Aspergillosis (M.p. :) )
Few or many lesions
May result in rapidly spreading red patch with a necrotic centre (blackened dead tissue)
May resemble pyoderma gangrenosum

Patients who
are at considerable risk include
those who are granulocytopenic
due to bone marrow transplantation,
those who are undergoing
intensive cytotoxic chemotherapy
for the treatment of neoplasia, and
those with a history of corticosteroid
use.

Answer
Cutaneous zygomycosis: The wound biopsy cultures grew out Rhizopus species, a fungus in the Mucorales order. Because of this finding, in conjunction with the findings on histopathology, dermatomycosis, specifically cutaneous zygomycosis, was diagnosed. Zygomycosis is an uncommon and potentially fatal infection caused by fungi of the class Zygomycetes. The incidence of zygomycosis is increased among immunocompromised patients (Gonzalez, 2002; Roden, 2005). The class Zygomycetes includes 2 orders of pathogens: Mucorales, which is responsible for most cases of human disease, and Entomophthorales (Gonzalez, 2002). Entomophthorales-related disease classically occurs in only tropical and subtropical areas, where it causes a mild form of disease limited to the nasal, sinus, and subcutaneous tissues. However, the geographic distribution and clinical characteristics of disease have increasingly broadened. Because the features of disease caused by Mucorales and Entomophthorales are nearly identical both clinically and histologically, the term mucormycosis is taxonomically inaccurate but nevertheless accepted in the medical terminology (Gonzalez, 2002).

Risk factors for zygomycosis include organ transplantation, malignancy, diabetes, corticosteroid therapy, neutropenia, desferoxamine therapy, HIV infection, metabolic acidosis, burns, and traumatic inoculation (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Greenberg, 2004; Roden, 2005). Patients with ketoacidosis are at particular risk for zygomycosis because the acidic environment appears to hinder neutrophil function (Gonzalez, 2002).

This patient had several of these risk factors, including ALL, hyperglycemia secondary to corticosteroid therapy, and neutropenia. Because neutrophils are the predominant mediators of the host defense's against fungal hyphae, the patient's state of neutropenia gave rise to invasive disease. Leukemia is the underlying risk factor in 15% of patients with zygomycotic infections (Dromer, 2002). This patient developed a cutaneous infection, which is generally less severe than rhinocerebral or pulmonary infection, but it may indicate disseminated infection (Gonzalez, 2002; Sundararajan, 2004). The incidence of disseminated infection is highest in patients with a hematologic malignancy (Dromer, 2002). Thorough examination and imaging studies should be performed to rule out disseminated infection (Gonzalez, 2002; Roden, 2005). Tissue biopsy and cultures are necessary to diagnose zygomycotic infection (Dromer, 2002; Gonzalez, 2002).

The management of zygomycosis starts with a high index of suspicion in appropriate populations, early diagnosis, and aggressive therapy (Dromer, 2002; Gonzalez, 2002). The most effective therapy is a combination of surgical debridement; high-dose amphotericin-B; and treatment of underlying conditions, such as neutropenia or hyperglycemia (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Pagano, 2004). Liposomal amphotericin-B continues to be the drug of choice, even though new antifungal agents have emerged (Kontoyiannis, 2000; Gonzalez, 2002; Pagano, 2004; Roden, 2005). No therapy prevents this infection (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Pagano, 2004).

In our case, liposomal amphotericin B at 5 mg/kg was started empirically shortly before the histopathologic diagnosis on clinical suspicion and was continued along with daily wet-to-dry dressings for general wound care. Computed tomography scans of the head, chest, abdomen, and pelvis were performed to evaluate for potential disseminated disease and were negative. Additionally, an ophthalmologic examination was performed and was unremarkable. After 6 days of therapy, the area around the excision site darkened and a repeat debridement and biopsy of the previous margins failed to reveal any fungal elements. The patient received liposomal amphotericin B for a total of 6 weeks with weekly monitoring of electrolyte levels. After treatment was completed, a skin graft was performed on the affected areas of her right forearm which took well and healed without complication.
[Ссылки могут видеть только зарегистрированные пользователи. ]

Коротенький вопрос из тестового экзамена по педиатрии.
 

4-х месячный ребёнок доставлен в пункт неотложной помощи (ER) с высокой температурой и общим беспокойством. Выполнена люмбальная пункция: в ликворе 10 эритроцитов и 1050 лейкоцитов, 50 мг% (0,5 г/л) белка, 40 мг% (2,26 ммоль/л) глюкозы. При окраске по Граму осадка ликвора бактерии не обнаружены. Адекватным лечением больного следует считать:
(A) наблюдение в стационаре без проведения антибиотикотерапии
(B) внутривенное введение ампициллина и гентамицина
(C) внутривенное введение цефтриаксона
(B) внутривенное введение оксациллина и гентамицина
(E) внктривенное введение ампициллина

PS: Если есть желание, то в дальнейшем опубликую "ещё парочку" (с)

1) Approximately 2-3% of bacterial meningitis cases have a negative Gram stain result and normal cell count, glucose level, and protein level yet positive bacterial cultures.
2) Хотелось бы также отметить, что важно не просто содержание глюкозы в ликворе, а ее соотношение с глюкозой крови. За бактериальный менингит , когда содержание глюкозы в ликворе составляет менее 50% от глюкозы в крови.
3) С нормами вашими я совсем запуталась :) , не могу перевести г/л в мг/dl, но, хотя, лейкоцитов для бактериального менингита явно не хватает (должно быть больше 2000), я, помня о пункте 1,
предлагаю вариант с цефтриаксоном до получения отрицательного посева.

А высокая температура и "общее беспокойство" у детей достаточны для подозрения на менингит? Про менингеальные симптомы ничего не сказано. Я бы выбрала вариант а.

Мне кажется, задача не имеет решения. Показания для люмбарной пунkции неизвестны. Нет результата осмотра. Нет крови.

У меня в анналах есть похожая задачка, сейчас гляну :)

Из ответа к задаче - "Болезнь может начинаться с проявления неспецифических симптомов, таких как раздражительность и лихорадка. Исследование СМЖ позволяет выявить повышенное содержание в ней лейкоцитов и белка. Уровень глюкозы снижается. Посев ликвора и окраска по Граму его осадка не всегда дают положительные результаты по выявлению возбудителя." У ребёнка бактериальный менингит. Как правило, промедление - смерти подобно.
Какие ещё будут мнения по терапии?
ЗЫ: 1мг/дл=1мг% (про цент, то есть в ста)

Bacterial meningitisClinical history.

-The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
-The child younger than 3 months may have very nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high pitched cry, or seizures.
-Meningismus and a bulging fontanel may be observed but are not needed for diagnosis.
-A child who is quiet at rest but who cries when moved or comforted may have meningeal irritation (paradoxical irritability).
-After age 3 months, the child may display symptoms more often associated with bacterial meningitis, with fever, vomiting, irritability, lethargy, or any change in behavior.
-After age 2-3 years, children may complain of headache, stiff neck, and photophobia.


Bacterial meningitisLabs.

-White blood cell (WBC) counts over 1000/mm3 usually are caused by bacterial infections. Counts of 500-1000/mm3 may be bacterial or viral and need further evaluation. Lower counts are usually associated with viral infections. The total WBC count cannot definitely distinguish between bacterial and other causes. It was generally believed that a predominance of polymorphonucleocytes (PMNs) pointed to bacterial meningitis, but this has been unreliable.
-Gram stain may aid in diagnosis, but the diagnosis may be missed in up to 30% of cases of culture-proven disease.
-The protein concentration usually is elevated in bacterial meningitis, but it also is elevated by a traumatic tap.
-The glucose is usually reduced in bacterial meningitis. Normal CSF glucose should be greater than two-thirds that of the serum glucose. Levels less than 50% of serum are suggestive of bacterial meningitis.
-Latex agglutination tests are available to test for S pneumoniae, H influenzae, group B Streptococcus, and N meningitidis. A negative result, however, does not rule out bacterial infection.
-Even with normal CSF results, the fluid should be sent for culture. N meningitidis and S pneumoniae are known to give normal CSF results.


Emergency Department Care:

Immediate stabilization and support of the critically ill or seizing child is necessary.
When meningitis or encephalitis is suspected, an LP is indicated.
If the child's condition is unstable or there is suspicion of increased intracranial pressure, the LP should be delayed.
It is very important that antibiotic therapy is immediately commenced in the ill child and not delayed until after the LP.
If prompt LP cannot be performed, administration of antibiotics should be initiated. However, sterilization of CSF will occur. It was previously thought that sterilization occurs within 2-3 hours. However, in a retrospective study, complete sterilization was found to occur within 2 hours for meningococcal meningitis. With pneumonococcal infections, sterilization occurred within 4 hours.
If the child is hemodynamically stable, intravenous fluids should be administered at maintenance. Careful record of the patient's weight, urine specific gravity, and serum osmolarity will help guide further fluid therapy. Patients who present with dehydration need rehydration and should not have fluid restriction. Seizures should be treated promptly and should be expected at any time during the initial management.

Empiric antimicrobial therapy for bacterial meningitis:

[Ссылки могут видеть только зарегистрированные пользователи. ]

Видимо, авторы подразумевают ответ В. внутривенное введение ампициллина и гентамицина. Хотя, если ребёнку больше 3 месяцев, его вроде бы должны лечить ампициллином и хлорамфениколом.

Видимо, В все-таки...

Тимур, ау!

Тута я :) .
Ирина правильно ответила, просто было интересно, какие ещё будут предложения.
Продолжение из ответа:"У детей грудного и старшего возраста чаще всего бактериальный менингит вызывают Haemophilus influenzae типа В, Streptococcus pneumoniae и Neiseria menugitidis. С учётом этого антибиотикотерапия включает цефалоспорины третьего покления: цефотаксим, цефтриаксон или ампициллин с левомицетином".

Но это же неправильный ответ.

Почему не правильный? Яна, по вашей же ссылке именно так и выходит:

"Immunocompetent children: age > 3 months - 18 years


H. influenzae

S. pneumoniae

N. meningitidis
Cefotaxime or ceftriaxone**
Ampicillin plus chloramphenicol"