A male 17 yrs of age attended local hospital with complain of two small swellings on the abdominal wall just below umbilicus with slight tenderness but no fever. On palpation swellings were soft and slight fluctuating. They were drained with pus and bloody discharge. Cefurixime was given for 7 days but they remained unhealed. After two weeks patient was given anti tubercular drugs and continued for next 1 and half month without any progress. He was admitted in Rangpur Medical College Hospital. In the mean time another two swellings appeared on the upper part of the abdominal wall. On investigation blood sugar,CBC were normal. Tuberculine test negative. Microscopy showed gram positive bacilli, gram positive cocci and gram negative bacilli. Culture showed pseudomonas aeroginosa only sensitive to gentamycin. Anaerobic culture not done for non availability. Thinking it as necrotizing fasciitis, Injectable metronidazole plus, amoxicillin and cefurixime started. Two weeks passed without any response. Anti tubercular drug not stopped. Four days ago a palpable inguinal lympnode was removed -biopsy done reported nonspecific inflammatory cells, good number plasma cell seen. What is the possible diagnosis. Patient is poor in a poor country Bangladesh.
Do you use gentamicine?. Any possibility for cutaneus tuberculosis?
Culture of mycobacterium tuberculosis
Carlos Acosta Batista- thanks, we used gentamycin and pt also getting anti-tubercular for about last 2 months
My suggestion is to take edge biopsy and send for histopathologic Examination to rule out malignancy and part to be sent for ZN staining and tuberculosis culture.
It really appears to be necrotizing fasceítis, may be by mixed microbial agents. Perhaps it would be necessary to enlarge the spectrum...
Could it be a leishmaniosis or other parasite?
I agree with doctor Azzouz, you have to search for unusual or rare germs or parasite
I think leshmaniasis must be ruled out. Biopsy to exclude malignancy is also mandatory.
This is never a necrotizing fasciitis , which is an acute serious fast spreading infection. The 2 abscess are open and cry for local antibiotics ! An open wound is like a Petri dish and its bacteria have to be killed there; serum levels are too low, especially , biofilms can never fought systemically. There is no logic behind the worldwide rejection of local applications of antibiotics. I often operate in India and Africa and treat all infections with an opened vial of cephalotin.: the effective level is 100 x higher than in the serum, and even resistant Pseudomonas is killed immediately. Therefore, try any antibiotic but put it into the wound, where it belongs.
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