Streptococcus bovis - Gundersen Lutheran Health System

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type of implant, method of sterilization, site of implementation, and the stress placed on the implant, 1,10 affect the degradation of biodegradeable implants, often making it difficult to pinpoint the cause of the an exaggerated inflammatory response. Risk factors purported to be responsible for adverse tissue responses are “the presence of quinine dye, an implant with a large surface area such as a screw, and implant sites with low vascularity.” 11 Our patient had 2 of the aforementioned risk factors: a screw was employed during the surgery, and repeated physical stress placed on the anchor-bone interface through the superspinatus tendon, affirming that these risk factors are potentially valid. Although bioabsorbable implants are absorbed readily by the body, thus eliminating the need for a follow-up surgery. They prevent radiographic obscurities, and they provide incremental stress transfer as they degrade, which promotes healing. However, clinicians need to be aware of the drawbacks of bioabsorbable implants. Compared with metallic implants, they are less strong and less stiff, have a limited shelf-life, cost more initially, and have a tendency for an exaggerated inflammatory reaction. The advantages do, however, appear to outweigh the disadvantages. 10 As shown in the case reported here, the risk of an exaggerated inflammatory response to bioabsorbable implants increases when the implant has a large surface area, such as a screw, and when it is subjected to repeated stress. These risk factors should be considered in the development of treatment options. GiAnt CeLL reACtion to A bioAbSorbAbLe iMpLAnt referenCeS 1. Bollom T, Meister K. Surgical principles: biodegradable materials in sports medicine. In: DeLee JC, Drez DJ, Miller MD, eds. DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice. 2nd ed. Philadelphia, PA: Saunders; 2003. 2. Kulkarni RK, Pani KC, Neuman C, Leonard F. Polylactic acid for surgical implants. Arch Surg. 1966;93(5):839-843. 3. Claes LE. Mechanical characterization of biodegradable implants. Clin Mater. 1992;10(1-2):41-46. 4. Ciccone WJ,2nd, Motz C, Bentley C, Tasto JP. Bioabsorbable implants in orthopaedics: new developments and clinical applications. J Am Acad Orthop Surg. 2001;9(5):280-288. 5. Simon JA, Di Cesare PE, Koval KJ. Bioresorbable materials in orthopaedics. Bull Hosp Jt Dis. 2000;59(4):232-240. 6. Weiler A, Hoffmann RF, Stahelin AC, Helling HJ, Sudkamp NP. Biodegradable implants in sports medicine: the biological base. Arthroscopy. 2000;16(3): 305-321. 7. Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol. 2008;20(2):86-100. 8. Athanasiou KA, Schmitz JP, Agrawal CM. The effects of porosity on in vitro degradation of polylactic acid-polyglycolic acid implants used in repair of articular cartilage. Tissue Eng. 1998;4(1):53-63. 9. Glueck D, Wilson TC, Johnson DL. Extensive osteolysis after rotator cuff repair with a bioabsorbable suture anchor: a case report. Am J Sports Med. 2005;33(5): 742-744. 10. Ambrose CG, Clanton TO. Bioabsorbable implants: review of clinical experience in orthopedic surgery. Ann Biomed Eng. 2004;32(1):171-177. 11. Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop Relat Res. 2000;(371)(371):216-227. Graceful John Larson Optometry Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 23
Authors: Meghana Raghavendra, MB, BS Department of Medical Education Gundersen Lutheran Medical Foundation Dr. Raghevendra now practices with IU Medical Group, Indianapolis, Indiana William A. Agger, MD Section of Infectious Disease Department of Internal Medicine Gundersen Lutheran Health System Address for correspondence: William A. Agger, MD Mail Stop C04-007 Gundersen Lutheran Health System 1900 South Avenue La Crosse, WI 54601 Telephone: (608) 775-2140 Facsimile: (608) 775-5542 email: waagger@gundluth.org Post–Cesarean Delivery Septic Ovarian Vein Thrombosis AbStrACt CASe A 32-year-old pregnant woman at 40 weeks gestation underwent a cesarean delivery due to failure to advance after prolonged rupture of membranes followed by chorioamnionitis. She was discharged 3 days after delivery but required readmission 8 days later for fever, left lower abdominal pain, and fullness in her left lower abdomen. Her white blood cell count was 22.9 x 10 9 /L with 24% bands, and her erythrocyte sedimentation rate was 96 mm/h. Urinalysis results were within normal limits. Cultures of blood drawn on admission remained negative for growth. Transvaginal ultrasonography revealed a mixed echogenic mass in the left adnexal area measuring 5.0 x 7.0 x 5.0 cm that appeared to be a mixture of small abscesses and phlegmon. Despite 48 hours of intravenous treatment with a broad-spectrum antibiotic (ertapenam), she continued to have fevers as high as 39°C. A computed tomographic (CT) scan of abdomen and pelvis with contrast was obtained and revealed left ovarian vein thrombosis and a complex tubo-ovarian abscess (Figures 1 and 2). Enoxaparin was begun, and fever resolution occurred within 24 hours. The patient was discharged home on oral amoxicillin/clavulanate and warfarin. Her oral anticoagulation was stopped at 5 days due to uterine bleeding, and she has remained well for the last 6 months. diSCuSSion Postpartum ovarian vein thrombosis (OVT) occurs after 0.003% to 0.18% of deliveries, 1,2 after 0.005% of febrile abortions, 3 and occasionally after other inflammatory pelvic pathologies. Many consider OVT to be an extension of a more controversial diagnosis, pelvic thrombophlebitis. 2,4,5 OVT should be considered in women who have lower abdominal pain, lower quadrant mass, fever, and/or neutrophilia after childbirth or after pelvic surgery. 1,6 Postpartum women with OVT usually develop fever within 48 to Eleven days after cesarean delivery, a 32-year-old woman was readmitted to hospital with fever and pain in her lower left abdomen. Her white blood cell count and erythrocyte sedimentation rate were elevated. Transvaginal ultrasonography revealed a mixed echogenic mass in the left adnexal area that appeared to be a mixture of small abscesses and phlegmon. She was started on an intravenous broad-spectrum antibiotic, but 48 hours later, her fever persisted. A computed tomographic scan of abdomen and pelvis with contrast was obtained and revealed left ovarian vein thrombosis and a complex tubo-ovarian abscess. Enoxaparin was begun, and the patient’s fever resolved within 24 hours. Postpartum pelvic infection with ovarian thrombosis and its therapy are reviewed. 96 hours after delivery. 1,6 Lower abdominal pain and/or a cord-like, tender, lower abdominal fullness may be found in 50% to 67% of patients. 1,6 Nausea, ileus, and other gastrointestinal complaints may also occur. The differential diagnosis includes appendicitis, pyelonephritis, tubo-ovarian abscess, and endometritis with or without retained products of conception. figure 1. Computed tomographic scan with contrast illustrating left ovarian vein thrombus (white arrow). 24 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
Page 1 and 2: Th e Gundersen Lu T h e r a n M e d
Page 3 and 4: editor David E. Hartman, PhD, BC-AN
Page 5 and 6: through our online Scholarly Activi
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Page 9 and 10: effect. These data suggest that the
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