Streptococcal Toxic Shock Syndrome in a 60 year old healthy male: Challenges in Diagnosis and Management

INTRODUCTION: Streptococcal toxic shock syndrome (STSS) is a rare disease that affects about 4 in 100,000 persons a year in resource rich countries. Despite increasing incidence, the factors responsible for this disease are not fully understood and diagnosis often remains elusive, leading to a mortality rate of around 60 percent. We describe a case of STSS in an elderly male, and the challenges associated with rapid diagnosis and appropriate treatment. CASE REPORT: A 60 year old male with history of methamphetamine abuse and hip osteoarthritis presented to the emergency department with left hip and lower leg pain. Hip X-ray demonstrated degenerative disease and patient was discharged home with lidocaine patches. Patient returned to the emergency department the following day with confusion and worsening left lower leg pain. His blood pressure was 80/40, white blood cell count 1.2, lactate 4.3, creatinine 4.55, procalcitonin 66.44, creatinine kinase 608, urinalysis without infection, and chest X-ray with mild vascular congestion. He was intubated and started on intravenous fluids, vasopressors, and broad spectrum antibiotics for presumed septic shock. A clear infectious source could not be identified when two deep venous stasis ulcers on his left shin were noted (Figure 1). Left lower leg X-ray completed one day prior demonstrated no evidence of gas or bony destruction (Figure 2). Clindamycin was started, and general surgery consulted due to concern for necrotizing fasciitis. General surgery found left leg wounds to be without fluctuance, discharge, odor, warmth, or tenderness and felt patient to not have a deep skin infection. Patient was, therefore, not taken for emergent surgical debridement. Patient then rapidly deteriorated, and therapy was escalated to five vasopressor agents. Two blood cultures collected 11 hours prior grew streptococcus pyogenes. Patient, however, at this time was too unstable hemodynamically to undergo further imaging or surgical intervention. Less than 29 hours after initial presentation, patient was pronounced dead. DISCUSSION: STTS is diagnosed when a patient has hypotension, multi-organ failure, and blood cultures growing streptococcus pyogenes. Treatment involves triple antibiotic coverage and early aggressive surgical intervention. Because the disease spreads rapidly, an early diagnosis prior to blood culture results is imperative to reducing mortality. Clinical clues include shock without a clear etiology in an otherwise healthy individual, renal impairment, an elevated creatinine kinase level, and skin findings that are not classic for infection; as was the case with our patient. We present this case to increase awareness among physicians in early recognition of this rapidly fatal disease, and the importance of advocating for early aggressive surgery, as every minute delayed exponentially increases mortality

Comparative study to assess the functional outcome in management of inter-trochanteric fractures by proximal femoral nail versus proximal femoral nail anti-rotation

Background: Proximal femoral fractures are one of the most common fractures occurring in elderly due to osteoporosis and increase in life expectancy. The management of these fractures poses a serious challenge in terms of obtaining a stable fixation and a good post-operative outcome. In this study, we compare two intramedullary devices: Proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFN-A), used commonly for the fixation of proximal femoral fractures.Methods: Patients presenting with inter-trochanteric fractures were included and randomly allocated to two groups for treatment with either PFN or PFN-A. Pre-operative radiographs of normal side were used to grade osteoporosis by Singh’s index. Post-operative radiographs were used to assess the tip-apex distance and quality of reduction. Functional outcome was compared on the basis of Harris hip score at final follow-up. Patients were followed up at an interval of 1, 3 and 6 months respectively.Results: The study included 30 patients with 15 patients in each group. The duration of surgery and blood loss was significantly less in PFN-A group as compared to PFN. Functional outcome as assessed by Harris hip score was similar in both the groups. Implant related complications, though less in PFN-A group, had statistically insignificant difference.Conclusions: It can be safely concluded that, in spite of no differences in functional outcome between the two groups, a shorter duration of surgery and less blood loss would still make PFN-A a better choice in such patients, especially the elderly and co-morbid/compromised patients

Comparative study between delto-pectoral and deltoid splitting approach in surgical treatment of proximal humerus fractures using philos plating

Background: The present study was done to compare the two approaches of proximal humerus PHILOS plating on the basis of functional outcome of patients and other perioperative parameters.Methods: 40 patients with type 2 and type 3 proximal humerus were assigned to group A and B pre-operatively using random alternate allocation. Patients in group-A were operated with deltoid splitting approach while patients in group-B were operated with delto-pectoral approach. Functional outcome was assessed at 6 weeks, 3-months and 6-months. Perioperative parameters like duration of surgery, associated complications, and hospital stay were also noted and compared.Results: In each group, there were 12 two-part fractures and 8 three-part fractures. For 2-part fractures the mean duration of surgery was 51.33 min for group A and 63.37 min for group B. While for 3-part fractures it was 67.5 min and 80 min respectively. Irrespective of fracture type, there was statistically significant difference between the constant scores in both groups at 3 months (2-part: group A: 67.67; group B: 44.7; p value=0.001. 3-part: group A: 66; group B: 48; p value=0.001). However, the difference between two groups at 6 months was not statistically significant.Conclusions: Both approaches show satisfactory outcomes over a long period. However, the significantly less operative time and minimal soft tissue dissection in deltoid splitting approach can be used as an advantage in particular cases. Moreover, there was an early return to day-to-day activities for the deltoid splitting group which should be considered when treating an active individual

Closed reduction and internal fixation with titanium elastic nailing system in pediatric both-bone forearm fractures

Background: The present study is designed to analyse the postoperative clinical and functional outcome of closed reduction and internal fixation of pediatric both-bone forearm fractures with titanium elastic nailing system (TENS).Methods: A total of 32 patients in the age group of 5 to 15 years with fracture both-bone forearm underwent closed reduction and internal fixation with TENS at our hospital. Patients with displaced fractures having angulation more than 10° and rotation of more than 45° or fractures with unacceptable reduction post conservative management were included in this study. For functional outcome, upper extremity rating scale (UERS) was used to evaluate the range of motion and grip strength.Results: Patients were followed up for a period of 6 months. In all cases fracture united in the range of 6-14 weeks without any malunion. All 32 cases had excellent outcomes according to UERS score. Two patients had deficient forearm pronation of 10° and 15° respectively. Skin irritation and implant impingement was seen in two patients each at final follow-up.Conclusions: Closed reduction and internal fixation with TENS seems to be a good treatment option for fixation of pediatric both bone forearm fractures. It gives excellent functional outcome in terms of range of motion and grip strength without any major complications

A Review on Diabetes Mellitus its Types, Pathophysiology, Epidermiology and its Global Burden

The spread of obesity and unhealthy lifestyles has contributed to a significant and increasing disease burden associated with diabetes in all countries worldwide. According to recent estimates, the worldwide prevalence of diabetes in 2013 was recorded at 382 million individuals, with projections indicating a significant increase to 592 million by the year 2035. The categorization of diabetes based on its aetiology has gained widespread acceptance in the scientific community. There are two primary classifications of diabetes, namely type 1 and type 2. Type 2 diabetes is the predominant kind, constituting a majority proportion (>85%) of the overall prevalence of diabetes. Both types of diabetes have the potential to result in a range of problems affecting several bodily systems. These complications can manifest as microvascular endpoints such as retinopathy, nephropathy, and neuropathy, as well as macrovascular endpoints including ischemic heart disease, stroke, and peripheral vascular disease. Diabetes is a significant public health concern because to its association with premature morbidity, death, diminished life expectancy, and substantial financial and societal burdens. Diabetes mellitus is a chronic metabolic illness characterised by heterogeneity and a complex pathophysiology. The condition is distinguished by increased amounts of glucose in the bloodstream, known as hyperglycemia, which arises from irregularities in either the production of insulin or the effectiveness of insulin, or both. Traditionally, diabetes has been classified into three distinct types: Type 1 DM, also known as insulin-dependent diabetes mellitus (IDDM), characterised by the body\u27s inability to make insulin, necessitating the administration of insulin by injections or the use of an insulin pump. This condition is commonly referred to as "juvenile diabetes" in medical literature. Type 2 diabetes mellitus, also known as non-insulin dependent diabetes mellitus (NIDDM), arises due to the presence of insulin resistance. This condition occurs when cells are unable to effectively utilise insulin, either with or without a complete absence of insulin. This particular classification was once denoted as "adult-onset diabetes". The third primary category is gestational diabetes, which manifests when women who do not have a prior medical history of diabetes experience elevated levels of blood glucose throughout their pregnancy. It is plausible that it may occur prior to the onset of type 2 diabetes mellitus. This article explores the various forms, pathophysiology, epidemiology, and global burden associated with the topic under discussion

A study on interfacial activities between Nb and liquid Al in static and dynamic condition

In the present study, an effort has been made to investigate the interfacial activities between the solid Niobium and liquid Aluminium. Aluminium was melted at 750 °C temperature and subsequently, solid niobium was immersed into the liquid aluminium and held for different time intervals. The study was conducted in static as well as dynamic conditions. Temperature and time were similar for both static and dynamic conditions. After solidification, the Nb-Al interface was studied under optical microscopy, scanning electron microscopy, EDS and X-Ray diffraction analyzer. The analysis revealed that there was no change in the dimension of Nb sample and no intermetallic compound formed on the surface or subsurface of solid Niobium under present experimental condition

A case of acute graft-versus-host disease in postliver transplantation

Graft-versus-host disease (GVHD) after liver transplantation, although rare, is well documented in liver transplant recipients. In this syndrome, donor T lymphocytes transferred with the graft are activated by alloantigens expressed by host antigen-presenting cells and initiate an immune response against recipient tissues, especially skin, gastrointestinal tract, and hemopoietic tissue. A descriptive study of clinical case and the management includes investigations, diagnosis, and treatment of GVHD. Diagnosis of the GVHD was based on combination of clinical features and histological features on skin biopsy. Possible differential diagnosis was ruled out on the basis of laboratory investigations. Empirical treatment with continuous immunosuppressant and antibiotics were continued. There was a transient response to the treatment with resurgence of the features culminating in multiple organ dysfunction leading to death. This first case of this rare complication in the experience of our institute of nearly one hundred and twenty liver transplantation amounts to the incidence of approximately 0.8%. This is in alignment with the worldwide incidence. The rarity of this complication coupled with fair incidence of infective complications of liver transplantation mimicking it clinically makes the diagnosis of GVHD more difficult until sought after proactively. Moreover, the balance between the immunosuppression and superadded infection thereof with ill-defined and ill-studied treatment options makes the treatment of the complication more difficult thus justifying its high mortality across the world. Although GVHD is a rare complication of LT and the mortality rate remains very high, clinical features represent an important tool for early diagnosis. The prognosis remains poor, and further research is needed to clarify the pathogenesis of GVHD and to provide new therapy

Retroperitoneoscopic nephrectomy for crossed-fused ectopic kidney

A 25-year-old female presented with a history of recurrent urinary tract infection and end stage renal failure. Voiding cystourethrography revealed bilateral Grade IV vesicoureteral reflux with left to right crossed ectopia. A computed tomography scan showed fusion of both kidneys with the left kidney situated at the lower and anterior part of the right orthotopic moiety. A retroperitoneoscopic nephrectomy with a right side ureterectomy was carried out

Mucinous cystadenocarcinoma of renal pelvis presenting as pyonephrosis

Mucinous cystadenocarcinoma of renal pelvis is a rare epithelial tumor with poor prognosis. It is postulated to arise from metaplastic glandular mucosa in response to chronic irritation, and comprises less than 0.3% of total renal pelvic tumors. We present this case of a tumor noted in a 45-year-old lady that was diagnosed as mucinous cystadenocarcinoma on histological examination after radical nephrectomy. The patient is remaining well over a follow-up of three months