SUMMARY Infection of a prosthetic knee joint with Peptostreptococcus magnus in an immunosuppressed patient with rheumatoid arthritis is described. The organism is a skin commensal, generally thought to be of low pathogenicity; the difficulty in making the diagnosis is emphasised.Key words: rheumatoid arthritis, pyrexia of unknown origin, immunosuppression.Case report A 54 year old man with erosive seropositive rheumatoid arthritis, unresponsive to gold, penicillamine, sulphasalazine and a course of intensive immunosuppression,1 underwent bilateral total knee replacement (TKR) under antibiotic cover, 10 years from onset. A right Stanmore TKR was performed in February 1985; the only complication was a small wound haematoma with sterile serosanguinous discharge, treated with flucloxacillin for 10 days. A kinematic TKR was inserted in the left knee the following June.Two months later, while taking 150 mg azathioprine and 7-5 mg of prednisolone daily, he developed fatigue and rigors. He was pyrexial; lymphadenopathy and splenomegaly, previously noted before intensive immunosuppression, persisted; and an ejection systolic murmur was heard. The knee joints were not painful and there were no clinical signs of septic arthritis. Eight sets of blood cultures were negative. An x ray of the prostheses was unremarkable; a bone scan showed increased activity in relation to the femoral component of the right TKR (Fig. 1), but this was difficult to interpret only nine months postoperatively. Lymph node and liver biopsy were performed: histology of each was
Femoral hernias are elusive conditions that, despite having life-threatening complications, are often undiagnosed in asymptomatic patients. They are less common than inguinal hernias and occur more frequently in females [Purushotham et al. (2014) J Evol Med Dent Sci 3(05):1160-1163]. In the first place, femoral hernia in a male patient is itself, a very rare clinical presentation, let alone complications like obstruction or strangulation in the second place. Thus, despite the fact that femoral hernias account for only 2-4 % of all groin hernias, their timely and correct diagnosis is vital due to the increased mortality associated with emergency surgery for their complications [Arkoulis et al. (2012) Ox J Med, J Surg Case Rep 2012(6):6]. This, however, is not always easy, where mortality has been found to be tenfold. Here, we present a case of right-sided obstructed femoral hernia of Richter's variety in a male of 52 years of age.
Lumbar hernias occur infrequently and can be congenital, primary (inferior or Petit type, and superior or Grynfeltt type), post-traumatic, or incisional. They are bounded by the 12th rib, the iliac crest, the erector spinae, and the external oblique muscle. Most postoperative incisional hernias occur in nephrectomy or aortic aneurysm repair incisions for which various surgical method in context of meshplasty are available. In this case 60 yr. male hypertensive patient presented to the outpatient clinic of institute with recurrent left side lumbar incisional hernia, patient was previously operated for left side nephrolithiasis 15 years back and onlay meshplasty 2 years back for incisional hernia. The patient was operated under high risk for recurrent incisional hernia repair by triple layered meshplasties in the same sitting. Lumbar incisional hernias are often diffuse with fascial defects that are usually hard to appreciate. Computed tomography scan is the diagnostic modality of choice with adjuvant clinical findings, which allows differentiating them from abdominal wall musculature denervation atrophy complicating flank incisions. Repairing these hernias is difficult due to the surrounding structures for which our surgical approach included a triple mesh repair consisting of underlay, inlay and onlay meshplasty thereby anticipating further such incidences of incisional hernia.
Blunt trauma by motor vehicle accidents and falls, followed by penetrating injuries comprise the common mechanisms of renal injury. Unilateral Penetrating Renal Trauma (UPRT) is extremely rare. Here, we reported a unique case of Right Penetrating Renal Trauma (RPRT). A nine-year-old male child, with a 124 cm height and 30 kg weight without any medical history, had a history of falling down from tree with right side penetrating abdominal injury. On admission, patient was vitally stable. Patient had macroscopic haematuria with haemoglobin count of 10 gm/dL, creatinine 1.2 mg/dL. The Computed Tomography (CT) demonstrated right-sided penetrating renal injuries by some foreign material perinephric haematoma with surrounding air foci with renal vascular pedicle injury. An emergency exploratory laparotomy was executed immediately. According to the American Association for the Surgery of Trauma (AAST) organ injury scale grading system, it was considered grade IV renal injury. Nephrectomy was done. Piperacillin and tazobactam was injected to prevent bacterial infection. The postoperative course was uneventful. Patient was discharged after seven days without any complications.
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