ro13-9904 and Gangrene

A 42-year-old woman with a history of acute myeloid leukaemia status postallogeneic stem cell transplant presented with fevers, altered mental status, pulmonary infiltrates and septic shock that further progressed to thrombocytopenia and purpura fulminans. Laboratory studies were consistent with a diagnosis of thrombotic thrombocytopenic purpura (TTP). Blood cultures grew

Topics: Adult; Anti-Bacterial Agents; Bacteremia; Ceftriaxone; Diagnosis, Differential; Female; Fibrinolytic Agents; Fingers; Gangrene; Glucocorticoids; Graft vs Host Disease; Humans; Immunologic Factors; Leukemia, Myeloid, Acute; Nose; Plasma Exchange; Pneumococcal Infections; Purpura Fulminans; Purpura, Thrombotic Thrombocytopenic; Rituximab; Shock, Septic; Single-Domain Antibodies; Stem Cell Transplantation; Toes

Topics: Anti-Bacterial Agents; Bacteremia; Ceftriaxone; Female; Fingers; Fluoroquinolones; Gangrene; Humans; Infant; Meningococcal Infections; Neisseria meningitidis; Purpura Fulminans; Toes

Abdominal pain is common feature of Henoch-Schonlein purpura, which may mimic appendicitis, leading to unnecessary laparotomy. Accordingly, the diagnosis must be confirmed by ultrasonography or computed tomography scan before laparotomy is performed. The authors report a case of simultaneous occurrence of Henoch-Schonlein Purpura and gangrenous appendicitis in an 18 year-old boy. The patient was admitted with abdominal pain, cramps, and mild dehydration. He also complained of small reddish purple on his lower limbs, bilateral knee pain, low-grade fever, as well as bloody stools. The symptoms subsided completely. Eight days later, he returned with nonbloody, nonbilious emesis, abdominal cramps, and right lower quadrant abdominal tenderness. Abdominal ultrasound evaluation was performed to rule out an intussusception but demonstrated appendiceal dilatation with a possible appendicolith without any evidence of intussusception. A laparotomy was undertaken, and appendectomy was performed for gangrenous appendicitis. Simultaneous occurrence of Henoch-Schonlein purpura and acute appendicitis is rarely observed. Clinical features of the patients may mislead the clinicians, resulting in delayed diagnosis or misdiagnosis. The use of ultrasonography and computed tomography scan would confirm the diagnosis before surgery.

Topics: Abdominal Pain; Adolescent; Anti-Bacterial Agents; Appendectomy; Appendicitis; Arthralgia; Ceftriaxone; Combined Modality Therapy; Diagnosis, Differential; False Negative Reactions; Fever; Gangrene; Gastrointestinal Hemorrhage; Humans; Hydrocortisone; IgA Vasculitis; Intussusception; Male; Metronidazole; Prednisone; Ultrasonography

The objective of the study was to determine the ceftriaxone levels achievable within lesions (toe or forefoot area) in patients with septic gangrene and to investigate the relationship between macro- and microcirculatory parameters and antibiotic concentration. Fifteen patients with severe chronic peripheral occlusive disease received an intravenous injection of 2 g of ceftriaxone. Antibiotic levels in venous and capillary blood and in an exudative part of the lesion were measured. Macrocirculatory functions were assessed by Doppler sonography, plethysmography, and angiography; microcirculatory functions were assessed by quantitative capillaroscopy and fluorescence video microscopy. The mean antibiotic concentrations measured between 4 and 8 h after injection were 92 +/- 26 micrograms/ml in venous blood and 84 +/- 46 micrograms/ml in capillary blood. The concentration in tissue reached its maximum 4 h after injection; the average concentration at between 2 and 8 h was 95 +/- 55 micrograms/ml. Only dynamic capillary parameters showed significant (P < 0.01) correlations to antibiotic levels in tissue. Significantly (P < 0.01) higher levels in tissue were observed in patients with adequate microcirculatory functions (138 +/- 48 micrograms/ml) than in patients with poor microcirculatory function (51 +/- 26 micrograms/ml). Microcirculatory dysfunction appears to be the limiting factor for tissue antibiotic levels. However, even those patients with poor microcirculatory function showed tissue antibiotic levels that were above the MICs for the pathogens most frequently isolated from gangrenous lesions. Therefore, intravenous application was found to be adequate and additional measures such as intra-arterial therapy or Bier's occlusion are basically unnecessary. Our finding that microcirculatory function is the limiting factor for the tissue antibiotic concentration is corroborated by computations based on a three-compartment model.

Topics: Aged; Angiography; Arterial Occlusive Diseases; Ceftriaxone; Female; Gangrene; Humans; Injections, Intravenous; Male; Microcirculation; Middle Aged; Plethysmography; Toes; Ultrasonography, Doppler