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Actinomycostic infections in children
ABSTRACTS
506
NSub
POSTER
SESSIONS
UP
“C02N0,
%GP
TGP
FROM
C
S
4 + .7
.13 + .Ol
.12 + .Ol
(5 mmol/L lactate + mmol/L alanine) .12 + .Ol 65 + 6 84 k 4
C
S
4r1
C
S
Sub
C
S
.I2 -t.Ol
0
23 5 1
16-t3*
19 z .2
14 *.2*
1
1921
14k.4'
142.7
10 2.7"
69 '-3
39 + 3'
.16 + .Ol
5
1621
10 + I*
12 2.6
7 *.7*
48 + 3
3453x
.22 + .Ol
.27 + .Ol*
10
1421
7 +1*
10 2.2
5 t .4
27 k 1
17r1*
.36 + .Ol
.47 k .01*
.23 2 .Ol*
*P < .Olvc.
enous (lactate)precursors. Rats (250 g) were either sham-operated (C) or made septic (S) by cecal ligation and single puncture. At 24 hours following operation the rats were hyperdynamic. Livers were isolated and perfused with Krebs buffer + RBCs (Hct = 20%) first with no substrate (NSub) followed by 5 mmol/L lactate + 0, 1,5, or 10 mmol/L alanine (Sub, n = 5 each group). Rates of total glucose production (TGP, pmoliglh), oxygen consumption (VO,, pLWg/ min) and urea production (UP, mg/g/h) were measured during NSub and Sub. During Sub a constant infusion of Y-lactate (25 nCi/mL) was administered to determine labeled glucose production from lactate ( 14C-GP, ~moliglh) and CO? production derived from lactate (‘CO,, pL/g/min). In sepsis, as nitrogenous substrate is added (as might occur in vivo) UP is significantly increased, much less lactate is oxidized, and there is a greater contribution by alanine and other precursors to VO, ( ‘“CO,/VOZ). Accelerated production of urea suggests that preference for amino acids develops and may contribute to metabolic dyshomeostasis during sepsis. Actinomycostic Infections in Children. Mary L. Brand& Gervais 0. Andze, Her& Blanchard, Hospital, Montreal, Quebec.
Ste-Justine
Actinomycosis is a chronic granulomatous and suppurative disease caused by Actinomyces israeli or bovis. It is a rare disease, especially in children. A retrospective review showed 11 children with actinomycosis from 1973 to 1988. There were 6 boys and 5 girls, with ages from 4 to 17 years. Six patients had incidental findings of actinomycosis in the tonsil after tonsillectomy and required no further treatment. Five patients had invasive actinomycotic infection. Two patients presented with cervical actinomycosis, one with recurrent infections of the thyroid that required thyroid lobectomy, and one with a chronic zygomatic arch mass diagnosed by biopsy. A third patient developed a deep wound abscess with massive ileocecal lymphadenopathy following a negative exploration for appendicitis. The fourth patient was admitted for evaluation of a nonhealing, epigastric wound. A small sinus tract was identified in the open wound, which was in continuity with a liver abscess containing actinomycosis. The fifth patient presented with right thoracic pain, a right pleural effusion, and a small mass on the right costal margin that contained actinomycosis on biopsy. All five patients with invasive actinomycosis had significant delays in diagnosis, usually due to an evaluation for possible neoplastic disease. All patients were treated by surgical debridement and drainage as well as intravenous penicillin for 2 to 3 weeks followed by oral penicillin for 1 to 3 months with resolution of the infection. Actinomycosis is a rare infection in childhood with varying presentations, and should be considered in any child with a nonhealing wound or unexplained truncal or cervical mass. The diagnosis is suspected by the presence of sulfur granules in affected tissue, and confirmed by stain or culture proof of actinomycosis. Long-term treatment with penicillin, with adequate surgical debridement and drainage, is adequate therapy. The incidental finding of actinomycosis after tonsillectomy requires no further treatment.
Management of a Massive Degloving Injury of the Torso and Extremities. Arthur .I. Ross, III, Steven R. Cohen, Don LaRossa, Henry T. Lau, Divisions of General and Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA.
An &year-old boy was riding a bicycle behind a garbage truck. The truck backed up dragging the child beneath it. The following injuries were documented: 360” degloving of approximately 60% of total body surface with avulsion of the skin and fascia extending from the axillae to the knees sparing only the region of the breast plate/upper abdomen as well as penis and upper scrotum. There was complete exposure of the musculature of the back, lower abdomen and gluteal regions with circumferential degloving of the thighs extending to the popliteal region. There was complete urethral transection at the base of the scrotum and transection of the rectum with avulsion of the central aspects of the ischial rectal fossa and loss of all anorectal sphincteric musculature. Also present were open sacral fractures with exposure of the sacroiliac joints and free access into the retroperitoneal cavity. Following laparotomy with fecal and urinary diversion, areas of devitalized skin and soft tissue were assessed with fluorescein and Woods lamp. With the degloved flaps still tixed to the wound bed, multiple layers of uniform split-thickness skin grafts (STSG) were obtained with the electric dermatome. First a 0.14-in STSG of epithehum and superficial dermis then a second layer of middle to deep dermis. The flaps were then excised, turned over, and completely defatted, producing a third layer of full-thickness skin. The outer two layers were expanded and stapled in place with the defatted dermis used as a biologic dressing on the remaining sites. Complete coverage of the massive injury was obtained at a single procedure. The defatted dermal biologic dressings were later replaced with STSG harvested from intact skin elsewhere on the child’s body. The child was discharged to home on his 130th hospital day. We believe that this is the first report of the use of this trilaminar skin coverage technique. We feel that it substantially improved our initial yield and complete coverage of a massive degloving injury involving the torso and extremities. Effects of the Fowler-Stephens Orchiopexy on Testicular Structure and Function. E. Huang, R. Kelly, H. Masuda, H. Liu, E. Fonkalsnui, Department of Surgery, UCLA School of Medicine, Los Angeles, CA.
The Fowler-Stephens orchiopexy (FSO) is often recommended for treatment of high undescended testes. The present study evaluates the changes in testicular structure, hormone production, and germ cell maturation after FSO. Fifty-six adolescent rats were randomly assigned to sham operation (n = 20), left orchiectomy alone (n = 18) or right FSO with left orchiectomy (n = 18). Groups of three rats were killed at 1, 2, 4, 6, 8. and 10 weeks postoperation. The testes were examined histologically. A testicular homogenate was assayed for concentration of LDH and SDH, markers of germ cell maturation. Serum testosterone concentrations were measured.
506
NSub
POSTER
SESSIONS
UP
“C02N0,
%GP
TGP
FROM
C
S
4 + .7
.13 + .Ol
.12 + .Ol
(5 mmol/L lactate + mmol/L alanine) .12 + .Ol 65 + 6 84 k 4
C
S
4r1
C
S
Sub
C
S
.I2 -t.Ol
0
23 5 1
16-t3*
19 z .2
14 *.2*
1
1921
14k.4'
142.7
10 2.7"
69 '-3
39 + 3'
.16 + .Ol
5
1621
10 + I*
12 2.6
7 *.7*
48 + 3
3453x
.22 + .Ol
.27 + .Ol*
10
1421
7 +1*
10 2.2
5 t .4
27 k 1
17r1*
.36 + .Ol
.47 k .01*
.23 2 .Ol*
*P < .Olvc.
enous (lactate)precursors. Rats (250 g) were either sham-operated (C) or made septic (S) by cecal ligation and single puncture. At 24 hours following operation the rats were hyperdynamic. Livers were isolated and perfused with Krebs buffer + RBCs (Hct = 20%) first with no substrate (NSub) followed by 5 mmol/L lactate + 0, 1,5, or 10 mmol/L alanine (Sub, n = 5 each group). Rates of total glucose production (TGP, pmoliglh), oxygen consumption (VO,, pLWg/ min) and urea production (UP, mg/g/h) were measured during NSub and Sub. During Sub a constant infusion of Y-lactate (25 nCi/mL) was administered to determine labeled glucose production from lactate ( 14C-GP, ~moliglh) and CO? production derived from lactate (‘CO,, pL/g/min). In sepsis, as nitrogenous substrate is added (as might occur in vivo) UP is significantly increased, much less lactate is oxidized, and there is a greater contribution by alanine and other precursors to VO, ( ‘“CO,/VOZ). Accelerated production of urea suggests that preference for amino acids develops and may contribute to metabolic dyshomeostasis during sepsis. Actinomycostic Infections in Children. Mary L. Brand& Gervais 0. Andze, Her& Blanchard, Hospital, Montreal, Quebec.
Ste-Justine
Actinomycosis is a chronic granulomatous and suppurative disease caused by Actinomyces israeli or bovis. It is a rare disease, especially in children. A retrospective review showed 11 children with actinomycosis from 1973 to 1988. There were 6 boys and 5 girls, with ages from 4 to 17 years. Six patients had incidental findings of actinomycosis in the tonsil after tonsillectomy and required no further treatment. Five patients had invasive actinomycotic infection. Two patients presented with cervical actinomycosis, one with recurrent infections of the thyroid that required thyroid lobectomy, and one with a chronic zygomatic arch mass diagnosed by biopsy. A third patient developed a deep wound abscess with massive ileocecal lymphadenopathy following a negative exploration for appendicitis. The fourth patient was admitted for evaluation of a nonhealing, epigastric wound. A small sinus tract was identified in the open wound, which was in continuity with a liver abscess containing actinomycosis. The fifth patient presented with right thoracic pain, a right pleural effusion, and a small mass on the right costal margin that contained actinomycosis on biopsy. All five patients with invasive actinomycosis had significant delays in diagnosis, usually due to an evaluation for possible neoplastic disease. All patients were treated by surgical debridement and drainage as well as intravenous penicillin for 2 to 3 weeks followed by oral penicillin for 1 to 3 months with resolution of the infection. Actinomycosis is a rare infection in childhood with varying presentations, and should be considered in any child with a nonhealing wound or unexplained truncal or cervical mass. The diagnosis is suspected by the presence of sulfur granules in affected tissue, and confirmed by stain or culture proof of actinomycosis. Long-term treatment with penicillin, with adequate surgical debridement and drainage, is adequate therapy. The incidental finding of actinomycosis after tonsillectomy requires no further treatment.
Management of a Massive Degloving Injury of the Torso and Extremities. Arthur .I. Ross, III, Steven R. Cohen, Don LaRossa, Henry T. Lau, Divisions of General and Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA.
An &year-old boy was riding a bicycle behind a garbage truck. The truck backed up dragging the child beneath it. The following injuries were documented: 360” degloving of approximately 60% of total body surface with avulsion of the skin and fascia extending from the axillae to the knees sparing only the region of the breast plate/upper abdomen as well as penis and upper scrotum. There was complete exposure of the musculature of the back, lower abdomen and gluteal regions with circumferential degloving of the thighs extending to the popliteal region. There was complete urethral transection at the base of the scrotum and transection of the rectum with avulsion of the central aspects of the ischial rectal fossa and loss of all anorectal sphincteric musculature. Also present were open sacral fractures with exposure of the sacroiliac joints and free access into the retroperitoneal cavity. Following laparotomy with fecal and urinary diversion, areas of devitalized skin and soft tissue were assessed with fluorescein and Woods lamp. With the degloved flaps still tixed to the wound bed, multiple layers of uniform split-thickness skin grafts (STSG) were obtained with the electric dermatome. First a 0.14-in STSG of epithehum and superficial dermis then a second layer of middle to deep dermis. The flaps were then excised, turned over, and completely defatted, producing a third layer of full-thickness skin. The outer two layers were expanded and stapled in place with the defatted dermis used as a biologic dressing on the remaining sites. Complete coverage of the massive injury was obtained at a single procedure. The defatted dermal biologic dressings were later replaced with STSG harvested from intact skin elsewhere on the child’s body. The child was discharged to home on his 130th hospital day. We believe that this is the first report of the use of this trilaminar skin coverage technique. We feel that it substantially improved our initial yield and complete coverage of a massive degloving injury involving the torso and extremities. Effects of the Fowler-Stephens Orchiopexy on Testicular Structure and Function. E. Huang, R. Kelly, H. Masuda, H. Liu, E. Fonkalsnui, Department of Surgery, UCLA School of Medicine, Los Angeles, CA.
The Fowler-Stephens orchiopexy (FSO) is often recommended for treatment of high undescended testes. The present study evaluates the changes in testicular structure, hormone production, and germ cell maturation after FSO. Fifty-six adolescent rats were randomly assigned to sham operation (n = 20), left orchiectomy alone (n = 18) or right FSO with left orchiectomy (n = 18). Groups of three rats were killed at 1, 2, 4, 6, 8. and 10 weeks postoperation. The testes were examined histologically. A testicular homogenate was assayed for concentration of LDH and SDH, markers of germ cell maturation. Serum testosterone concentrations were measured.