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 A 13 YEAR OLD GIRL HAS A WOUND IN LEFT LOWER LEG WHICH ON PROBING IS LEFT LOWER LEG WHICH ON PROBING IS FOUND TO BE A SINUS. FOUND TO BE A SINUS.

MORE INFORMATION NEEDED

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.

THE SINUS IS LINED BY GRANULATION TISSUE WHICH MAY GET EPITHEALIZED.

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;

1) SINUS DUE TO OSTEOMYELITIS.

2) TUBERCULOUS SINUS.

3) 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

LIKE IN ANY OTHER CASE THE SCHEME REMAINS THE SAME:

1. HISTORY TAKING

2. PHYSICAL EXAMINATION

3. SPECIAL INVESTIGATIONS

4. CLINICAL DIAGNOSIS

5. TREATMENT

6.PROGRESS

7.FOLLOW UP

8.TERMINATION

HISTORY

PATIENT PARTICULARS

AGE:13 YEARS

SEX:FEMALE

SOCIAL STATUS-

LOW

BAREFOOTEDMADURA

FOOTIGNORANCE

COSTISSUES

PRESENTING COMPLAINT OOZING WOUND FROM LEFT LOWER LEG.

ON PROBING FOUND TO BE A SINUS.

H/O PRESENT ILLNESS

1. DURATION

2. ONSET

3. CONDITION AT BEGINNING wrt 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. ACUTE ILLNESS

2. HIGH FEVER

3. CHILLS

4. LOCALIZED PAIN& TENDERNESS

5. SWELLING

6. APPARENT INFECTION ELSEWHERE.

CHRONIC OSTEOMYELITIS

1. NO ACUTE CONSTITUTIONAL SYMPTOMS.

2. PAST HISTORY OF ACUTE OSTEOMYELITIS.

3. LONG STANDING DISCHARGING SINUS RESISTANT TO TREATMENT.

4. 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. BARE FOOT WALKING.

2. A TRIVIAL TRAUMA SAY DUE TO A THORN PRICK.

3. A LOCAL PAINLESS LESION AT FIRST WITH A SLOW PROGRESSION.

4. NODULAR SWELLING.

5. 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. PREVIOUS HISTORY OF T.B.

2. FORMATION OF A COLD ABSCESS BEFORE THE FORMATION OF SINUS

3. LYMPH NODE ENLARGEMENT..

BOTRYOMYCOSIS

1. A HISTORY OF TRAUMA,ABSCESS.

2. FEVER

3. 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 AFFECTED: LEFT LOWER LEG.

INSPECTION

1. NUMBER:

MULTIPLE SINUSES STRONGLY SUGGEST OF MADURA FOOT.

2. 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.

2. 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

THEY DONT HAVE A DIAGNOSTIC BUT A PROGNOSTIC IMPORTANCE.

1. C.B.P:DLC WILL GIVE AN IDEA OF INFECTION.

LYMPHOCYTOSIS:CHRONIC INFECTION

HIGH POLYMORPHS:ACUTE.

2. ESR: NON SPECIFIC BUT CAN BE USED AS A GUIDE TO EFFECTIVENESS OF TREATMENT.

3. RANDOM BLOOD GLUCOSE.

4. URINE: ROUTINE MICROSCOPY.

SPECIAL

THEY ARE:

1. MICROBIOLOGY

2. RADIOLOGY

3. BONE BIOPSY.

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 OFDISCHARGE

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 YELLOW-ACREMONIUM,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.

ACTINOMYCES1.GRAM STAINING

SHOWS DENSE NETWORK OF THIN GRAM+VE FILAMENTS SORROUNDED BY-VE CLUBS.

SUNRISE APPEARANCE.

NOCARDIAL GRANULES

GRANULES SHOULD BE STAINED WITH MODIFIED ZIEHL NEELSEN STAINING.

ACID FAST BACILLI DETECTED.

ACID FASTNESS DIFFERENTIATES FROM ACTINOMYCETES

FUNGAL GRANULES

IN GRAM STAINING CLUBBING OF FUNGAL HYPHAE IS APPARENT.

CULTURE

CULTURE SHOULD BE DONE ON:

1. BLOOD AGAR

2. MAC CONKEY AGAR.

3. L.J SLANT.

4. S.D.A AGAR[CHLORHEXIDINE]

5. B.H.I AGAR

6. ANAEROBIC MEDIUM.

INCUBATE AT 25OC AND 370 C AS HYPHAE GROW AT LOWER TEMP.

SMEAR

A GRAM STAIN-ACTINOMYCETES,FUNGUS

ZIEHL-NEELSEN STAINING-M.TUBERCULOSIS

MODIFIED Z.N.STAINING-NOCARDIA.[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 TREATMENT-LESS DAMAGE.

USED-Tc99 LABELLED PHOSPHONATES.

SPECIAL THANKS

DR.S.S PAL DR.DEEPTI CHAURASIA DR.SHOAIB KHAN