Necrotizing soft tissue infections (NSTIs) are polymicrobial infections with high morbidity and mortality. We report a case of retroperitoneal NSTI in an immunocompetent young male, with clinical symptoms and signs mimicking acute pancreatitis (pseudo-Cullen's and pseudo-Grey-Turner's signs. The initiating lesion was a pustule which progressed and mimics acute pancreatitis. CT scan showed features of retroperitoneal NSTI. After extensive debridement and antibiotics, the patient improved. NSTI of the retroperitoneum is rare. The absence of external clinical signs and anatomical barriers make the disease difficult to manage.
Primitive neuroectodermal tumor of the kidney is a rare tumor. A total of approximately 79 primary renal cases have been reported to date. Primitive neuroectodermal tumors occur preferentially in the soft-tissues of the paravertebral region and chest wall, less frequently in extremities, with a slight male predominance. We report a case of primitive neuroectodermal tumor of the kidney in a 17-year-old male with a pre-operative diagnosis of renal cell carcinoma-stage 4. The patient underwent radical nephrectomy and histopathological examination revealed a highly aggressive tumor of monotonous sheets of round cells with focal areas of rosette formations and high mitotic rate with Ki67 index of 25-30%. Tumor cells were positive for CD 99 confirming the diagnosis of primitive neuroectodermal tumor. Primitive neuroectodermal tumor of the kidney needs to be kept in mind as a differential diagnosis in young adults presenting with a large kidney mass.
A 40 year old woman presented with an ever-increasing lump in right upper abdomen that she was noticed after drainage of an abscess in the same region during her pregnancy 15 years back. On examination it was a smooth, globular, 10 x 8 cm size lump in right hypochondrium and lumbar region that moved with respiration and could have been mistaken for a gall bladder lump but for a well defined upper margin. A CECT abdomen showed a 6.6x5.8x4.5 cm 3 oval non enhancing soft tissue lesion having fat density and calcification adjacent to ascending colon & small bowel loops. On exploration it was found to be an ovarian cyst that was adherent to the surrounding bowel and had a long pedicle going into the pelvis. On histopathology it was reported to be a mature ovarian teratoma.
Penile fracture is an unusual though not a rare condition but underreported. It is defined classically as the disruption of the tunica albuginea with rupture of the corpus cavernosum. Penile fracture can be misdiagnosed with rupture of corpus spongiosum clinically. Therefore, we are presenting three cases due to its varied clinical presentation and management. In first patient, there was a tear in the corpus spongiosum and a partial tear in the ventral urethra. Both defects were repaired with interrupted sutures. In the second patient, there was a rupture of corpus cavernosum, which was primarily repaired. After 1-year of primary surgery, patient again came with similar complaints, and diagnosis of scar dehiscence was made. Patient was treated conservatively with satisfactory results on follow-up. Third patient came with a history of 1-week. Intra-operative findings revealed only hematoma without any defect in corpora cavernosum, corpus spongiosum, and urethra. Only evacuation of hematoma was done. Early surgical treatment of penile fracture is advantageous. In recurrent penile fracture, if no penile deformity or any reasonable clinical and radiological evidence, then conservative management is advocated. Even when presentation is delayed up to 1-week, operative management has shown good results.
A needs assessment is the process of identifying performance requirements or 'gaps' between what is required and what exists at present. To identify these gaps, the inputs of all stakeholders are needed. In medical education, graduating medical students are important stakeholders who can provide valuable feedback on deficiencies in their training.To know the students' perceptions about effectiveness of their surgical training, an anonymous questionnaire seeking their opinion on the duration, content, methods of teaching and assessment was administered. Their responses were analysed using descriptive statistics.The students were largely in favour of active methods of learning and there was very little preference for didactic lectures. For clinical teaching, involvement in ward rounds and patient care activities, in addition to case discussions, was considered to facilitate learning. A clerkship model of clinical training was favoured. Any teaching-learning activity in small groups of 8-10 students were preferred. As regards their evaluation, besides internal assessment, the students felt the need for direct constructive feedback from teachers on how to improve their performance. A large number (73.5%) were opposed to attendance being considered a qualifying criterion for taking the examination.Students' feedback about their 'perceived needs' should be considered when revising training programmes.
A rare case of crossed fused renal ectopia is presented where the fused kidneys were present on the right side and there was a single ureter opening into the right side of the bladder. To the best of our knowledge, this variant of crossed fused ectopia has not been reported previously. This case challenges the embryological theory that deviation of one of the ureteric buds to the opposite side results in crossed fused renal ectopia.
Pyomyositis (PY) is a primary infection of the skeletal muscles, leading to inflammation of the muscle fibers followed by pus formation and even necrosis in late stages. Because of overlap in presentation of intermuscular abscess (IM) and PY, the exact incidence and severity of PY is under-appreciated.We conducted a prospective analytical study in a tertiary care center in North India from October 2011 to January 2013, recruiting patients with abscesses involving the chest wall, abdomen (parietal wall including back), and extremities. Subcutaneous, hepatic, intra-abdominal abscess, and secondary abscesses were excluded. Primary PY was defined as a primary infection of skeletal muscle without any foci from adjacent skin, soft tissue, or bone. Clinical, radiologic, pathologic, and operative findings suggested diagnosis; loss of striations and lymphocytic infiltration in the muscle fibers was confirmatory. The chief outcome variables were death and length of hospital stay.Thirty patients with a mean age of 29.5 y (IM: 29.7 ± 16.7, PY: 25.28 ± 17.6) were classified as IM (18/30, 60%) or PY (12/30, 40%). Most PY occurred in the lower limb (41.7% had multi-site involvement); most had a history of trauma or immunocompromised state. Fever, tachycardia, tachypnea, hypotension, pallor, and hyperesthesia were significantly higher (p < 0.05) in PY. Mean Sequential Organ Failure Assessment (SOFA) score was 0.33 for IM, 2.5 for PY. Staphylococcus aureus was predominant in both groups; however, all four patients with methicillin-resistant S. aureus (MRSA) were in the PY group. Both deaths also occurred in the PY group. The mean duration of hospital stay was 3.22 ± 1.11 d for IM and 10.27 ± 2.32 d for PY patients (p = 0.03).PY is a specific and potentially fatal infection, which is common in our country and must be differentiated from IM. A high index of suspicion and early institution of specific antibiotics followed by operation is therapeutic.
Placement of a drain following abdominal surgery is common despite a lack of convincing evidence in the current literature to support this practice. The use of intra-abdominal drain is associated with many potential and serious complications. We report a drain site evisceration of the right fallopian tube after the removal of an intra-abdominal drain. The drain was placed in the right iliac fossa in a patient who underwent a lower segment Caesarean section (LSCS) for meconium liquor with fetal distress. The Pfannenstiel incision made for LSCS was reopened and the protruding inflamed fimbrial end of the right fallopian tube was excised. The patient made an uneventful recovery. Routine intra-abdominal prophylactic drain following an abdominal surgery including LSCS should be discouraged.
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