[Acute abdominal pain caused by neuroborreliosis]

BACKGROUND

Lyme disease is a multisystem disease which can present itself in several ways. When the nervous system is involved, it is called Lyme neuroborreliosis. Both central and peripheral nervous systems can be affected.

CASE DESCRIPTION

A 39-year-old man visited the emergency department multiple times with severe abdominal-pain attacks with motoric unrest. Extensive diagnostic work-up was done, which was initially inconclusive. Lyme neuroborreliosis was suspected when he developed a facial-nerve palsy during admission; the abdominal pain was thought to be caused by thoracic radiculoneuropathy. Serologic testing for antibodies against Borrelia burgdorferi was positive, confirming the diagnosis. The patient was treated with intravenous ceftriaxone.

CONCLUSION

This case shows abdominal pain being caused by radiculoneuropathy at thoracic level, an uncommon presentation of Lyme neuroborreliosis. Often, this diagnosis is only made when neurological paralysis occurs. Information regarding skin lesions or a recent tick bite can lead to earlier recognition of the diagnosis.

Acute abdomen due to group A streptococcus bacteremia caused by an isolate with a mutation in the csrS gene

Streptococcus pyogenes (group A streptococcus) is an aerobic gram-positive coccus that causes infections ranging from non-invasive pharyngitis to severely invasive necrotizing fasciitis. Mutations in csrS/csrR and rgg, negative regulator genes of group A streptococcus, are crucial factors in the pathogenesis of streptococcal toxic shock syndrome, which is a severe, invasive infection characterized by sudden onset of shock and multiorgan failure, resulting in a high mortality rate. Here we present a case of group A streptococcal bacteremia in a 28-year-old Japanese woman with no relevant previous medical history. The patient developed progressive abdominal symptoms that may have been due to spontaneous bacterial peritonitis, followed by a state of shock, which did not fulfill the proposed criteria for streptococcal toxic shock. The isolate was found to harbor a mutation in the negative regulator csrS gene, whereas the csrR and rgg genes were intact. It was noteworthy that this strain carrying a csrS mutation had caused group A streptococcal bacteremia characterized by acute abdomen as the presenting symptom in a young individual who had been previously healthy. This case indicates that group A streptococcus with csrS mutations has potential virulence factors that are associated with the onset of group A streptococcal bacteremia that does not meet the diagnostic criteria for streptococcal toxic shock syndrome.

Diagnosing abdominal tuberculosis in the acute abdomen

BACKGROUND

Despite recent improvements in medical treatments, the incidence of abdominal tuberculosis (ATB) in the United Kingdom has increased over the past two decades. This case series examined the difficulties encountered in correctly diagnosing this infection.

PATIENTS AND METHODS

A retrospective study was undertaken, reviewing the records of 36 patients diagnosed with ATB from 2000 to 2012 at a district general hospital in outer East London.

RESULTS

The commonest presenting feature was abdominal pain in 67% of patients, and the most common sites of infection were the iliocaecal junction and peritoneum, seen in 36.1% and 33.3% respectively. Six patients were initially investigated for Crohn's disease and one for ileitis. The highest disease prevalence was seen in patients born in India and Pakistan, which was 27.8% and 19.4% of patients respectively. Colonoscopy was performed in nine patients, and three of these reported normal findings. The other six reported visible non-specific inflammatory changes. Three patients had abdominal X-rays reported and one patient had an abdominal ultrasound, all of which were normal. An abdominal computerised topography (CT) scan was performed in 26 patients and a chest CT was undertaken in 19 patients. Varying degrees of inflammatory changes were seen in all of the patients who had CT scans. Microbiological culture was positive for Mycobacterium tuberculosis or acid-fast bacilli in 71% of patients.

CONCLUSIONS

Abdominal tuberculosis can be very difficult to diagnose as symptoms are non-specific and can mimic other types of granulomatous inflammatory bowel diseases. Radiology appears largely unhelpful due to the non-specificity of any positive imaging findings, and there is a lack of diagnostic procedural and microbiological tests with high specificity and sensitivity. In view of the increasing incidence of tuberculosis in London, there should be a high index of suspicion for ATB in individuals from high-incidence countries who present with non-specific abdominal symptoms.

[Ileocaecal actinomycosis - a case report]

Abdominal actinomycosis as an aetiological cause of acute abdomen in immunocompetent patients is considered to be very rare. The authors present a case of a young patient with acute appendicitis in the terrain of specific colitis imitating caecal tumour. Especially nowadays, in the era of globalization, it would be an unnecessary mistake not to think of this aetiological unit when the pain and tenderness in the right hypogastrium with signs of peritonism are expressed.

Salmonella ovarian abscess in young girl presented as acute abdomen--case report

Ovarian abscess in young sexually non-active girls can represent a diagnostic challenge. 15-years old girl was admitted to the Clinic for Gynaecology and Obstetrics under the suspicion of torsion of an ovarian cyst. Her clinical status deteriorated after the admission with development of acute abdomen. Laparoscopic exploration was performed and unilateral ovarian abscess was found without involvement of other pelvic structures. The surgical procedure was minimal invasive for a young girl and Salmonella staleyville was isolated from pus. Solitary ovarian abscess can be of hematogenous origin and the causative pathogens are different from pathogens usually involved in pelvic inflammatory disease. To avoid later fertility problems it is of great importance to treat infections in pelvic region correctly according to the isolated microorganism and that surgery is the least invasive.

[Mesenteric cryptococcal lymphadenitis: report of one case]

Cryptococcosis is an invasive mycotic infection caused by Cryptococcus neoformans, an encapsulated, yeast-like fungus. It is considered an opportunist infection, since it mainly affects immunocompromised subjects. However there are isolated reports of the infection in immunocompetent subjects. Cryptococcal infection of intra-abdominal organs or tissues is extremely rare. We report a 21-year-old HIV positive male that, during the treatment of a meningeal cryptococcosis, presented a clinical picture of an acute abdomen suggesting acute appendicitis. The patient was operated, finding enlarged mesenteric lymph nodes forming conglomerates and a macroscopically normal appendix. The conglomerated lymph nodes and the appendix were excised. The pathological study of the surgical piece revealed an intra abdominal cryptococcal lymphadenitis and a normal appendix.

Bacteriological aspects implicated in abdominal surgical emergencies

The purpose of the present study was to establish the microbial etiology of abdominal surgical emergencies as well as the relationship between the bacterial etiology and the virulence factors produced by the respective isolated strains. 110 bacterial strains were isolated from 100 randomized clinical cases, operated during 2009-2010 in the First Surgical Clinic of the University Hospital of Bucharest. The clinical cases (sex ratio 52 M/48F aged between 22-85 years old) were classified into three risk groups, as related to their severity. The isolated strains were characterized by cultural, microscopic and biochemical methods. After identification, the bacterial strains were investigated for their virulence potential (adherence to abiotic surface and production of soluble virulence factors).

RESULTS

The specimens were collected from different clinical pathologies: diffuse acute peritonitis, biliary duct infections, severe acute pancreatitis followed by septic processes etc. The 110 bacterial (72 aerobic and 38 anaerobic) strains were isolated only in 70 out of 100 cases. Out of these 70 cases, in 45 already submitted to pre-operatory empiric broad spectrum antibiotic therapy, there were isolated 74 strains, whereas in 25 cases without any treatment, there were isolated 36 strains. The etiology was either mono-specific or multi-specific (aerobic-anaerobic associations, especially in old persons). Out of the 30 negative culture cases, 16 were already submitted to pre-operatory parenteral empiric antibiotic therapy at the moment of specimen collection. The aerobic etiology was dominated by Enterobacteriaceae. The most frequent anaerobic species belonged to Clostridium, Peptococcus and Bacteroides genera. It is to be mentioned that the isolation of Bifidobacterium and Veillonella spp. in 11 (10%) severe cases of the studied abdominal surgical emergencies is pleading for the fact that in certain conditions, bacteria belonging usually to commensal gut flora can turn to pathogenic becoming responsive for life-threatening cases. All aerobic and anaerobic strains exhibited some of the following virulence factors: mucinase, esculinase, pore-forming toxins (lecithinase), proteolytic enzymes, adherence ability (slime factor). The presence of these virulence factors (VF) could explain the severity of the clinical aspects.

CONCLUSIONS

The bacterial etiology of the abdominal surgical emergencies exhibited a very large spectrum, the highest number of strains being of endogenous origin (Enterobacteriaceae and anaerobic strains). It was demonstrated that the isolated strains produced (cell associated and soluble) VF proving in this way their role as important virulence sources in the hospital environment and explaining the large diversity and severity of the clinical abdominal pathology. The results of the present study are also pleading for periodical readjustments of the pre-operatory empiric antibiotic therapy.

[Acute abdomen as initial manifestation of meningococcemia]

Abdominal pain as an initial symptom of meningococcemia is an infrequent entity, rarely described in literature. We present a case of a 4 year-old, male, previously healthy child with a 24 hour history of fever and abdominal pain. He is admitted in a surgical unit with a diagnosis of acute abdomen for surgical resolution. The clinical course turns unfavorably, and patient presents signs of severe sepsis. Urgent laparotomy is performed, observing little brownish fluid and mesenteric adenitis. He then exhibits palpable purpuric rapidly progressive lesions in lower extremities, progressing to septic shock. Later, Neisseria meningitidis serogroup B is isolated from blood cultures. The aim of this article is drawing attention to a nontypical form of manifestation of meningococcemia, as a delayed diagnosis and treatment has an impact on morbidity and mortality among the pediatric population.

Ruptured abdominal aortic aneurysm after resection of an infected cardiac myxoma

A 12-year-old girl with a high fever underwent echocardiography and was found to have a myxoma that arose from the atrial side of the anterior mitral valve leaflet. The tumor was successfully excised. Histologic examination of the tumor showed myxoma cells and an organized thrombus with bacterial colonization. The patient was discharged from the hospital on antibiotic treatment. After remaining asymptomatic for 3 weeks, she was readmitted with acute abdomen. Ultrasonography and magnetic resonance angiography detected intra-abdominal hemorrhaging and a saccular aneurysm of the abdominal aorta. The patient underwent successful emergency surgery. To our knowledge, no other report has been published concerning an abdominal aortic aneurysm secondary to bacterial infection of a cardiac myxoma. Although complications this severe are rarely observed in patients who have endocarditis, early recognition and treatment can be life-saving.

A case of miliary tuberculosis presenting with bowel perforation

Tuberculosis is a disease that should never be underestimated. It can affect anybody at any age. Doctors in the West do not have much experience of peritonitis secondary to tuberculosis. It is a condition that requires urgent and aggressive management as it can be fatal, even in the young and fit, as this case report illustrates.

Is neuroborreliosis a medical emergency?

Although Lyme disease affects the nervous system in many ways (collectively known as neuroborreliosis), only rarely does it present as a medical emergency. In extreme cases, it may cause (1) encephalitis, (2) a rapidly progressive peripheral neuropathy, or (3) a painful truncal radiculopathy that may be confused with a severe visceral process. Knowing when to consider this spirochetosis in the differential diagnosis requires an understanding of its true clinical spectrum, and of an appropriate diagnostic and therapeutic approach.

[Abdominal sepsis in surgical patients. Pathophysiology and prevention]

Abdominal sepsis is a rare but life threatening condition due to several causes. Although several advances in medicine have been performed in last years, abdominal sepsis could have a negative potential evolving beyond exitus. The authors present a review of the literature and a commentary of their own clinical experience.

Portal and systemic endotoxemia in abdominal operations: the significance of acute abdomen

Little evidence is available for the implication of bacterial translocation in cases of acute abdomen. Intraoperative endotoxemia in both portal and systemic circulation was studied in 20 surgical patients with acute abdomen and in 36 controls undergoing elective abdominal surgery. Blood was sampled simultaneously from a mesenteric vein immediately after opening the peritoneum and from a peripheral vein. Endotoxin was measured by a colorimetric Limulus amebocyte lysate assay and malondialdehyde (MDA) was measured by the thiobarbiturate assay and passage through a high-performance liquid chromatography (HPLC) system as a marker of the oxidative status. LPS concentrations (mean +/- SE) in portal vein blood from patients with acute abdomen was 5.69 +/- 1.58 and from patients with chronic diseases 1.05 +/- 0.07 EU/ml (P < 0.0001). Respective values for the systemic circulation were 4.98 +/- 1.47 and 1.36 +/- 0.31 EU/ml (P < 0.0001). Concentrations of MDA (mean +/- SE) in portal vein blood from patients with acute abdomen was 11.16 +/- 4.00 and from patients with chronic diseases was 10.56 +/- 2.39 mum (P NS). Positive correlations were observed between endotoxin and MDA in both portal and systemic circulation. These results indicate increased levels of endotoxin in acute abdominal conditions pointing to the gut as the site of origin of the bacterial products.

Intestinal invasion and disseminated disease associated with Penicillium chrysogenum

Background

Penicillium sp., other than P. marneffei, is an unusual cause of invasive disease. These organisms are often identified in immunosuppressed patients, either due to human immunodeficiency virus or from immunosuppressant medications post-transplantation. They are a rarely identified cause of infection in immunocompetent hosts.

Case presentation

A 51 year old African-American female presented with an acute abdomen and underwent an exploratory laparotomy which revealed an incarcerated peristomal hernia. Her postoperative course was complicated by severe sepsis syndrome with respiratory failure, hypotension, leukocytosis, and DIC. On postoperative day 9 she was found to have an anastamotic breakdown. Pathology from the second surgery showed transmural ischemic necrosis with angioinvasion of a fungal organism. Fungal blood cultures were positive for Penicillium chrysogenum and the patient completed a 6 week course of amphotericin B lipid complex, followed by an extended course oral intraconazole. She was discharged to a nursing home without evidence of recurrent infection.

Discussion

Penicillium chrysogenum is a rare cause of infection in immunocompetent patients. Diagnosis can be difficult, but Penicillium sp. grows rapidly on routine fungal cultures. Prognosis remains very poor, but aggressive treatment is essential, including surgical debridement and the removal of foci of infection along with the use of amphotericin B. The clinical utility of newer antifungal agents remains to be determined.

Gonococcal infection as a cause of acute abdomen

Gonococcal infection in the postantibiotic era continues to cause disseminated and severe disease in some patients. The differential diagnosis of pain in the lower abdomen in young women is difficult. Our case report described a 19-year-old patient who presented with acute abdomen as a result of Gonococcal infection, assessed as a local complication, pelveoperitonitis: pelvic inflammatory disease. The message of our case report is sexually transmitted infections should invariably be considered in young women and searched for accordingly.

Cryptococcal mesenteric lymphadenitis: an unusual cause of acute abdomen

Cryptococcal infection of intraabdominal organs or tissues is extremely rare. Herein we report a child with mesenteric cryptococcal lymphadenitis who presented with an acute abdomen misdiagnosed as acute appendicitis. Definitive diagnosis was established with 2nd look and lymph node biopsy. Clinicians should remember that cryptococcal infection of mesenteric lymph nodes may rarely mimic an acute abdomen and cause delay in diagnosis.

Liver abscess due to Bacillus cereus: a case report

Bacillus cereus is a food-borne pathogen that causes a self-limiting gastroenteritis. We describe the case of a 72-year-old woman admitted to our hospital because of acute abdominal colic pain. Over a 2-day period, her clinical condition deteriorated rapidly, with the appearance of acute abdomen. Computed tomography investigation of the abdomen showed a liver abscess (diameter approximately 3 cm). At laparotomy, the abscess was found to be ruptured to the free peritoneal cavity. The final clinical diagnosis was acute peritonitis due to a ruptured liver abscess. Bacillus cereus was isolated from culture of the pus. Up to now, no case of liver abscess due to this organism has been reported.

Septicemia due to Yersinia pseudotuberculosis--a case report

A case report is presented concerning Yersinia pseudotuberculosis septicemia presenting as an acute abdominal emergency in an elderly diabetic man with multiple medical problems.

Acute abdomen due to Brucella melitensis

A case of acute abdomen caused by a Brucella melitensis is reported. The patient presented with biliary involvement in the form of acute acalculous cholecystitis and developed acute appendicitis that resulted in his surgical treatment.

[Diverticulosis as a background of "abdominal catastrophe" in the course of peritoneal dialysis. Care Report]

Peritonitis complicating peritoneal dialysis (PD) may represent a difficult diagnostic and therapeutic problem if it coexists with surgical pathology of intra-abdominal organs defined as "abdominal catastrophe". The illustration of this problem is the case of 70-year-old patient treated with automated PD, in whom recurrent episodes of peritonitis (Escherichia coli) were typical of "abdominal catastrophe" and were probably caused by microperforations of the colon in the course of diverticulosis.

Capnocytophaga canimorsus sepsis presenting as an acute abdomen in an asplenic patient

Acute abdominal symptoms are frequently caused by surgical intra-abdominal problems. However, the differential diagnosis also includes several internal diseases. Overwhelming infections may present with acute abdominal signs, particularly in the immunocompromised host. Asplenic patients are highly susceptible to infections with encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. Severe infections due to Capnocytophaga canimorsus (DF2), are also common in this group. C. canimorsus is a Gram-negative rod, present as a commensal organism in cat and dog saliva. We describe the atypical presentation of a fatal C. canimorsus-sepsis in a 46-year-old man, who underwent traumatic splenectomy two decades earlier.

[Gangrene of the round liver ligament: an unrecognized pathology]

The necrosis of the ligamentum teres hepatis is a very rare and unrecognized pathology. Two cases only were reported in the literature. The presence of generalized or epigastric peritoneal signs, simulates acute cholecystitis or perforated pyloric ulcer. The diagnosis could be suggested by ultrasonography and CT scan of the abdomen revealing a hyperechogenic and hypodense focal lesion at the junction of the segments III and IV of the liver, associated with inflammatory signs and/or collection along the ligamentum teres. The etiology of this necrosis remains unclear, although in this case report, a ligament infection with E. Coli, Enterococcus and Klebsiella pneumoniae was observed. However, the primum movens of the infection is unknown. The proposed treatment is resection of the ligament from umbilicus up to the liver, associated with systemic antibiotherapy, because of the possible risk of propagation of the infection to the portal vein.

Measurement for breath concentration of hydrogen and methane in horses

This study concerns the establishment of a simple testing method for breath concentration of hydrogen and methane in horses. Twenty-eight healthy thoroughbreds and 24 Arabians were used. Breath samples were collected using one-minute closed circulatory respiration through an aluminum bag filled with 10 liters of pure oxygen, which was mounted on the subjects by means of a face mask. Breath samples obtained, were analyzed by gas chromatography. A significant correlation in both hydrogen and methane levels was observed for samples collected at separate times. These findings confirmed the usefulness of our approach for testing breath concentrations of hydrogen and methane in horses.

Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: case report

We describe a very late manifestation of pelvic abscesses after oocyte retrieval for in-vitro fertilization (IVF). In a twin pregnancy achieved after intracytoplasmic sperm injection, rupture of bilateral ovarian abscesses occurred at the end of the second trimester. An emergency laparotomy was necessary because of an acute abdomen. This complication led to severe maternal and neonatal morbidity, preterm birth and neonatal death. The rare occurrence of acute abdomen in pregnancy due to pelvic infection and the non-specific symptoms of a pelvic abscess after oocyte retrieval for IVF are discussed.

[Anaerobes in children's acute abdomen]

Bacterial contamination of the abdominal cavity was studied in 30 children aged from 2.5 to 14 years with acute abdominal conditions. Anaerobes were detected in 63.9% of the children. It was established that on the initial stages of development of acute diseases in the abdomen the antagonism between aerobes and anaerobes was not present. 3 days and later after surgery the antagonism between aerobes and anaerobes arises which results in potentiation of the inflammatory process by either aerobes (25% of cases) or anaerobes (75% of cases). The complicated course of postoperative period in patients with acute abdomen more than in 83% of cases is due to anaerobes and in 50%--to aerobes.

An unusual cause of an 'acute abdomen'

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Postsplenectomy Capnocytophaga canimorsus sepsis presenting as an acute abdomen

Patients with intra-abdominal processes that require prompt surgical intervention, including appendicitis, perforated viscus, ischemic bowel, volvulus, and bowel obstruction, often present with signs and symptoms of an acute abdomen. Several medical problems can mimic an acute abdomen. Overwhelming postsplenectomy infection is a life-threatening condition that can present with acute abdominal symptoms. The incidence of overwhelming postsplenectomy infection ranges from 1% to 25%, and is caused by Streptococcus pneumoniae in 50% of cases. Capnocytophaga canimorsus, a bacteria commonly found in dog saliva, accounts for less than 1% of cases. Overwhelming postsplenectomy infection has a rapidly deteriorating course that progresses to respiratory and renal failure, cardiovascular collapse, and death. The mortality associated with overwhelming postsplenectomy infection is 60% to 80%. Early diagnosis and institution of appropriate antibiotic therapy and supportive care is essential to improve patient outcome. A previously healthy woman who had undergone splenectomy secondary to trauma 11 years earlier presented with symptoms of an acute abdomen. A diagnosis of overwhelming postsplenectomy infection due to C canimorsus was made based on her peripheral blood smear and blood culture findings. Early aggressive care and antibiotic treatment resulted in a successful outcome for this patient with no long-term morbidity. This patient's clinical course demonstrates the importance of early diagnosis and treatment of overwhelming postsplenectomy infection.

Necrotizing myofasciitis: an atypical cause of "acute abdomen" in an immunocompromised child

We report the case of an immunocompromised 15-year-old boy who presented with symptoms mimicking an "acute abdomen" related to necrotizing myofasciitis of the anterior abdominal wall. CT demonstrated the abdominal wall process as the cause of the patient's symptoms and sonographically guided aspiration confirmed the diagnosis. Despite prompt diagnosis and aggressive surgical debridement, the infection continued to progress and the patient died within 24 h of presentation.

Surgical drainage for idiopathic suppurative pylephlebitis

Idiopathic suppurative pylephlebitis is quite rare and only a few cases have been reported. Conservative systemic administration of antibiotics and urokinase is reported to be effective. In this report, surgical drainage was performed on an 18-year-old man who complained of fever and abdominal pain. He had no past history of abdominal inflammatory disease or abdominal surgery. Ultrasonography and computed tomography showed wide spread thrombosis of the portal vein. Laparotomy was performed and the occluded superior mesenteric vein was incised. Massive pus was removed. Thereafter, a drain was placed at the opened mesenteric vein. Drainage resulted in a dramatic decrease in fever. Postoperative radiographic studies of the colon, the small intestine, and other organs did not show any abnormalities. Emergency surgical drainage was performed successfully, instead of systemic administration of antibiotics and urokinase. Surgical drainage may be useful for wide spread pylephlebitis and pylethrombosis.

Antibiotics for the acute abdomen

Antibiotics are only an adjunct to proper surgical therapy for the treatment of the acute abdomen associated with bacterial secondary peritonitis. Upon presentation, all patients require a preoperative dose of antibiotics for prophylaxis against infection of remaining sterile tissues. Patients found intraoperatively to have an established peritoneal infection benefit from an immediate postoperative course of therapeutic antibiotics. A regimen that adequately covers facultative and aerobic gram-negative bacilli and anaerobic organisms is essential. The duration of therapeutic antibiotics is probably best decided on an individual patient basis. The goal of antibiotics is to reduce the concentration of bacteria invading tissues. The pathogens of bacterial peritonitis are influenced by such factors as the patient's pre-existing chronic diseases, state of acute physiologic debilitation, immunocompetence, recent antibiotic use, recent hospitalization, and neutralization of gastric acidity. Intraoperative peritoneal cultures are most useful in patients suspected of having impaired local host defenses. In these patients, all identified organisms, such as Enterococcus or Candida, may be potential pathogens. The common practice of administering empiric and prolonged courses of broad-spectrum antibiotics in patients who manifest persistent signs of inflammation may be more harmful than beneficial. These patients warrant an exhaustive search for extra-abdominal and intraperitoneal sources of new infection. Otherwise, such use of antibiotics may continue to promote the selection of bacteria that are highly resistant to conventional antibiotics and permit the overgrowth of organisms commonly seen with tertiary peritonitis. The best chance of resolving bacterial peritonitis is through early, aggressive surgical management complemented by short courses of potent antibiotics and appropriate physiologic support. Through these efforts, the clinician tries to help the systemic inflammatory response to benefit the host and not become unregulated, result in MOFS, and produce a high mortality.

[Anaerobic surgical infection and septic shock]

In the period 1990 through 1995, one-hundred patients operated for acute abdomen or admitted on a routine basis, presenting evidence of anaerobic infection, undergo treatment in the clinic of emergency surgery. Septic shock develops in 10/100 patients (10 per cent). In six of the latter the outcome is fatal--three with infection caused by spore-forming anaerobes (gas gangrene of the inguinal region--of Fournier, and anterior abdominal wall--anus praeternaturalis--two), and three with infection caused by non-spore-forming anaerobes (mixed anaerobic-aerobic infection). Anaerobic surgical infection and septic shock specificity is discussed, with an algorithm of therapeutic approach, based on clinical experience had with 100 patients, being proposed in either of them. Special emphasis is laid on antibiotic prophylaxis against anaerobic surgical infection. Its implementation in the concrete clinical conditions in this country demands a clearcut hospital drug policy (adoption of the "Drug Formularies" system), and elaboration of a new economical approach to the choice of antibacterial agents (using some of the forms of pharmaco-economical analysis, practicable with a view to the Bulgarian health-care model).

Pneumonia in unexpected locations: an occult cause of pediatric abdominal pain

Although pneumonia is a known cause of pediatric abdominal pain, it may go unrecognized on a patient's initial evaluation. This is particularly true when the infection lies outside of the typically described basilar location. We report three pediatric patients in whom acute abdominal pain was the sole or primary manifestation of a nonbasilar pneumonia.

Acute abdomen as atypical presentation of brucellosis: report of two cases and review of literature

Abdominal involvement in brucellosis is seen in the acute, subacute and chronic disease. It is not typical, however, that acute abdomen is the presenting feature of brucellosis. In this paper, two cases of serologically diagnosed brucellosis are reported, both presenting initially with acute abdomen and fever. In brucella-endemic regions of the world, brucellosis has to be considered in the differential diagnosis of acute abdomen and fever. With definitive diagnosis, unnecessary laparotomy can be avoided.

[Aerobic and anaerobic bacterial flora in acute abdominal illnesses]

366 specinmens taken from patients suffering from acute abdominal illnesses who had undergone operations were examined. Bacterial pathogens were isolated from 318 specimens. Aerobic bacteria were isolated from 53.8% specimens. Anaerobic bacteria were isolated from 12.6% specimens. Mixed bacterial flora were isolated from 33.6% specimens. Among aerobic bacteria E. coli and Streptococcus faecalis were most often isolated. Among anaerobic bacteria Bacteroides fragilis, Peptostreptococcus spp. and Peptococcus spp. were most often seen.

[Invasive Streptococcus pyogenes infection (beta-hemolytic Streptococcus of group A)]

Group A streptococcal infections are frequent and most often benign. Severe invasive infections due to this microorganism have nevertheless been reported with increasing frequency in various countries for several years. Moreover, a toxic shock-like syndrome has recently been recognized and characterized in such infections. Two cases of invasive group A streptococcal infections (one primary peritonitis and one toxic shock syndrome) are reported to increase a better understanding of this disease in the light of a review of the pertinent literature. This is hoped to contribute to better management of what is a growing problem for many physicians who are nowadays no longer familiar with the broad spectrum of group A streptococcal infections.

Gastroenteritis due to Salmonella sp: clinical and radiologic signs mimicking surgical peritonitis

Salmonella infections most often are self-limited illnesses confined to the gastrointestinal system. They can, however, produce clinical and radiographic findings consistent with peritonitis. Careful attention to evaluation and treatment is required to avoid unnecessary surgery for what may initially appear to be a surgical condition.

[Acute abdomen secondary to cytomegalovirus infection]

A case of a HIV-positive patient hospitalized with acute abdomen secondary to infection by cytomegalovirus (CMV), is presented. Infection by CMV is frequent in HIV-positive patients, with a relevant intestinal affection. However, its presentation as acute abdomen is more rare, although it has to be considered given that the demonstration of the presence of CMV and its potential pathogenic power have important therapeutic connotations. Currently, the use of diagnostic techniques based in specific monoclonal antibodies and DNA hybridization methods increases the diagnostic sensitivity of the traditional methods based on histological demonstration of the cytopathic effect and/or viral cultives.

Microbiology and antibiotics in infectious abdominal emergencies

The appropriate treatment of intra-abdominal infection is often confusing and controversial. Much of the controversy is due to the availability of a substantial number of newer, broad-spectrum antimicrobials. An understanding of the spectrum of activity, toxicity, and clinical efficacy of these drugs is critical in the selection of therapy for the treatment of intra-abdominal sepsis.

Experimental induction of abdominal tympany, abomasitis, and abomasal ulceration by intraruminal inoculation of Clostridium perfringens type A in neonatal calves

The etiologic role of Clostridum perfringens type A in the acute abdominal syndrome characterized by abomasal and rumen tympany, abomasitis, and abomasal ulceration was investigated in neonatal calves. Eight calves, 4 to 12 days old, were inoculated intraruminally with toxigenic C perfringens type A. Before and after C perfringens inoculation, blood samples were collected from all calves for blood gas and serum biochemical analysis and for determination of serum copper concentration; ruminal fluid was obtained for isolation of C perfringens. Calves were monitored daily for clinical signs of the syndrome and, depending on the severity of clinical signs, they were either euthanatized or redosed within 4 to 7 days. After necropsy, specimens obtained from the abomasum and rumen for macroscopic and microscopic examination and for anaerobic bacteriologic culture were processed in routine manner. Intraruminal inoculation of C perfringens type A into healthy calves induced anorexia, depression, bloat, diarrhea, and in some calves, death. Serum copper concentration was within normal range. Necropsy revealed variable degrees of abomasitis, petechial and ecchymotic hemorrhages, and ulcers (ranging from pinpoint to nearly perforate) in the abomasum. Seven of those calves also had multiple trichobezoars in the rumen. These necropsy findings were not seen in calves (controls) given distilled H2O only. In affected calves, acute abdominal syndrome was unrelated to copper deficiency, and C perfringens type A given intraruminally was able to induce clinical signs similar to those of the naturally acquired disease.

Yersinia enterocolitica infection in patients with acute surgical abdominal disease. A prospective study

The rate of yersiniosis in patients with acute abdominal disease was studied in a 16-month prospective investigation in 1972-1973 of 205 acutely ill patients referred to a surgical clinic of a Copenhagen City hospital with complaints of abdominal pain suggestive of appendicitis. Yersinia enterocolitica, biotype 4, was isolated from 11 patients (5.4%), 8 of whom were children. Yersinia was grown from faeces in 8 cases and from appendix of all 9 patients operated upon. Rising or falling agglutinin titres larger than or equal to 100, indicative of yersiniosis, were found in 22 patients (10.7%) including all bacteriologically verified cases. Eight additional patients (3.9%) had less significant titres larger than or equal to 100, suggestive of recent or present infection. 28 patients (13.7%) had insignificant titres, including 3 with antibodies against serotype 9. In all cases except these 3, antibodies were against Y. enterocolitica, serotype 3. A differential diagnosis between Y. enterocolitica infection and other types of appendicitis could not be made within this highly selected group of patients using available clinical data. All cases were rather mild and self-limiting. It is suggested that in future epidemiological and other studies of yersiniosis, early bacteriological and serological examinations be carried out.