Sung-Yuan Hu

Wound infections secondary to snakebite in central Taiwan

There are very few microbiological data on wound infections following snakebites. The objective of this study was to investigate the treatment of secondary infection following snakebites in central Taiwan. Microbiological data and antibiotic sensitivity of wound cultures were retrospectively analyzed from December 2005 to October 2007 in a medical center in central Taiwan. A total of 121 snakebite patients participated in the study. Forty-nine (40.5%) subjects were bitten by cobra (Naja atra); 34 of them had secondary infection, and 24 of them (70.6%) needed surgical intervention. Cobra bites caused more severe bacterial infection than other snakebites. Morganella morganii was the most common pathogen, followed by Aeromonas hydrophila and Enterococcus. Gram-negative bacteria were susceptible to amikacin, trimethoprim/sulfamethoxazole, cefotaxime, cefepime, ciprofloxacin, and piperacillin/tazobactam. Enterococcus were susceptible to ampicillin, gentamicin, penicillin and vancomycin. It is reasonable to choose piperacillin/tazobactam, quinolone, second- or third-generation cephalosporin for empirical therapy following snakebite. Surgical intervention should be considered for invasive soft tissue infections.

Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study.

BackgroundPercutaneous drainage (PCD) and surgical intervention are two primary treatment options for iliopsoas abscess (IPA). However, there is currently no consensus on when to use PCD or surgical intervention, especially in patients with gas-forming IPA. This study compared the characteristics of patients with gas-forming and non-gas forming IPA and their mortality rates under different treatment modalities. An algorithm for selecting appropriate treatment for IPA patients is proposed based on our findings.MethodsEighty-eight IPA patients between July 2007 and February 2013 were enrolled in this retrospective study. Patientsu2009<u200918xa0years of age or with an incomplete course of treatment were excluded. Demographic information, clinical characteristics, and outcomes of different treatment approaches were compared between gas-forming IPA and non-gas forming IPA patients.ResultsAmong the 88 enrolled patients, 27 (31%) had gas-forming IPA and 61 (69%) had non-gas forming IPA. The overall intra-hospital mortality rate was 25%. The gas-forming IPA group had a higher intra-hospital mortality rate (12/27, 44.0%) than the non-gas forming IPA group (10/61, 16.4%) (Pu2009<u20090.001). Only 2 of the 13 patients in the gas-forming IPA group initially accepting PCD had a good outcome (success rateu2009=u200915.4%). Three of the 11 IPA patients with failed initial PCD expired, and 8 of the 11 patients with failed initial PCD accepted salvage operation, of whom 5 survived. Seven of the 8 gas-forming IPA patients accepting primary surgical intervention survived (success rateu2009=u200987.5%). Only 1 of the 6 gas-forming IPA patients who accepted antibiotics alone, without PCD or surgical intervention, survived (success rateu2009=u200916.7%). In the non-gas forming IPA group, 23 of 61 patients initially accepted PCD, which was successful in 17 patients (73.9%). The success rate of PCD was much higher in the non-gas forming group than in the gas-forming group (P <0.01).ConclusionsBased on the high failure rate of PCD and the high success rate of surgical intervention in our samples, we recommend early surgical intervention with appropriate antibiotic treatment for the patients with gas-forming IPA. Either PCD or primary surgical intervention is a suitable treatment for patients with non-gas forming IPA.

Rhabdomyolysis from an intramuscular injection of glyphosate-surfactant herbicide

Introduction. Glyphosate-surfactant herbicide (GlySH) is widely used as a non-selective herbicide. Most intoxicated cases are from ingestion, inhalation, and skin exposure. Intramuscular injection of GlySH has never been reported. We present a case of GlySH intoxication via intramuscular injection. Case Report. A 42-year-old woman came to the emergency department complaining of painful swelling of left upper limb for 12 h. She had performed an intramuscular injection of 6 mL of GlySH over the lateral aspect of the left elbow 15 h previously. Physical examination disclosed painful swelling over left distal arm, elbow, and forearm with three needle punctures. CT scan revealed ill-defined areas of heterogeneous high density with marked swelling at subcutaneous tissue over posterior aspect of the elbow. Discussion. The mechanism of toxicity of GlySH is complicated and surfactant was thought to play an important role in GlySH intoxication. Intramuscular GlySH poisoning is different from oral GlySH intoxication. Care should be taken when monitoring acute rhabdomyolysis and compartment syndrome, which may develop rapidly and contribute to the surfactant component of glyphosate formulation.

Pneumoscrotum after blunt chest trauma.

Pneumoscrotum, the accumulation of air inside the scrotum, is a rare complication associated with blunt chest trauma. We report a case of severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum after blunt chest trauma in a 44-year-old man. He presented with progressive swelling of the neck that descended to the chest, abdomen, both legs, and scrotum. Radiography and computed tomography of the chest and abdomen confirmed the diagnosis of a tracheal injury complicated by severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum. Primary repair of the tracheal injury was performed, and he was weaned successfully from the ventilator by day 5. He was discharged on day 7.

Fatal haemoptysis caused by a ruptured Rasmussen's aneurysm

A 47-year-old woman with a past history of pulmonary tuberculosis presented to our institution with out-of-hospital cardiac arrest because of massive haemoptysis after severe coughing. On arrival, immediate cardiopulmonary resuscitation with chest compression, endotracheal intubation and intravenous epinephrine 1u2005mg with an interval of 3u2005min for asystole was performed. Twelve minutes later she was defibrillated twice with 150u2005joules and intravenous epinephrine of 1u2005mg with an interval of 3u2005min for ventricular fibrillation was given. Return of spontaneous circulation with a blood pressure of 181/98u2005mmu2005Hg and a pulse rate of 80u2005beats/min was achieved 4u2005min later. Fluid replacement, blood transfusion, tranexamic acid and pitressin were given for persistent gushing of fresh blood from the endotracheal tube. It was suspected that …

Otalgia and eschar in the external auditory canal in scrub typhus complicated by acute respiratory distress syndrome and multiple organ failure

BackgroundScrub typhus, a mite-transmitted zoonosis caused by Orientia tsutsugamushi, is an endemic disease in Taiwan and may be potentially fatal if diagnosis is delayed.Case presentationsWe encountered a 23-year-old previously healthy Taiwanese male soldier presenting with the right ear pain after training in the jungle and an eleven-day history of intermittent high fever up to 39°C. Amoxicillin/clavulanate was prescribed for otitis media at a local clinic. Skin rash over whole body and abdominal cramping pain with watery diarrhea appeared on the sixth day of fever. He was referred due to progressive dyspnea and cough for 4 days prior to admission in our institution. On physical examination, there were cardiopulmonary distress, icteric sclera, an eschar in the right external auditory canal and bilateral basal rales. Laboratory evaluation revealed thrombocytopenia, elevation of liver function and acute renal failure. Chest x-ray revealed bilateral diffuse infiltration. Doxycycline was prescribed for scrub typhus with acute respiratory distress syndrome and multiple organ failure. Fever subsided dramatically the next day and he was discharged on day 7 with oral tetracycline for 7 days.ConclusionScrub typhus should be considered in acutely febrile patients with multiple organ involvement, particularly if there is an eschar or a history of environmental exposure in endemic areas. Rapid and accurate diagnosis, timely administration of antibiotics and intensive supportive care are necessary to decrease mortality of serious complications of scrub typhus.

Spontaneous Renal Artery Dissection Complicating With Renal Infarction

Spontaneous renal artery dissection (SRAD) is a rare entity. We reported a 30-year-old healthy man presenting with sudden onset of left flank pain. Abdominal plain film and sonography were unremarkable. The contrast-enhanced abdominal computed tomographic (CT) scan demonstrated a dissecting intimal flap of the left distal renal artery (RA) complicating infarction. Selective angiography of the renal artery disclosed a long dissection of left distal RA with a patent true lumen and occlusion of left accessory RA. Conservative treatment with control of blood pressure and antiplatelet agent was prescribed. The patient was discharged with an uneventful condition on day 5.

Disseminated histoplasmosis presenting as haemolytic anaemia

A 65-year-old woman, a hepatitis C virus carrier with a history of gallstones for which she had laparoscopic cholecystectomy in August 2007 (when complete blood cell counts and chest x-ray were normal) started taking prednisolone 10u2005mg per day for haemolytic anaemia in March 2008 (when a chest x-ray revealed an infiltrative lesion over the right middle lung). She was admitted to our institution in September 2008 for a cough with scanty sputum, night sweating and leg oedema for 1u2005month and a body weight loss of 6u2005kg over the preceding 6u2005months. Physical examination showed a pale appearance with mild icteric sclera and no hepatosplenomegaly. Laboratory evaluation revealed: a white blood cell count of 4000/mm3 with 84.1% neutrophils; haemoglobin 8.8u2005g/dl; platelet count of 42×103/mm3; C-reactive protein 4.2u2005mg/dl; …

Prostatic abscess of Klebsiella pneumonia complicating septic pulmonary emboli and meningitis: A case report and brief review

Prostatic abscess is a rare entity with an incidence of 0.5%-2.5% in all prostate diseases and usually occurs in the 5th and 6th decades of life with immunocompromised status. Prostatic abscess might be a process of evolution from acute prostatitis. Klebsiella pneumoniae is the leading microorganism in the diabetic patients of prostatic abscess in Taiwan. A 60-year-old diabetic man, with a one-week history of acute bacterial prostatitis was reported in this study, presenting to the emergency department with sudden altered mental status. The abdominal computed tomographic scan demonstrated lobulated prostatic abscess and multiple septic pulmonary emboli with lung abscesses. Analysis of cerebrospinal fluid showed white blood cells of 10771 counts/mm3 with segmented neutrophils of 99%. Cultures of blood, cerebrospinal fluid and sputum yielded Klebsiella pneumoniae. We concluded that computed tomographic scan can make a definite diagnosis of prostatic abscess associated with complications and management with empiric antibiotics and adequate drainage is suggested.

Oculomotor nerve palsy in invasive intracranial aspergillosis

• Radiologic studies to exclude mass or vascular lesion, including computed tomography and magnetic resonance imaging, should be mandatory in patients of oculomotor palsy.