the bacterial isolate.

Sequential therapy versus standard triple drug therapy for eradication of Helicobacter pylori in patients with perforated duodenal ulcer following simple closure.

Abstract Background. Resistance to clarithromycin, a component of standard triple therapy, leads to inconsistent eradication rates of Helicobacter pylori infection. Some studies have shown higher eradication rates for H. pylori using sequential regimen. This study was done to compare the eradication rates for H. pylori infection between the standard triple drug therapy and the sequential therapy. Methods. Seventy-three patients with perforated duodenal ulcer following simple closure with H. pylori infection were randomized to receive either standard triple drug therapy or the sequential therapy. Standard triple drug therapy comprised of omeprazole, clarithromycin, and amoxicillin for 10 days. Sequential therapy comprised of omeprazole and amoxicillin or the first 5 days followed by omeprazole, clarithromycin, and amoxicillin for the next 5 days. Follow-up endoscopy was done at 2 months to assess the eradication rates, compliance, and side effects with each regimen. Results. Eradication rates for standard triple therapy and sequential regimen were 81.25% and 87.09%, respectively (p = 0.732). The cost of sequential therapy was cheaper and incidence of side effects and compliance were similar in each group. Conclusion. Standard triple therapy and sequential therapy have similar efficacy for eradication of H. pylori and sequential therapy is an economical alternative to standard triple therapy.

Primary retroperitoneal mucinous cystadenoma in a man.

Primary retroperitoneal mucinous cystadenomas (PRMC) are rare benign cystic neoplasms commonly detected as asymptomatic incidental masses on routine imaging exclusively in women. We report the second case of PRMC in the world to be described in a man. A 45-year-old male presented with a progressively enlarging painful lump in his abdomen over the past 3 months. Per-abdominal examination revealed a huge bosselated fixed retroperitoneal mass involving the left half of the abdomen and extending across the midline, which was confirmed by ultrasonography. Plain and contrast-enhanced computed tomography (CT) scan of the abdomen revealed a large 23 20 cm multiloculated retroperitoneal tumor with calcifications in its wall, occupying the entire left side of the abdomen, pushing the bowel loops and the great vessels to the right (Fig. 1). The left kidney was compressed, elongated, pushed postero-medially, and was engulfed by the tumor. A provisional diagnosis of a primary retroperitoneal cystic teratoma infiltrating the left kidney was entertained and laparotomy was performed. Laparotomy revealed a huge 27 15 16 cm multiloculated mass occupying the retroperitoneum and engulfing the left kidney (Fig. 2). Rest of the abdominal viscera including the pancreas was normal. The tumor was resected along with the left kidney. Cut section of the tumor revealed a multiloculated cyst filled with thick gelatinous mucoid material engulfing the left kidney. Microscopic examination of the cyst wall revealed fibrocollagenous tissue with areas of calcification lined internally by a single layer of columnar mucin secreting cells (Fig. 3). A diagnosis of benign primary retroperitoneal mucinous cystadenoma was made. The cortical parenchyma of the

Lymphadenovarix in the axilla – an unusual presentation of filariasis

Clinical manifestations of lymphatic filariasis depend on the area of lymphatic involvement and the duration of infection. A 21 year old man, resident in a filariasis endemic region, presented with multiple matted lymph nodes with cystic areas forming a large mass in his left axilla. An ultrasound scan of the axilla using a 7.5 MHz transducer revealed grossly dilated lymphatics but no filarial dance sign. Fine needle (21 G) aspiration cytology (FNAC) from the dilated lymphatics and solid areas in the lymph node mass revealed multiple microfilariae in a background of reactive lymphoid cells. Peripheral blood smears revealed microfilaremia with significant eosinophilia. Diagnosis of left axillary Bancroftian lymphadenovarix was made. On the administration of oral diethylcarbamazine, the diameter of the lymphatic vessels in the lymphadenovarix reduced considerably in size and microfilaremia disappeared. We report this case because axillary lymphadenovarix is a rare presentation of filariasis. This case is also unique since microfilariae were demonstrated in the fluid aspirated from the dilated lymphatics of the lymphadenovarix in the absence of live adult worms.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT). METHODS Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up. RESULTS Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00. CONCLUSION H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Enterocutaneous fistula due to mesh fixation in the repair of lateral incisional hernia: a case report.

Enterocutaneous fistula following mesh repair of incisional hernia is usually due to mesh erosion of the underlying viscus and presents late. We describe an early enterocutaneous fistula due to an unusual but a potential mode of bowel injury during mesh fixation. This case is reported to emphasize the need for greater attention to the technique of mesh fixation. We suggest laparoscopic guidance to prevent this serious complication in lateral Incisional hernias with ill defined edges of the defect.

Clinico-microbiological Profile of Septic Diabetic Foot with Special Reference to Anaerobic Infection

Introduction Diabetic foot infections are a major cause of non-traumatic amputations. The role of anaerobes in the prognosis of these infections is particularly unclear. This study was conducted with the aim of correlating microbiological profiles with clinical outcomes in these diabetic foot ulcer patients. Methodology This prospective observational study was done in a tertiary care centre in South India. All patients admitted with diabetic foot ulcers for two years were included in the study. Tissue biopsies were collected from the ulcer for aerobic and anaerobic cultures. The patients were grouped as those with aerobic infection alone (anaerobe negative) and those with mixed aerobic and anaerobic infections (anaerobe positive). Anaerobic culture was performed using the Robertson cooked meat (RCM) medium. The ulcer of the foot was described with respect to site, size, duration, history of previous amputation(s), and history of number and class of antibiotic intake prior to hospitalization. Clinical course and Wagner’s grades of the diabetic foot ulcers were compared for aerobic and anaerobic infections. Results A total of 104 patients were included in the study. There were no significant differences between the two groups with regards to duration of diabetes, random blood sugar (RBS) at the time of admission, compliance to drugs, and mode of blood sugar control and prior intake of antibiotics. Patients with anaerobic infections were found to have a higher incidence of fever in this study (38.1% vs. 14.5%; p = 0.0057), as compared to patients with aerobic infections. More than half of the patients in the anaerobic infection group presented with Wagner’s grade IV and above, as compared to the aerobic infection group (59.5% vs. 32.2%; p = 0.0059), which was statistically significant. Patients with anaerobic infections also had high numbers of major and minor amputations when compared to patients with aerobic infections. Conclusion Septic diabetic foot patients with fever at the time of admission and a high Wagner’s grade have a greater chance of harbouring anaerobic infections. Drugs for anaerobic coverage should be considered for wounds beyond Wagner’s grade III. Anaerobic infections resulted in increased risk of morbidity in diabetic foot ulcer patients but did not have any influence on mortality.

Gastric Carcinoma in a Patient with Chronic Lymphocytic Leukemia: Coincidence or Consequence?

Chronic lymphocytic leukemia (CLL) is a neoplasm of mature B-cells of unknown etiology. There is a site-specific increased incidence of second malignancy in patients with CLL. Leukemia and cancer can thus occur in the same patient either simultaneously or sequentially. We present a case of gastric adenocarcinoma in a patient with chronic lymphocytic leukemia. A 47-year old female presented with a history of abdominal pain for one year, along with nausea and vomiting for two months. On examination, she was pale and had generalized lymphadenopathy. Her abdominal examination revealed vague fullness in the epigastrium, but there was no definite palpable mass. The complete hemogram showed features suggestive of CLL, which was later confirmed by a lymph node biopsy and bone marrow examination. While upper gastrointestinal endoscopy revealed an ulceroproliferative growth in the body of the stomach, its biopsy revealed a well-differentiated adenocarcinoma. Gastric cancer developing in a patient with CLL may be due to the immunological impairment associated with other etiological factors, such as Helicobacter pylori infection, smoking, etc. The treatment of gastric cancer consists of a gastrectomy with regional lymphadenectomy followed by adjuvant chemotherapy. The co-existence of CLL and carcinoma stomach can pose a challenge in the management of such patients.