Lieberman, B.A.

Norwich, I

English

AJOL - African Journals Online

1192 .A. MEDiCAL JOURNAL 27 September 1969SUMMARY AND CO CLUSIO STwelve cases subjected to upper femoral osteotomy for para-lytic luxation of the hip are analysed. It is ugge ted that thecause of recurrence in a proportion of the younger case isinadequacy of the osteotomy to ensure congruous reduction,particularly during weight-bearing, rather than persistence ofmuscle imbalance.It is concluded that upper femoral osteotomy is at presentthe most satisfactory procedure for the correction of paralyticluxation, but that It must procure adequate varus to ensurecomplete congruity under all circumstances, as evidenced by apostoperative, weight-bearing radiograph.In some younger patients with grossly shelving acetabula, itmay be necessary to supplement the femoral osteotomy by aSalter pelvic osteotomy, but iliopsoa transfer is unlikelyper se to reduce the recurrence rate and probably has littleplace in the management of the condition.In patients in whom the luxation develops slowly and whopresent for treatment at a relatively later age, recurrence is lesslikely; and bone modelling seems to take the form of adaptationto the less than perfect relationships, rather than deteriorationand relapse.I wish to thank Dr J. W. Tate, Superintendent of WynbergOrthopaedic and Convalescent Hospitals, and Prof. C. E.Lewer AlIen, of the Department of Orthopaedics, Universityof Cape Town, for permission to publish this paper, and Mrde Meneaud for the photographs.REFERE CES1. Jones, G. B. (1954): J. Bone Jt Surg., 36 - B, 375.2. Somerville, E. W. (1959): Ibid., 41 - B, 279.3. Jones, R. W. (1926): Brit. J. Surg., 14, 36.4. Jones, G. H. (1962): J. Bone Jl Surg., 44 - B. 573.5. Parsons, O. W. and Seddon, H. J. (1968): Ibid., 50 - B, 266.6. Muslard, W. T. (1959): Ibid., 41 - B, 289.7. Shands. A. R. and Sleele, M. K. (1958): Ibid., 40 - A, 803.8. Phelps, W. M. (1967): Ibid., 39 - A, 143 .AMOEBIASIS OF THE ANTERIOR ABDOMINAL WALL*I. NORWICH, ER.C.S., Part-Time Head, Department of Surgery, AND B. A. LIEBERMAN, M.B., B.CH. (RAND),Medical Officer, Edenvale Hospital, TransvaalAmoebiasis is well known for its varied and often bizarremode of presentation in sites other than the gastro-intestinal tract. One of us (I. .), in fact. recorded a case ofamoebic granuloma of the buttock, as long ago as 1947.'This communication concerns a case of amoebiasis ofthe anterior abdominal wall in which the diagnosis couldnot be firmly established initially. The true nature of thecondition only became apparent when the patient sub-sequently presented with a discharging sinus of tbeanterior abdominal wall.CASE REPORTJ.S., a 22-year-old Bantu male resident in AlexandraTownship, Johannesburg, presented at Edenvale Hospitalon 25 September 1968, complaining of a painful epigastricswelling of some 2 weeks' duration.There had been no alteration in his bowel habit, nodysentery, nausea or vomiting, and there were no factorswhich aggravated or relieved the pain. He had not left thelocal environs over the past year. This was the firstoccasion on which he had sought medical advice for anabdominal complaint.On examination the patient was found to be wellnourished. He was apyrexial with a normal blood pressureand pulse rate. Systematic examination was essentiallynormal, the only abnormal feature being that of a firm,tender mass situated in the midline 3 in. above the um-bilicus. The mass appeared to lie in the anterior abdominalwall. There was no detectable difference in temperaturebetween the mass and the surrounding structures and noskin oedema was present. 0 impulse was detected oncoughing.Rectal examination, stool and urine analysis werenormal.At this stage it was impossible to establish a firm diag-nos!s and the patient was submitted to laparotomy, thetentative diagnosis being that of an incarcerated ventralhernia or a desmoid tumour.'Date received: 10 February 1969.Fig. J. Site and healing of sinus 4 days after commence-ment of treatment. .DISCUSSIOAt operation an extraperitoneal mass wa found lyingbetween the rectu muscles and peritoneum. The ma s washard in consistency, firmly attached to the surroundingstructures and macroscopically was thought to be asarcoma.The peritoneum wa opened but nothing abnormal couldbe found in the liver, stomach, tran verse colon and smallbowel. The mesenteric lymph nodes were not enlarged. Themass wa exci ed and ubmitted for histological examina-tion.Biopsy report (Dr E. Henschel. pathologist. SAlMR.Johannesburg). 'The specimen consi ted of keletal muscle.fascia and non-specifically inflamed fibro-fatty ti sue. Thelatter possibly represented peritoneal tissue attached to thefascia. The inflammatory response was chronic in natureand no evidence of malignant neoplasia was present. Thefeatures suggested a non-specific process involving theanterior abdominal wall.'The patient's postoperative course was uneventful andhe was discharged on the tenth postoperative day, thewound being fully healed.Jt is now well documented that amoebiasis may present inmany forms other than the classical amoebic liver ab cessor amoebic dysentery. There are numerous reports ofperianal and perirectal skin involvement,'" and also ofamoebiasis involving the skin secondary to the drainageof amoebic liver abscesses, adjacent to colostomies andfollowing appendicectomies.'Primary involvement of healthy normal kin by amoebaerarely, if ever, occurs and we would agree with previousauthors'" that the majority of cases of amoebic skin in-festation are econdary to damage and devitalization of theskin.We are aware of case of amoebiasi of the anteriorabdominal wall unas ociated with any underlying overt1193REFERENCES'D EI. 'or"ich, 1. and Muskat, D. A. (1947): Brit. J. Surg., 3~. 2872. Capentanakis, J. (1966): Amer. J. ProclOl .. 17, 5 .3. MeLeney, F. L. and MeJenex, H. E. (193 ): Arch. Surg .. 30. 9HO.4. 'gaL S. K. and Frazier, C. '. (1933): Chin. Med. J., 47, 11 4.5. Manson·Bahr, P. (1935): Trans. Roy. Soc. Trop. Med. Hyg., 32, 223.6. O'born, H. (1960): Cent. Afr. J. Med., 6, 3114.7. Freeman, B. S. (1940): Amer. J. Path., 16. 74.Bor, . (19 ): Personal communication.IIIIIIIIIIIIIIIIIIIII-~-~---__IWe should like to thank Dr J. Meyer, Senior Physician andActing Superintendent of Edenvale Hospital. who wasresponsible for the medical management of this patient. forpermission to publish this case.SUMMARYA case of amoebiasis of the anterior abdominal wall ispresented. The origin of such lesions is briefly discussed.A plea is made for repeated pus swabs and histological ex-aminations in the diagnosis of this condition.visceral amoebic infestation."·" One of the e cases ihighly instructive in that the amoebae could not be culturedfrom the pus alone and the diagnosis could only be con-clusively proved on biop y of the ulcer wall.We are in full agreement with 0 born" who describeda ery similar case to the one pre ented above. He is of theopinion that these cases represent the spread of amoebicemboli via the portal vein from the gut by way of thepara-umbilical veins which lie in the free border of thefalciform ligament and anastomose with the uperior andinferior epigastric veins of the anterior abdominal wall.In support of this viewpoint we should like to draw• ttention to the close imilarity between our case and thetirst case described by Osborn.The difference of duration of symptoms, viz. 2 weekscompared with 2 month , probably accounts for the factthat our case presented only with a painful mass and notan abscess on the point of rupture, as did Osborn'spatient.Both patients denied any dysentery. It is interesting tonote that amoebae apparently passed from bowel toanterior abdominal wall without leaving any signs orsymptoms in their wake. There were no macro copicchanges present at the time of operation in the liver or largeor small bowel. The diagno is of. this condition dependson the finding of amoebae in pus swabs or in theirbiopsy specimens.As has been repeatedly stressed by previou author, thepus swabs must be taken directly from patient to laboratorybecause the time lag and subsequent drop in temperaturewill result in a loss of motility and will make identificationmore difficult. In our case the pus swabs were immersedin warm saline and rushed to the laboratory. These pre-cautions still do not guarantee a 100°1" success rate andit is advisable that a generous biopsy specimen be takenfrom the ulcer wall and submitted for histological examina-tion. This, however. is also not infallible, as was demon-strated in the initial biopsy specimen, but it does ensurea higher success rate. Repeated pus swabs and biopsyspecimens may be neces ary to prove the diagnosis.IR GE EE KTYD KRIFS.27 September 1969Subsequent CourseHe wa readmitted on 27 October 1968, approximatelyone month after the operation, as the wound had brokendown. Reddish-yellow purulent matter was being dis-charged from the wound, and the surrounding skin wasexcoriated. The wound was extremely tender.Specimens of the discharge, together with a biopsyspecimen of the wall of the ulcer, were submitted forlaboratory investigation. The pus swab disclosed thepresence of vegetative forms of Entamoeba hislOlyTica whilethe biopsy revealed necrotic debris, inflammatory cellsand amoebae.He was placed on the following regimen: oxytetra-cycline, 500 mg. 6-hourly orally for 5 days; metronidazole,200 mg. thrice daily; and chloroquin sulphate, 800 mg.orally for 48 hours, followed by 400 mg. daily in divideddoses for 19 days. Following the commencement of treat-ment the discharge rapidly decreased in amount, the painand tenderness disappeared, and the wound was fullyhealed 10 days hter.

Amoebiasis of the anterior abdominal wall

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Amoebiasis of the anterior abdominal wall

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