Basidiobolomycosis is an unusual fungal skin infection that rarely involves the gastrointestinal (GI) tract. We report a 10-year-old boy diagnosed as suffering GI basidiobolomycosis after being misdiagnosed first as suffering intestinal malignancy then schistosomiasis. The patient presented with fever, abdominal pain, vomiting, abdominal tenderness and rigidity with marked blood eosinophilia. Abdominal ultrasonographic and computed tomographic scans revealed a large caecal mass. Biopsy of the mass showed transmural granulomatous inflammation interpreted as schistosomal granuloma, ruling out lymphoma. The patient's condition deteriorated despite anti-schistosomal therapy. Emergency surgery was then performed, and caecal perforation was found. The mass was excised; cultures were negative and histopathological examination was suggestive of schistosomal granuloma. The mass recurred 3 weeks post-operatively. Secondopinion histopathological examination diagnosed Basidiobolus ranarum infection. Treatment with itraconazole produced marked improvement, with diminution of the mass. B. ranarum was unequivocally identified in the archival formalin-fixed and paraffin-embedded (FFPE) tissue by PCR. This case emphasizes the need to consider GI basidiobolomycosis in children presenting with fever, abdominal mass and eosinophilia, especially those complicated by bowel perforation. IntroductionBasidiobolus species are filamentous fungi that belong to the order Entomophthorales. Unlike other fungi (e.g. Mucorales) classified to the former zygomycetes, they cause subcutaneous zygomycosis in healthy individuals (Singh et al., 2008). Basidiobolus ranarum was first described as an isolate from frogs in 1886. It was cultured from frogs' intestinal contents and excreta (Ribes et al., 2000). It is commonly found in soil and decaying vegetable matter. It is occasionally present as a commensal in the gastrointestinal (GI) tracts of amphibians, reptiles, fish and mammals such as frogs, toads, turtles, fish, chameleons, horses, dogs and bats (Kaufman et al., 1990;Zahari et al., 1990;Gugnani, 1999). The micro-organism was first isolated in 1955 from decaying plants in the United States. Subsequently it was found in soil and vegetation worldwide (Greer & Friedman, 1966). Basidiobolus is endemic in Uganda and certain other areas of Africa, and in parts of Asia including India (Ribes et al., 2000). In the past, clinical isolates of Basidiobolus were classified as B. ranarum, B. meristosporus and B. haptosporus. However, recent taxonomic studies based on antigenic analysis, isoenzyme banding and restriction enzyme analysis indicate that all human pathogens belong to B. ranarum. In two studies, B. ranarum was commonly isolated from South India (Khan et al., 2001;Sujatha et al., 2003).Zygomycosis is characterized by tissue invasion with broad, non-septate hyphae of fungal species such as Rhizopus, Rhizomucor, Absidia and Basidiobolus. Fungal elements of B. ranarum include hyphae and zygospores (Hocquet, 1979;Gugnani, 1999). The hyphae are thin-wall...
We report the clinical findings and pathological lung changes in four children following a cultural practice of forced feeding with animal fat (ghee) during infancy. The clinical presentation was of acute or chronic chest infection which failed to respond to antimicrobial therapy. The radiographic features ranged from extensive bronchopneumonia to collapse/consolidation and bronchiectasis. The light microscopy findings included diffuse mononuclear interstitial pneumonia, intraalveolar desquamation of pneumocytes, lipid granuloma formation, lung atelectasis and bronchiectasis. In the two children with longstanding reactions, the striking feature was the minimal lipid engulfment by the macrophages, the continuation of the mononuclear interstitial pneumonia, bronchiectasis and minimal lung fibrosis. In these two older children, the lung lymphatics were probably the main channels for drainage of the aspirated ghee.
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A total of 249 patients, undergoing appendectomy for acute appendicitis, were prospectively randomized into two groups. Group I, comprising 132 patients, received sterile normal saline irrigation to the surgical wound at closure. Alternatively, Group II included 117 patients, who received intraoperative topical ampicillin irrigation of the wound. Both groups were comparable with regard to age, sex, duration of symptoms, and severity of appendicitis. All patients additionally received preoperative systemic gentamicin and Flagyl. Wound infection occurred in 5.3% of Group I compared to only 0.9% of Group II (P<0.05). The reduction in infection rate was significant (P<0.05) in histologically proven appendicitis. We conclude that the addition of intraoperative topical ampicillin to systemic gentamicin and Flagyl augments prophylaxis against wound infection in acute appendicitis. Ann Saudi Med 1994;14(3):233-236. A considerable morbidity following appendectomy is caused by wound infection, 1-5 the rate of which ranges from 9% to 30% in early appendicitis and may reach up to 70% in advanced appendicitis.3-6 Systemic antibiotics were shown to reduce the wound infection rate significantly. 3,4,7 In vitro studies demonstrated 100% kill rates with clinically usable concentrations of antimicrobials in irrigating solutions after only 60-second exposure of the organisms. 8,9 Unlike parenterally administered antimicrobials, topical usage was found to attain prolonged effective local concentrations when used in the powder form. 10Experimental studies have shown that the combined use of systemic and topical antibiotics is better in advanced appendicitis than systemic antibiotics alone.11 Similarly, Seco et al. 12 have concluded in a clinical study that prophylaxis with a combination of systemic clindamycin and topical ampicillin solution, when compared with systemic clindamycin alone, was more effective in preventing wound infection after appendectomy, especially in patients with high wound contamination. However, the study of Seco et al. was criticized because the control group wounds were not irrigated with normal saline and clindamycin may not be the systemic antibiotic of choice for many surgeons. This communication aims at investigating the efficacy of the addition of topical ampicillin to systemic antimicrobials in reducing post appendectomy wound infection rate in a properly controlled randomized prospective study. Material and MethodsAll patients who underwent appendectomy through gridiron incision for clinically suspected acute appendicitis were considered for the study. Exclusion criteria were allergy to ampicillin and other systemic diseases requiring systemic antibiotic administration and therefore three patients who were allergic to ampicillin were excluded from the study, as well as another two patients who had valvular heart disease warranting preoperative prophylactic systemic ampicillin in addition to the systemic gentamicin and Flagyl. A total of 254 patients fulfilled the criteria of the study and were random...
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