Dd Wound Sinus Leg
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CLINICAL CASE PRESENTATION ROLL NO-28-36
preface
EVEN A TINY THORN WHEN INVADED RETALIATES,CAN GIVE U BOTRYOMYCOSIS,MADURA FOOT AND LOTS OF PAIN.
INFORMATION PROVIDED-: A 13 YEAR OLD GIRL HAS A WOUND IN LEFT LOWER LEG WHICH ON PROBING IS FOUND TO BE A SINUS.
MORE INFO RM ATI ON N EEDE D TO
REACH A SHORTEST LIST OF PROBABLE DIAGNOSIS ONE SHOULD KNOW AT LEAST TWO THINGS-: PAST HISTORY OF THE LESION. AN ACCOUNT OF GROSS APPEARANCE OF THE DISCHARGE THAT OOZES OUT.
WHAT IS A SINUS? A
SINUS IS A BLIND TRACK LEADING FROM THE SURFACE DOWN TO THE TISSUES. THERE MAY BE A CAVITY IN THE TISSUE WHICH IS CONNECTED TO THE SURFACE THROUGH A SINUS.
PERSISTENT SINUS *PRESENCE OF FOREIGN BODY OR NECROTIC TISSUE LIKE SEQUESTRUM IN DEPTH. . *NONDEPENDENT DRAINAGE OR INADEQUATE DRAINAGE OF AN ABSCESS.
3.WHEN SPECIFIC CHRONIC INFECTION LIKE TUBERCULOSIS,ACTINOMYCOSIS IS THE CAUSE. 4. WHEN THE TRACT BECOMES EPITHEALIZED. 5. DENSE FIBROSIS PREVENTING COLLAPSE.
TENTATIVE DIAGNOSIS CONSIDERING THE AGE OF THE PATIENT AND SITE OF SINUS PROBABLE PATHOLOGY MAY BE; 3) 4) 5)
SINUS DUE TO OSTEOMYELITIS. TUBERCULOUS SINUS. ACTINOMYCOSIS.
4. MYCETOMA aka MADURA
FOOT,MADURAMYCOSIS . 5.BOTRYOMYCOSIS CAUSED BY STAPH.AUREUS. 6.OTHER MISC. CONDITIONS LIKE INCOMPLETE ABSCESS DRAINAGE.{IF HISTORY CORRELATES.}
APPROACH
2. 3. 4. 5.
LIKE IN ANY OTHER CASE THE SCHEME REMAINS THE SAME: HISTORY TAKING PHYSICAL EXAMINATION SPECIAL INVESTIGATIONS CLINICAL DIAGNOSIS
5. TREATMENT 6.PROGRESS 7.FOLLOW UP 8.TERMINATION
HISTORY PATIENT
PARTICULARS
AGE:13 YEARS
SEX:FEMALE
SOCIAL STATUSLOW
BAREFOOTED MADURA FOOT
IGNORANCE
COST ISSUES
PRESENTING COMPLAINT OOZING ON
WOUND FROM LEFT LOWER LEG.
PROBING FOUND TO BE A SINUS.
H/O PRESENT ILLNESS DURATION 2. ONSET 3. CONDITION AT BEGINNING wrt 1.
DISCHARGE ITS COLOR,AMOUNT,SMELL. 4. PROGRESS 5. CONDITION AT PRESENT. 6. RELATION WITH NORMAL FUNCTIONS LIKE WALKING.
TYPICAL PRESENTATIONS LETS
DISCUSS THE PRESENTATION OF DISEASES THAT WE ARE CONSIDERING IN DIFFERENTIAL DIAGNOSIS.
ACUTE OSTEOMYELITIS 1. 2. 3. 4. 5. 6.
ACUTE ILLNESS HIGH FEVER CHILLS LOCALIZED PAIN& TENDERNESS SWELLING APPARENT INFECTION ELSEWHERE.
CHRONIC OSTEOMYELITIS NO ACUTE CONSTITUTIONAL SYMPTOMS. 2. PAST HISTORY OF ACUTE OSTEOMYELITIS. 3. LONG STANDING DISCHARGING SINUS RESISTANT TO TREATMENT. 1.
1.
HISTORY OF ANY SURGICAL PROCEDURE IN THE AFFLICTED BONE.
5. PRESENCE OF PROSTHETICS.
BRODIES ABSCESS SAME
PRESENTATION AS CHRONIC OSTEOMYELITIS BUT WITHOUT A HISTORY OF ACUTE OSTEOMYELITIS.
MADURA FOOT 1. 2. 3. 4. 5.
BARE FOOT WALKING. A TRIVIAL TRAUMA SAY DUE TO A THORN PRICK. A LOCAL PAINLESS LESION AT FIRST WITH A SLOW PROGRESSION. NODULAR SWELLING. NO CONSTITUTIONAL SYMPTOMS.
6. LOCAL SPREAD OF LESION,BREAKING OF NODULE AND FORMATION OF MULTIPLE SINUSES DRAINING OUT SEROPURULENT FLUID WITH GRANULES.
TUBERCULOR OSTEOMYELITIS 1. 2.
3.
PREVIOUS HISTORY OF T.B. FORMATION OF A COLD ABSCESS BEFORE THE FORMATION OF SINUS LYMPH NODE ENLARGEMENT..
BOTRYOMYCOSIS 1. 2. 3.
A HISTORY OF TRAUMA,ABSCESS. FEVER SINUS DRAINING CHARACTERISTIC PUS.
H/O
PAST ILLNESS
TUBERCULOSIS
WITH ALL ITS SYMPTOMS SHOULD BE ENQUIRED FOR.
IMMUNIZATION
STATUS SHOULD BE ENQUIRED FOR WITH DUE IMPORTANCE TO TETANUS.
LOCAL EXAMINATION PART
LEG.
AFFECTED: LEFT LOWER
INSPECTION 1.
3.
NUMBER: MULTIPLE SINUSES STRONGLY SUGGEST OF MADURA FOOT. EXACT SITE: MADURA FOOT IS LIKELY TO HAVE PRIMARY LESION ON PLANTAR SURFACE WHILE OSTEOMYELITIS,T.B AFFECT LONG BONES LIKE TIBIA.
3.DISCHARGE:
AMOUNT
CONTENTS : BLOOD: NOCARDIAL MADURA FOOT. PUS: IF FRANK THEN STAPH OR SOME OTHER PYOGENIC BACTERIA MUST BE SUSPECTED.
BONE CHIPS:VERY STRONGLY SUGGESTIVE OF OSTEOMYELITIS.
PALPATION 1. TEMPRATURE:INDICATOR OF ACTIVE INFLAMMATION.COLD ABSCESS CHARECTERISTIC OF T.B. 3.
TENDERNESS:OF THE UNDERLYING BONE SHOULD BE SPECIALLY NOTED.
3. DISCHARGE ON PRESSING:MORE OF THE DISLODGED GRANULES MAY COME OUT OR BONE CHIPS FROM SEQUESTRUM. 4. PULSATIONS:BLOOD SUPPLY SHOULD BE EVALUATED AS IT MAY HAVE A ROLE IN PATHOGENESIS AND HAS A CERTAIN ROLE IN HEALING. 5. FIXITY OF SINUS WITH UNDERLYING STRUCTURES.
6. LYMPH NODES:ENLARGEMENT SUGESTS T.B.
INVESTIGATIONS THEY
CAN BE GENERAL AND SPECIAL.
GENERAL
3.
THEY DONT HAVE A DIAGNOSTIC BUT A PROGNOSTIC IMPORTANCE. C.B.P:DLC WILL GIVE AN IDEA OF INFECTION. LYMPHOCYTOSIS:CHRONIC INFECTION HIGH POLYMORPHS:ACUTE.
1. 2. 3.
ESR: NON SPECIFIC BUT CAN BE USED AS A GUIDE TO EFFECTIVENESS OF TREATMENT. RANDOM BLOOD GLUCOSE. URINE: ROUTINE MICROSCOPY.
SPECIAL
THEY ARE:
3.
MICROBIOLOGY RADIOLOGY BONE BIOPSY.
4. 5.
MICROBIOLOGY BLOOD
CULTURE CAN BE DONE BUT IS LESS LIKELY TO BE OF MUCH HELP.
MICROBIOLOGICAL
EXAMINATION OF THE DISCHARGE IS NOT ONLY THE KEY TO DIAGNOSIS BUT ANTIBIOTIC SUSCEPTIBILITY IS KEY TO TREATMENT ALSO.
COLLECTION OF DISCHARGE
GRANULE EXAMINATION
SMEAR
CULTURES
GROSS EXAMINATION PRESENCE
OF GRANULES IS A SURE INDICATOR OF MADURA FOOT. COLOR IS ORGANISM SPECIFIC. BLACK- MADURELLA MYCETOMI,M.GRISEA,EXOPHIALA JEANSEMEI. RED-A.PELLETIERI
WHITE YELLOWACREMONIUM,PSEUDOALLESHERIA, ACTINOMADURA. YELLOW-STREPTOMYCES SOMALIENCIS
GRANULE EXAMINATION GRANULES
ARE RECOVERED FROM SALINE SOAKED GAUZE KEPT OVER THE WOUND OVERNIGHT. GRANULE IS CRUSHED BETWEEN TWO GLASS SLIDE,GRAM STAINING IS DONE AND SEEN UNDER MICROSCOPE.
FINDINGS. ACTINOMYCES 1.GRAM STAINING SHOWS DENSE NETWORK OF THIN GRAM+VE FILAMENTS SORROUNDED BYVE CLUBS. SUNRISE APPEARANCE.
NOCARDIAL GRANULES GRANULES
SHOULD BE STAINED WITH MODIFIED ZIEHL NEELSEN STAINING.
ACID ACID
FAST BACILLI DETECTED.
FASTNESS DIFFERENTIATES FROM ACTINOMYCETES
FUNGAL GRANULES IN
GRAM STAINING CLUBBING OF FUNGAL HYPHAE IS APPARENT.
CULTURE 2. 3. 4. 5. 6. 7.
CULTURE SHOULD BE DONE ON: BLOOD AGAR MAC CONKEY AGAR. L.J SLANT. S.D.A AGAR[CHLORHEXIDINE] B.H.I AGAR ANAEROBIC MEDIUM.
INCUBATE AT 25OC AND 370 C AS HYPHAE GROW AT LOWER TEMP.
SMEAR A
GRAM STAINACTINOMYCETES,FUNGUS ZIEHL-NEELSEN STAININGM.TUBERCULOSIS MODIFIED Z.N.STAININGNOCARDIA.[1%SULFURIC ACID DECOLORIZATION.]
RADIODIAGNOSIS SIMPLE
X-RAY. SINOGRAM CT-SINOGRAM USG MRI NUCLEAR MEDICINE.
SIMPLE X-RAY
WILL NOT BE OF MUCH HELP JUST GIVING AN IDEA OF SOFT TISSUE SWELLING. INVOLUCRUM IN 3WEEKS.
SINOGRAM
RADIO OPAQUE DYE INJECTED IN THE SINUS. WILL GIVE THE DEPTH OF SINUS.
MRI
GOLD STANDARD DETECTS INTRAMEDULLARY SITE OF INFECTION. RELATION WITH SOFT TISSUES. D/D OF SOFT TISSUE SWELLINGS.
RADIONUCLIDE SCANNING
DIAGNOSIS CAN BE DONE IN 48 HRS. EARLY TREATMENTLESS DAMAGE. USED-Tc99 LABELLED PHOSPHONATES.
SPECIAL THANKS DR.S.S
PAL DR.DEEPTI CHAURASIA DR.SHOAIB KHAN
preface
EVEN A TINY THORN WHEN INVADED RETALIATES,CAN GIVE U BOTRYOMYCOSIS,MADURA FOOT AND LOTS OF PAIN.
INFORMATION PROVIDED-: A 13 YEAR OLD GIRL HAS A WOUND IN LEFT LOWER LEG WHICH ON PROBING IS FOUND TO BE A SINUS.
MORE INFO RM ATI ON N EEDE D TO
REACH A SHORTEST LIST OF PROBABLE DIAGNOSIS ONE SHOULD KNOW AT LEAST TWO THINGS-: PAST HISTORY OF THE LESION. AN ACCOUNT OF GROSS APPEARANCE OF THE DISCHARGE THAT OOZES OUT.
WHAT IS A SINUS? A
SINUS IS A BLIND TRACK LEADING FROM THE SURFACE DOWN TO THE TISSUES. THERE MAY BE A CAVITY IN THE TISSUE WHICH IS CONNECTED TO THE SURFACE THROUGH A SINUS.
PERSISTENT SINUS *PRESENCE OF FOREIGN BODY OR NECROTIC TISSUE LIKE SEQUESTRUM IN DEPTH. . *NONDEPENDENT DRAINAGE OR INADEQUATE DRAINAGE OF AN ABSCESS.
3.WHEN SPECIFIC CHRONIC INFECTION LIKE TUBERCULOSIS,ACTINOMYCOSIS IS THE CAUSE. 4. WHEN THE TRACT BECOMES EPITHEALIZED. 5. DENSE FIBROSIS PREVENTING COLLAPSE.
TENTATIVE DIAGNOSIS CONSIDERING THE AGE OF THE PATIENT AND SITE OF SINUS PROBABLE PATHOLOGY MAY BE; 3) 4) 5)
SINUS DUE TO OSTEOMYELITIS. TUBERCULOUS SINUS. ACTINOMYCOSIS.
4. MYCETOMA aka MADURA
FOOT,MADURAMYCOSIS . 5.BOTRYOMYCOSIS CAUSED BY STAPH.AUREUS. 6.OTHER MISC. CONDITIONS LIKE INCOMPLETE ABSCESS DRAINAGE.{IF HISTORY CORRELATES.}
APPROACH
2. 3. 4. 5.
LIKE IN ANY OTHER CASE THE SCHEME REMAINS THE SAME: HISTORY TAKING PHYSICAL EXAMINATION SPECIAL INVESTIGATIONS CLINICAL DIAGNOSIS
5. TREATMENT 6.PROGRESS 7.FOLLOW UP 8.TERMINATION
HISTORY PATIENT
PARTICULARS
AGE:13 YEARS
SEX:FEMALE
SOCIAL STATUSLOW
BAREFOOTED MADURA FOOT
IGNORANCE
COST ISSUES
PRESENTING COMPLAINT OOZING ON
WOUND FROM LEFT LOWER LEG.
PROBING FOUND TO BE A SINUS.
H/O PRESENT ILLNESS DURATION 2. ONSET 3. CONDITION AT BEGINNING wrt 1.
DISCHARGE ITS COLOR,AMOUNT,SMELL. 4. PROGRESS 5. CONDITION AT PRESENT. 6. RELATION WITH NORMAL FUNCTIONS LIKE WALKING.
TYPICAL PRESENTATIONS LETS
DISCUSS THE PRESENTATION OF DISEASES THAT WE ARE CONSIDERING IN DIFFERENTIAL DIAGNOSIS.
ACUTE OSTEOMYELITIS 1. 2. 3. 4. 5. 6.
ACUTE ILLNESS HIGH FEVER CHILLS LOCALIZED PAIN& TENDERNESS SWELLING APPARENT INFECTION ELSEWHERE.
CHRONIC OSTEOMYELITIS NO ACUTE CONSTITUTIONAL SYMPTOMS. 2. PAST HISTORY OF ACUTE OSTEOMYELITIS. 3. LONG STANDING DISCHARGING SINUS RESISTANT TO TREATMENT. 1.
1.
HISTORY OF ANY SURGICAL PROCEDURE IN THE AFFLICTED BONE.
5. PRESENCE OF PROSTHETICS.
BRODIES ABSCESS SAME
PRESENTATION AS CHRONIC OSTEOMYELITIS BUT WITHOUT A HISTORY OF ACUTE OSTEOMYELITIS.
MADURA FOOT 1. 2. 3. 4. 5.
BARE FOOT WALKING. A TRIVIAL TRAUMA SAY DUE TO A THORN PRICK. A LOCAL PAINLESS LESION AT FIRST WITH A SLOW PROGRESSION. NODULAR SWELLING. NO CONSTITUTIONAL SYMPTOMS.
6. LOCAL SPREAD OF LESION,BREAKING OF NODULE AND FORMATION OF MULTIPLE SINUSES DRAINING OUT SEROPURULENT FLUID WITH GRANULES.
TUBERCULOR OSTEOMYELITIS 1. 2.
3.
PREVIOUS HISTORY OF T.B. FORMATION OF A COLD ABSCESS BEFORE THE FORMATION OF SINUS LYMPH NODE ENLARGEMENT..
BOTRYOMYCOSIS 1. 2. 3.
A HISTORY OF TRAUMA,ABSCESS. FEVER SINUS DRAINING CHARACTERISTIC PUS.
H/O
PAST ILLNESS
TUBERCULOSIS
WITH ALL ITS SYMPTOMS SHOULD BE ENQUIRED FOR.
IMMUNIZATION
STATUS SHOULD BE ENQUIRED FOR WITH DUE IMPORTANCE TO TETANUS.
LOCAL EXAMINATION PART
LEG.
AFFECTED: LEFT LOWER
INSPECTION 1.
3.
NUMBER: MULTIPLE SINUSES STRONGLY SUGGEST OF MADURA FOOT. EXACT SITE: MADURA FOOT IS LIKELY TO HAVE PRIMARY LESION ON PLANTAR SURFACE WHILE OSTEOMYELITIS,T.B AFFECT LONG BONES LIKE TIBIA.
3.DISCHARGE:
AMOUNT
CONTENTS : BLOOD: NOCARDIAL MADURA FOOT. PUS: IF FRANK THEN STAPH OR SOME OTHER PYOGENIC BACTERIA MUST BE SUSPECTED.
BONE CHIPS:VERY STRONGLY SUGGESTIVE OF OSTEOMYELITIS.
PALPATION 1. TEMPRATURE:INDICATOR OF ACTIVE INFLAMMATION.COLD ABSCESS CHARECTERISTIC OF T.B. 3.
TENDERNESS:OF THE UNDERLYING BONE SHOULD BE SPECIALLY NOTED.
3. DISCHARGE ON PRESSING:MORE OF THE DISLODGED GRANULES MAY COME OUT OR BONE CHIPS FROM SEQUESTRUM. 4. PULSATIONS:BLOOD SUPPLY SHOULD BE EVALUATED AS IT MAY HAVE A ROLE IN PATHOGENESIS AND HAS A CERTAIN ROLE IN HEALING. 5. FIXITY OF SINUS WITH UNDERLYING STRUCTURES.
6. LYMPH NODES:ENLARGEMENT SUGESTS T.B.
INVESTIGATIONS THEY
CAN BE GENERAL AND SPECIAL.
GENERAL
3.
THEY DONT HAVE A DIAGNOSTIC BUT A PROGNOSTIC IMPORTANCE. C.B.P:DLC WILL GIVE AN IDEA OF INFECTION. LYMPHOCYTOSIS:CHRONIC INFECTION HIGH POLYMORPHS:ACUTE.
1. 2. 3.
ESR: NON SPECIFIC BUT CAN BE USED AS A GUIDE TO EFFECTIVENESS OF TREATMENT. RANDOM BLOOD GLUCOSE. URINE: ROUTINE MICROSCOPY.
SPECIAL
THEY ARE:
3.
MICROBIOLOGY RADIOLOGY BONE BIOPSY.
4. 5.
MICROBIOLOGY BLOOD
CULTURE CAN BE DONE BUT IS LESS LIKELY TO BE OF MUCH HELP.
MICROBIOLOGICAL
EXAMINATION OF THE DISCHARGE IS NOT ONLY THE KEY TO DIAGNOSIS BUT ANTIBIOTIC SUSCEPTIBILITY IS KEY TO TREATMENT ALSO.
COLLECTION OF DISCHARGE
GRANULE EXAMINATION
SMEAR
CULTURES
GROSS EXAMINATION PRESENCE
OF GRANULES IS A SURE INDICATOR OF MADURA FOOT. COLOR IS ORGANISM SPECIFIC. BLACK- MADURELLA MYCETOMI,M.GRISEA,EXOPHIALA JEANSEMEI. RED-A.PELLETIERI
WHITE YELLOWACREMONIUM,PSEUDOALLESHERIA, ACTINOMADURA. YELLOW-STREPTOMYCES SOMALIENCIS
GRANULE EXAMINATION GRANULES
ARE RECOVERED FROM SALINE SOAKED GAUZE KEPT OVER THE WOUND OVERNIGHT. GRANULE IS CRUSHED BETWEEN TWO GLASS SLIDE,GRAM STAINING IS DONE AND SEEN UNDER MICROSCOPE.
FINDINGS. ACTINOMYCES 1.GRAM STAINING SHOWS DENSE NETWORK OF THIN GRAM+VE FILAMENTS SORROUNDED BYVE CLUBS. SUNRISE APPEARANCE.
NOCARDIAL GRANULES GRANULES
SHOULD BE STAINED WITH MODIFIED ZIEHL NEELSEN STAINING.
ACID ACID
FAST BACILLI DETECTED.
FASTNESS DIFFERENTIATES FROM ACTINOMYCETES
FUNGAL GRANULES IN
GRAM STAINING CLUBBING OF FUNGAL HYPHAE IS APPARENT.
CULTURE 2. 3. 4. 5. 6. 7.
CULTURE SHOULD BE DONE ON: BLOOD AGAR MAC CONKEY AGAR. L.J SLANT. S.D.A AGAR[CHLORHEXIDINE] B.H.I AGAR ANAEROBIC MEDIUM.
INCUBATE AT 25OC AND 370 C AS HYPHAE GROW AT LOWER TEMP.
SMEAR A
GRAM STAINACTINOMYCETES,FUNGUS ZIEHL-NEELSEN STAININGM.TUBERCULOSIS MODIFIED Z.N.STAININGNOCARDIA.[1%SULFURIC ACID DECOLORIZATION.]
RADIODIAGNOSIS SIMPLE
X-RAY. SINOGRAM CT-SINOGRAM USG MRI NUCLEAR MEDICINE.
SIMPLE X-RAY
WILL NOT BE OF MUCH HELP JUST GIVING AN IDEA OF SOFT TISSUE SWELLING. INVOLUCRUM IN 3WEEKS.
SINOGRAM
RADIO OPAQUE DYE INJECTED IN THE SINUS. WILL GIVE THE DEPTH OF SINUS.
MRI
GOLD STANDARD DETECTS INTRAMEDULLARY SITE OF INFECTION. RELATION WITH SOFT TISSUES. D/D OF SOFT TISSUE SWELLINGS.
RADIONUCLIDE SCANNING
DIAGNOSIS CAN BE DONE IN 48 HRS. EARLY TREATMENTLESS DAMAGE. USED-Tc99 LABELLED PHOSPHONATES.
SPECIAL THANKS DR.S.S
PAL DR.DEEPTI CHAURASIA DR.SHOAIB KHAN
