Pages

Monday, October 20, 2014

Mucormycosis of the skin in a diabetic woman


Mucormycosis is a very rare but nasty and often deadly infection caused by fungi in the order Mucorales, such as Mucor or Rhizopus species. It is more common in people whose immune systems don't work properly - AIDS sufferers, cancer patients, folks receiving immunosuppressive treatment after organ transplantation... High doses of steroids and uncontrolled diabetes mellitus are risk factors too, for precisely the same reason - they weaken the body's natural defenses, making it easier for these opportunistic fungi to strike. 

Mucormycosis is an infection with many faces. It often involves the sinuses, brain or lungs; other affected areas include the gastrointestinal tract and skin, especially after injuries. Fungal invasion of blood vessels leads to blood clot formation, so that blood supply is lost in the affected body parts, causing tissue necrosis. If the infection has attacked the lungs, symptoms include difficulty breathing and a persistent cough; if the skin is affected, it becomes red and swollen at first, with a significant amount of pain, then turns black. Without an early diagnosis, the outcome can be dismal. Treatment involves amphotericin B therapy and, frequently, surgery to remove the affected tissue - often resulting in significant disfigurement or limb amputation. In cases of disseminated mucormycosis, where the fungi have attacked the entire body, mortality reaches 90% (in AIDS patients, the mortality rate is almost 100%).

Ahmadinejad et al. describe a case of mucormycosis that occurred in Iran in September 2011. A 63-year-old lady with poorly controlled diabetes (she was on oral medication - Metformin - but apparently it didn't help much) who had fallen from a vehicle and dislocated her wrist. She had been treated by an alternative practitioner who applied a poultice made of herbs, egg, flour and turmeric and bandaged her hand. Four days later, she was still in severe pain, so her family removed the dressing and found out that the hand and forearm were now swollen and turning black.

 Necrosis of the skin and soft tissues of the hand and forearm in a female diabetic patient with mucormycosis.


The woman was admitted to the Imam Khomeini hospital in Tehran. Apart from the excruciating pain, edema and discoloration in her left hand, she was found to have a low-grade fever (38 degrees Celsius), but her laboratory findings were more or less normal. The skin on her left hand and forearm was already necrotic, and the range in wrist motion had become limited. She was initially treated with antibiotics. Ultrasonography showed fluid collection inside her wrist. A diagnosis of tenosynovitis was made, and an operation was performed, but the patient was still suffering from pain and fever after 24 hours. Thrombosis of arterial vessels in her hand was diagnosed; the antibiotics were changed and heparin was added to treat the blood clotting, but to no avail. On the 10th day after admission, mucormycosis was finally suspected and the patient was put on amphotericin B. A smear and tissue biopsy showed fungal hyphae, and a tissue culture finally made it possible to identify the "criminal" - a fungus from the genus Rhizopus:



Unfortunately, it was too late to save the hand; the necrosis had spread to the palm area and to the fifth finger. 18 days after admission, limb gangrene was diagnosed, so the hand and forearm had to be amputated below the elbow. The patient received amphotericin B for 9 more days. Six months later, she was alive and well. 

Take a look again at the chain of events that led to the amputation: diabetes, a fall from a vehicle, a herbal dressing applied by an alternative medicine practitioner (it was probably very unwise on the patient's part to rely on traditional medicine instead of seeing a doctor right after her injury) and a delayed diagnosis. One wonders whether the outcome would have been different if the doctors in the hospital had decided to use amphotericin B earlier, instead of trying several different antibiotics in vain.


Literature:

Ahmadinejad Z, (2013)  Cutaneous Mucormycosis in a Diabetic Patient following Traditional Dressing. Case Rep Dermatol Med. 2013: 894927.

Wikipedia: Mucormycosis





Saturday, October 18, 2014

Farm labourer injured by a Rototiller blade


A short case report published in the journal Proceedings of the Royal Society of Medicine (now known as the Journal of the Royal Society of Medicine) in 1956, entitled "An Unusually Large Foreign Body in the Hand", describes the story of a man who had a bad accident while doing farm work, ending up with his hand impaled upon a large, curved blade. Surgeons removed the foreign body. Miraculously, there was almost no lasting damage.


"A farm labourer had his right hand impaled by a Rototiller blade, and was brought to hospital with the foreign body in situ. [The blade, which measured 4 7/8 in. by 5 in. overall and weighed 9 3/4 oz. had entered the ulnar border of the wrist and emerged through the palmar aspect of the thumb. Owing to its curvature, removal was impossible without open operation, where it was found to be lying between the tendons and nerves in front of the wrist and withing the abductor policis brevis.]

Post-operatively, there was temporary median palsy and anaesthesia, but this recovered, and he was left with an almost normally functioning hand, the only residual function being incomplete flexion of 5th finger."


Given the dimensions of the blade, this sounds like a very lucky escape!




Source:

Strange F. G. S. C. (1956) An Unusually Large Foreign Body in the Hand. Proc R Soc Med. 49(4): 183.



Thursday, October 16, 2014

Fooling around with a needle


People sometimes get pretty strange ideas. Probably every ER doctor has seen at least one bizarre case where an unlikely foreign body has been inserted into the male genitalia and needs to be removed. Sometimes the motive is sexual pleasure, sometimes it's about adornment or penis enlargement, and sometimes it's difficult to ascertain the reason. The 20-year-old male who came to a hospital in Nellore, India with an unusual penetrating injury to his penis was initially too ashamed to admit what actually happened. A stitching needle, 6 cm in length, was stuck at the base of his penis, the sharp tip only just palpable. At first, he claimed it had been an accidental injury. Yeah, right. After some prodding, he admitted inserting the needle himself. The motive? Sexual gratification. Please don't ask me how it's possible to achieve sexual gratification with a needle.

Here's an X-ray showing a sharp metallic object in the pelvic area. The tip of the needle had pierced the prostate.



The needle had to be removed surgically, with fluoroscopic guidance. A pressure dressing was applied afterwards. The wound healed well, with only mild penile swelling in the postoperative period. The patient had no trouble passing urine and no erectile dysfunction after healing.

And here's a picture of the needle after removal. As you can plainly see, it was not a small needle.


Source:

S.V. Krishna Reddy (2013) Unusual Penetrating Injury to the Male Genitalia. Int Neurourol J. 17(1): 38–40.





Tuesday, October 14, 2014

Huge ovarian cysts


An ovarian cyst is a fluid-filled, thin-walled sac that forms within the ovary. These cysts are usually benign in nature, although they may cause symptoms such as abdominal pain, swelling or bloating and uterine bleeding. They can be as small as a pea or as large as an orange. Occasionally, they grow even larger, sometimes reaching truly gargantuan proportions.

A short report published in the British Medical Journal 1951 describes the cases of two ladies, both Christian Scientists, who were admitted to hospital in London during the flying bomb era with huge ovarian cysts. One cyst contained an impressive 76 pints (42 litres), the other 60 pints (33 litres) of brown viscous fluid. The fluid was drained first; afterwards, surgical removal of the cysts proved easy. Blood transfusion was unnecessary, but both patients received two pints (1100 mL) of plasma during the operation. They both made a full recovery.

The grainy old photo below shows the massive belly of one of the patients. Imagine lying in a hospital with over 30 litres of fluid in your abdomen, probably barely able to walk (if at all) and unable to care for yourself, while World War II is raging and London is being bombed by the Germans.




Something tells me, too, that the operation wouldn't have been the end of this unfortunate woman's problems. In those times, even after all the fluid had been drained, the excess skin probably wouldn't have been removed, leaving the patient with a hanging "apron" of skin that would have made walking and hygiene difficult (it's not easy to maintain cleanliness under a heavy skin fold, as many obese people know). The report doesn't specify how old the ladies were (I'm guessing at least middle-aged), or from what social class.

In the same year, the British Medical Journal published a letter describing the case of an 86-year-old woman who also suffered from an enormous ovarian cyst. There is no photo, but the description of the case is quite interesting and touching:

"A woman 86 years of age had been bedridden for 16 years, and the cyst had grown to a huge size. She refused operation because she thought it would kill her, and then became so uncomfortable that she decided to have the operation in order that it would put her out of her trouble. She was really nothing more than a small woman attached to an enormous cyst. It had to be propped up on either side, and she was very attenuated."

It was impossible to perform the operation in a hospital, since the patient's belly was so huge by now that she couldn't fit through the door. The surgeon arranged for an operating table to be brought into the room, but discovered that to operate, he needed to be near the electric light hanging from the ceiling, so he ultimately had to perform the operation on the patient's bed! The operation itself presented no technical difficulties. The patient's abdomen was tapped, and the fluid was allowed to flow into a zinc bath. When this container became full, it was carried into a nearby bathroom and emptied.

"A careful count was made of the emptyings of this bath, and then a measurement was made of the amount of fluid that was put into the bath [...] It amounted to 22 gallons (100 litres). She made a very steady recovery, but when she came out of the anaesthetic she refused to believe that she was alive. She thought that she had died and was a disembodied spirit because she could not feel her body [...] Her progress was steady, and she lived until she was 103. She became rather like Queen Victoria in appearance, for she put on weight, was round-faced, and was very much looked up to by her friends. She was very proud of the royal telegrams that were sent to congratulate her on her age. She ended her life very happily, mainly being very well."


16 years of lying bedridden is a very long time, but at least this story had a happy ending!




Literature: 

V. B. Green-Armytage (1951) Enormous Ovarian Cyst. Br Med J. 1(4715): 1145.

J. Collingwood Stewart (1951) Enormous Ovarian Cyst. Br Med J. 1(4718): 1332.

Wikipedia: Ovarian cyst


Saturday, October 4, 2014

"Dirty Harry" syncope


When I found an abstract entitled "Dirty Harry" syncope in PubMed, I was intrigued. Silly me, I wondered whether the term refers to an existing medical condition. After reading the article in question (it's actually just a brief account of a case), I laughed. The story is almost disappointingly commonplace, but funny all the same. The attending physician obviously had a sense of humor.

Syncope, colloquially known as "fainting" or "passing out", is a transient loss of consciousness due to inadequate blood flow to the brain, most commonly resulting from low blood pressure. It is usually preceded by symptoms such as dizziness, nausea, weakness, sweating and loss of vision ("black flakes"). There are three broad categories of syncope: cardiogenic (due to heart problems), reflex (neurally mediated) and orthostatic hypotension. The condition is very common, especially in teenagers and aged people. In itself it is fairly harmless, although it may indicate a much more serious health problem, e.g. heart disease.

And now for the case report, published in the Canadian Medical Association Journal in 1972:

"Hollywood can apparently influence our health as well as our minds. The midnight visit of a 21-year-old girl to the Emergency Room of the Kingston General Hospital was recorded as follows by the intern on duty, Dr. B. R. Reid:

PHYSICIAN'S RECORD: Watching particularly bloody portion of the movie "Dirty Harry" at 11:00 p.m. Felt dizzy and thought she would be sick. Put head between knees with no relief. Asked boy friend to escort her to bathroom and on the way fainted. No injuries incurred. Vital signs stable and patient feeling much better. 

DIAGNOSIS: "Dirty Harry" syncope.

INSTRUCTIONS TO PATIENT: Never see Dirty Harry again!"




Clint Eastwood in his famous role as "Dirty Harry" Callahan.


The description sounds like a classic case of situational reflex syncope triggered by the sight of blood on the screen. Fainting spells during a brutal movie are probably much less common today than over 40 years ago, since we're all pretty much desensitized to TV violence.


Literature:

Simon JB. (1972) "Dirty Harry" syncope. Can Med Assoc J. 107(4): 280. 

Wikipedia: Syncope

Tuesday, September 16, 2014

7 cm pencil stuck in eye orbit


Every once in a while, children tend to get a bit wild while playing. Unfortunately, sometimes just one moment of carelessness can have severe consequences. Even something as banal as tripping and falling can result in a serious injury, as this case from Iran shows. 


In 2011, a 6-year-old boy with orbital trauma was brought to the the Ophthalmology Department of Imam Khomeini Hospital in Kermanshah. According to his parents, he suddenly fell when playing and landed on a pencil, which penetrated the upper part of his right orbit and split, so that half of it remained lodged above the eye. Because the pencil had broken at the entry point, it could not be removed manually. The situation was quite grim, since the penetration of objects into the orbit can lead to blindness and even to the death of the patient as a result of brain damage and/or infection.



 A broken piece of pencil sticking out from the upper cavity of the right orbit. Ouch!


A physical examination with a slit lamp biomicroscope showed no damage to the boy’s cornea. The conjunctiva was lacerated, with sub-conjunctival hemorrhage, and the eyeball itself was severely hypertonic and tense. Since the child was in great pain and severely agitated, doctors were unable to perform a CT scan. However, an X-ray showed a straight object, clearly looking like a pencil, stuck in the orbital space.



An X-ray shows a long object in the orbital space, behind the eye. You can see that the object's outer shell is less dense (dark) as compared to the core. X-rays pass easily through wood, but not through carbon.


The child was rushed to the operation room to try to save his eye. After general anesthesia, the pencil was carefully removed from the orbit. It turned out to be a whopping 7 centimeters long! By comparing the two broken sections of the pencil, the surgeon could confirm that nothing was left behind, but to be absolutely sure, a CT scan was performed. It showed the complete removal of the foreign object from the orbit and no damage to the patient's eye or brain. (The boy's parents must have breathed a huge sigh of relief at this point.)



The bloodstained piece of pencil - 7 centimeters long - after removal.
(All images from: Rezae et al. 2014)

The boy was supervised for two months after surgery and showed no adverse effects from the trauma. Notably, his eyesight did not suffer as a result of this accident - his visual acuity was still 10/10. He's one lucky child, since he could have very easily lost his eye.


Source:

Rezae L, Naiafi F, Moradinazar M, Ahmadijouvbari T. (2014) Case report on the successful removal of an organic penetrating object into the orbit. J Inj Violence Res. 6(1): 50–52.

Friday, September 12, 2014

Elephantiasis nostras verrucosa: two cases


Chronic lymphedema (tissue swelling caused by impaired lymphatic flow) can be an extremely disfiguring and disabling condition. In the past, I've posted descriptions and photos of the disfigurement caused by lymphatic filarial disease, with cases from Haiti and from India. I've also described a case of scrotal lymphedema caused by chronic infections of the urinary tract. This post is about an associated dermatological condition - elephantiasis nostras verrucosa. Be warned - it's not pretty.

Elephantiasis nostras verrucosa is a rare, disfiguring complication of longstanding chronic lymphedema. Recurrent soft tissue infections worsen the condition. Disruption of lymphatic vessels due to trauma or surgery, venous stasis (sluggish blood flow in the veins), radiation, obstruction due to tumors, portal hypertension, obesity and congestive heart failure can all be the precipitating factors of this disease. The affected extremity swells, sometimes to huge proportions; the skin thickens, becomes lichenified and can become covered with knobbly growths. Treatment options include use of elastic bandages, pneumatic stockings, mechanical massage, oral retinoids and surgery. The goal is to restore function and to reduce physical disability. For refractory cases, microsurgical lymphovenous anastomosis can be performed. Amputation should be the last option.

The photo below shows the legs of a 63-year-old obese patient, with chronic lymphedema, tissue inflammation (note the reddened skin) and pronounced elephantiasis nostras verrucosa of the left lower extremity, where the swelling is much greater. 8 years earlier he had received treatment for colon cancer, consisting of surgery and radiotherapy to the lower abdomen. Chronic lymphedema developed after radiotherapy in both legs.




And this is a close-up shot of the left leg. Note the size of the swelling and the thickened, rough skin.




Berngard and Narayanan have described a rather more striking case - that of a 54-year-old man with morbid obesity and congestive heart failure, who sought medical attention, complaining of difficulty breathing at night, swollen legs and weight gain. Physical examination revealed a large abdominal pannus (a thick sheet of skin and fat tissue hanging down from the belly) with lichenified skin containing cobblestone-like nodules and papules with hyperpigmentation. This large, heavy "apron" completely encircled the patient’s genitals and left a fibrotic tract from which he urinated. Ick!



Huge pannus hanging down between an obese man's legs. 



A close-up of the knobbly, hyperpigmented growths on the abdomen.


The patient was treated for decompensated heart failure and was discharged home with outpatient follow-up to be evaluated for surgical removal of the pannus.


Literature:

Akturk HK, Gbadamosi-Akindele M. (2014) Elephantiasis nostras verrucosa. BMJ Case Rep.

Berngard SC, Narayanan V. (2011) Elephantiasis nostras verrucosa of the pannus. J Gen Intern Med 26(7): 810