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Preseptal cellulitis is a worrying condition in children. One of the commonest causes is from insect bite. The Charlie ant or Paederus fuscipes has been reported as a dermatitis-causing agent due to its toxin, pederin. The aim is to report a case of preseptal cellulitis secondary to Charlie ant insect bite. A two-year-old girl presented with bilateral eyelid swelling, redness, and pain for two days. The Charlie ant was at the nasal bridge before the presentation. There was presence of generalised bilateral eyelid swelling, redness with multiple pustules, excoriated skin, and eye discharge. She was admitted and started on antibiotics. The pustules ruptured, left the skin exposed, and her condition improved. Preseptal cellulitis is a contiguous spread of infection. An attack by Charlie ant has become a public health concern. There is no specific treatment for this condition. Early detectionmay prevent complications.

Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space. Bacteria gain access to the epidural space either by hematogenous spread, contiguous spread from a neighboring infected structure, or through iatrogenic inoculation. The diagnosis of SEA is a challenge, largely because of its rarity. We present here a case of SEA of iatrogenic origin (post spinal anesthesia), which we treated at Tata Main Hospital, Jamshedpur.

» Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. » Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. » Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. » Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. » For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Objective: Examine sequence of weakness in arm muscles from longitudinal hand-held dynamometry (HHD) data in ALS for congruence with contiguous spread of neurodegeneration along spinal cord segments. Methods: Longitudinal HHD data from the Ceftriaxone clinical trial were examined using nonlinear mixed models, assuming a logistic trajectory from normal to zero strength. Unobserved baseline normal strength of weak muscles was assumed using strength of the best-preserved muscle. A novel metric called “time from onset to midway strength” (TOMS) was estimated for each muscle group, and TOMS ratios were examined to identify sequence of weakness, overall and by onset site. Results: Shoulder flexion (SF), elbow flexion (EF), elbow extension (EE), wrist extension (WE), and first dorsal interosseous (FDI) were measured on each side. Over a median of 36 weeks, 513 subjects provided 2589 sets of HHD measures. TOMS increased sequentially in the following order: FDI, WE, SF, EF, and EE. TOMS ratios estimates with 95% CIs (adjusted for multiple comparisons) were: WE/FDI 1.32 (1.24–1.41), SF/WE 1.06 (1.01–1.10), EF/SF 1.06 (1.02–1.10), and EE/EF 1.18 (1.12–1.23). Elbow and shoulder flexors weakened sooner than did elbow extensors. The sequence of arm muscle weakness progression was similar regardless of onset site. Conclusion: Nonsegmental progression of arm muscle weakness that is similar for different onset sites favors cortical influence/network spread over contiguous spread of neurodegeneration in the spinal cord. Furthermore, this study confirms the “split elbow” pattern. TOMS and other proposed methods may have value as outcome measures in clinical research.

Pyogenic Spondylodiscitis is a common affliction of the spine in which microorganism can spread by either direct or indirect route destroys the disc and vertebral end plates. Contiguous spread from nearby structures like mediastinum, oesophagus, intestines, penetrating injuries are well known. We report one such case where Self-expanding metallic [SEM] stenting done for Boerhaave syndrome lead on to T3-4 Spondylodiscitis with pathological fracture resulting in acute paraplegia as a complication. Spinal complications related to oesophageal stents are rarely reported in literature. We present our experience in managing this catastrophic presentation with a review of literature of similar cases. Keywords: Spondylodiscitis, Self-expanding metallic esophageal stent, Boerhaave syndrome

Nocardia spp. are filamentous Gram positive bacteria that are ubiquitous soil saprophytes. The majority of nocardial infections occur in severely immunocompromised patients who are particularly susceptible to pulmonary disease and dissemination. Extrapulmonary nocardiosis is relatively common and can occur through hematogenous dissemination or a contiguous spread of necrotizing pneumonitis. Primary cutaneous and soft tissue nocardiosis can result from traumatic injury to the skin that involves contamination with soil. After skin inoculation, a superficial abscess or localized cellulitis can develop. Co-trimoxazole is the drug of choice for all types of nocardiosis. We are reporting a case of Nocardia cyriacigeorgica presenting as cellulitis followed tooth extraction.

Objective: This study aimed to investigate whether the spread pattern affects functional staging in amyotrophic lateral sclerosis (ALS). We examined the spreading patterns of disease following symptom onset and the affected regions in ALS using electromyography. Methods: This study reviewed the medical records of 103 patients with sporadic ALS in the Second Hospital of Hebei Medical University from 2012 to 2017. According to the clinical manifestation and the distribution of the affected regions on electromyography, spread patterns were classified as discontiguous or contiguous. The patients were graded according to the ALS-Milano-Torino staging (MITOS) system. Results: The clinical spread patterns were contiguous in 91.5% of patients and discontiguous in 8.5% of patients. The electrophysiological spread patterns were contiguous in 87.4% of patients and discontiguous in 12.6% of patients. Sex, age, or delay in diagnosis did not affect the clinical or electrophysiological spread patterns. No significant correlation was observed between the clinical classification and the ALS-MITOS grade, but the electrophysiological spread was significantly correlated with the ALS-MITOS. Conclusion: This study provides evidence that not all ALS patients show contiguous clinical or electrophysiological spread patterns. The electrophysiological spread pattern can affect the functional staging in ALS patients.

Malignant melanoma of the anal canal is a rare and aggressive tumour associated with significant mortality. Early diagnosis and early curative surgical resection have shown to offer a survival advantage. We present a case of 53-year-old woman, who was accidentally diagnosed to have a localised lesion of malignant melanoma of the anal canal on histopathology report of the specimen of haemorrhoidectomy done for thrombosed external haemorrhoids. She refused any form of treatment and did not return for follow-up. Two years after the initial diagnosis, she presented with intestinal obstruction. The malignant melanoma had become advanced with multiple metastases to the lungs, the liver, the peritoneum and the spine. The patient underwent a diverting loop ileostomy. At the time of surgery, it was found that the primary malignant melanoma of anal canal had contiguously involved the entire large intestine up to the ileocaecal junction and hence transverse colostomy could not be done.

A 70-year-old man underwent Tc-methylene diphosphonate scintigraphy for staging of adenocarcinoma prostate. Scintigraphy revealed diffuse increased tracer uptake in skeletal system along with faint renal visualization, a pattern compatible with metastatic superscan. The scintigraphy also revealed increased radiotracer uptake in the body of the mandible-Lincoln sign or black beard sign. Radiological imaging revealed sclerotic lesions throughout the skeleton including the mandible, confirming widespread skeletal metastases. Lincoln sign is previously described in monostotic Paget disease of the mandible and in contiguous spread of oral malignancy. We describe this pattern in distant metastatic involvement from carcinoma prostate with coexistent superscan pattern.

Mediastinitis is an inflammatory process; it can be either acute or chronic and it can advance rapidly. Causes of acute mediastinitis usually arise from perforation of the oesophagus or from contiguous spread of neck infections. An important neck or chest pain with fever or the onset of inflammatory index and the enlargement of the mediastinal x-ray image should lead to suspect mediastinitis. The TC-scan of neck and thorax is the gold standard for mediastinitis diagnosis.

Discitis—the infection of the intervertebral disc space—can result from hematogenous dissemination, direct disc inoculation (either iatrogenic or traumatic), or contiguous spread from an adjacent structure. Unless there is a chronological relationship between symptom onset and recent spine intervention or injury, the diagnosis may be delayed for weeks or months. The initial symptoms are often non-specific (severe back pain, stiffness, occasional fever, and malaise) with evidence of elevated inflammatory markers on work-up. Once discitis is suspected, imaging studies (contrast MRI, PET, or CT scan) should be immediately obtained. Image-guided aspiration biopsy is performed when blood cultures or serologic tests fail to identify the responsible pathogen. Conservative treatment with intravenous antibiotics should be guided by microbiology results. If general or neurologic deterioration occurs, empiric antimicrobial therapy should be initiated and surgery should be considered (Berbari et al., Clin Infect Dis. 61(6):e26–46, 2015).

Many complex systems that produce cascading events are thought to be self-organized critical (SOC). So far, models of SOC treat a cascade as a spread strictly between adjacent nodes, while in many real systems, e.g., the power-grid or the brain, this restriction is invalid. Here, we demonstrate for the first time SOC behavior in a model for which the spread is non-contiguous, i.e., not restricted to neighboring nodes. We illustrate our results in a circuit model obeying Kirchhoff’s laws and demonstrate mitigation strategies that avoid large-scale cascades. We found that the following two unconventional strategies break SOC: (1) upgrade lines at random in addition to fixing failures and (2) upgrade a tripped line with one that has a random trip threshold. These results enhance our understanding about the conditions under which SOC can occur and may lead to insights that help avoid catastrophic events in real-world systems.

Here, we document the case of mediastinitis in an adult individual, developed upon contiguous spread of oesophageal infection. Our findings are noteworthy, because the presence of Prevotella oris , P. veroralis , Dialister pneumosintes , Klebsiella pneumoniae in tissue sample from mediastinum cannot be identified by standard culturing and Gram-staining. Importantly, however, 16S rDNA sequencing did lead to an unambiguous diagnosis and guided successful antimicrobial therapy.

Purpose: The aim of this review is to analyze all reported cases of histologically confirmed adenoid cystic carcinoma (ACC) with cavernous sinus involvement identified in the literature in order to elucidate the clinical symptoms, neuro-ophthalmic and neuro-imaging findings.Methods: A systematic electronic database search (Medline, Biosis and Cochrane) and a literature review were used to identify reported cases which were assessed for demographic information; primary tumour site; pattern of spread; extent and timing of cranial nerve involvement; and neuro-imaging findings.Conclusions: Neuro-ophthalmologic evaluation is extremely important in the diagnosis of this disease which has a propensity for perineural and direct orbital invasion.

The minimally invasive "pinless" external fixation device provides soft-tissue immobilization and osseous stabilization while limiting the potential for contiguous spread of bacterial infection.

Osteomyelitis is an invasive infection of bone, occurring through direct inoculation of pathogens after trauma, by contiguous spread of microorganisms from soft tissue infections, or via hematogeno...

Peripheral nerve tumors are soft-tissue tumors that can occur in any nerve throughout the body. The majority of peripheral nerve tumors arise from elements of the nerve sheath with the two most common being neurofibromas and schwannomas. More than 90% of all peripheral nerve tumors are benign. When there is peripheral nerve involvement in metastatic carcinoma, it is often via contiguous spread from the primary mass; hematogenous seeding to a peripheral nerve is seldom seen. In this report the authors describe the even rarer case of metastatic renal cell carcinoma mimicking a schwannoma in a dorsal root ganglion. Cases from the literature show the rarity of this finding and its late clinical appearance. Given that survival in patients with metastatic carcinoma continues to increase, dorsal root ganglion metastasis may become more common over time.

Basidiobolomycosis classically presents as a noninflammatory, nonulcerated, nontender woody indurated mass without much contiguous spread. It is almost always seen in an immunocompetent host younger than 20. We report a case of a 9-month-old baby with a rapidly expanding malignant presentation of basidiobolomycosis with nonhealing ulcers and spread to underlying muscles, mimicking lymphoma. She responded poorly to itraconazole alone but showed dramatic improvement with a combination therapy of itraconazole and potassium iodide. The case also highlights an early acquisition of the infection at 1 month of age.

The retropharyngeal space is a potential route for the spread of infection and malignancy. We present patients with squamous cell carcinoma of the larynx and tongue with superior contiguous spread along the retropharyngeal space resulting in skull base erosion. The fascia defining the retropharyngeal space is attached to the skull base and pathological processes can extend superiorly to destroy the skull base.

Introduction. Actinomycosis is an uncommon chronic granulomatous infection first described by Bollinger in 1877. The infection is caused by actinomyces species and it is characterized by slow contiguous spread and suppurative inflammation, formation of multiple abscesses and sinus tracts with possible drainage of ?sulfur granules?. Case Outline. We report an unusual case of actinomycosis of the cheek that occurred 6 years after buccal odontogenic abscess. A 56-year-old male was referred to the Department of Oral Surgery because of a painless swelling of the left cheek, which initiated three weeks prior to the referral. The diagnosis of actinomycosis was confirmed by histopathologic examination. In accordance with the diagnosis oral penicillin was prescribed for four months with complete resolution. Conclusion. This case of actinomycosis is presented as a rarity. For proper diagnosis, careful examination and a high degree of clinical suspicion are necessary.

Normally, the pleural spaces contain sterile lubricating fluid that enables smooth expansion and contraction of the lungs. But when microorganisms gain entry, directly or through contiguous spread of infection, the fluid becomes increasingly dense and viscous as purulence progresses. This article outlines clinical, radiographic, and pleural fluid features that can aid in distinguishing between pleural collections that usually respond to medical therapy and those that probably require surgical intervention.

Acute infections of bones, joints and soft tissues are a common clinical problem in children and adults, and considered therapeutic emergencies. Their manifestations are variable and influenced by many circumstances, such as patient age, acute or chronic nature of the infection, infecting organism (bacteria, mycobacteria, fungus), location (bone marrow, bony cortex, periosteum, soft tissue, synovial joint, intervertebral disc), route of infection (hematogenous seeding, contiguous spread, direct traumatic or iatrogenic implantation), and pre-existing predisposing pathologies (immunocompromising diseases, bone diseases, implants).

In recent years, the concept of contiguous spread of the disease process in amyotrophic lateral sclerosis (ALS) has become more accepted,1 although how this might occur is still uncertain. Kanouchi et al 2 reviewed the extensive clinical, physiological and molecular evidence for this process in this journal, noting that ALS can be recognised to spread both contiguously and non-contiguously, the latter implying more than one focus of disease onset—a ‘skipping’ pattern of spread. They concluded that contiguous spread explains regional progression, but offered no explanation for the process of propagation itself. It has been suggested that cell-to-cell spread requires that abnormal cytosolic proteins in ALS, for example, TDP-43, which seems to underlie the ubiquitinated inclusions so characteristic of sporadic ALS, are misfolded, self-aggregate and form toxic proteinaceous inclusions with a β cross-conformation, resembling prions.3 A prion-like propagation process implies that the abnormal protein spreads to involve other nearby cells, whether neuronal or glial. Prusiner,4 from whose insight the prion …

A 48-year-old woman receiving hemodialysis via arterial-venous fistula presented with right gluteal region pain and fever. Initially, antibiotics were prescribed but her fever did not subside. Computed tomography (CT) pelvic images displayed low attenuation lesions on the right pyriformis muscle (Fig. 1, panel A) and psoas muscle (Fig. 1, panel B). Muscle abscess was suspected. The surgeon and radiologist suggested a CT-guided percutaneous drainage for pyriformis muscle and antibiotics. The drainage yielded a large amount of pus fluid. Three days later, the patient’s lower back pain and fever had not subsided. A second pelvic CT was done, which disclosed an enlarged lesion on the iliopsoas muscle (Fig. 2). Subsequently, exploratory retroperitoneum open drainage was performed for the abscess on the iliopsoas muscle. Cultures from the pus and blood showed methicillin-resistant Staphylococcus aureus. After a month of therapy with vancomycin and drainage, follow-up CT showed complete remission. Fig 1. Computed tomography scan reveals (A) a low-attenuation lesion on the right iliopsoas muscle (white arrow) and (B) a low-attenuation lesion on the right pyriformis muscle (black arrow). Fig 2. Computed tomography scan demonstrates the enlarged lesion on the right iliopsoas muscle (arrow). A single-muscle abscess in a uremic patient has been reported,1,2 which may arise through contiguous spread from adjacent structures or by the hematogenous route from a distant site. In our case, a uremic patient presented pyriformis and psoas muscle abscesses simultaneously. However, it is difficult to determine whether these two muscle abscesses occurred at the same time or developed one after the other. Neither could we determine the micro-organic cause of the muscle abscess. To our knowledge, this is the first case in which a uremic patient has presented multiple muscle abscesses.

The central zone (CZ) of the prostate is embryologically, anatomically, and histologically distinct. High-grade prostatic intraepithelial neoplasia (HGPIN) and prostatic adenocarcinoma (PAC) are encountered in the CZ, but have not been well studied. Non-CZ PAC that spread into the CZ can mimic CZ PAC. We reviewed 300 consecutive radical prostatectomies performed for PAC to identify cases showing PAC and HGPIN in the CZ. There were nine PAC (3%) localized predominantly in the CZ, presenting as a single tumor nodule (8/9) and associated with 4.5+/-1.1 foci HGPIN in the CZ and with only 1.7+/-0.5 foci in the PZ. Of the 291 non-CZ PAC, 24 cases showed satellite tumor nodules in the CZ, and 92 cases demonstrated secondary contiguous spread to the CZ. As compared to the non-CZ PAC, CZ PAC tended to have lower tumor volume, but had higher Gleason scores (8.10+/-0.6 vs. 6.30+/-0.7, p0.05), as well as a higher incidence of a ductal carcinoma component (6/9), higher rates of capsular penetration, positive resection margins (4/9), and seminal vesicle spread (2/9). The CZ HGPIN associated with CZ PAC demonstrated cells with prominent nucleoli and formed either slender papillary structures or cribriform/solid patterns. The correlating positive biopsy cores were from the mid portion or from base of prostate and contained foci of HGPIN in 4/7 cases. The CZ PAC is characteristically accompanied by more foci of HGPIN in the CZ than in non-CZ and is associated with high grade and high stage. Preoperative diagnosis of CZ PAC can be suspected due to the histopathological features in the biopsy and is important to improve the free surgical resection rate.

Tropical pyomyositis was first described by Scriba in 1885, as an endemic disease in the tropics. The most common organism implicated is staphylococcus aureus (90% of cases in tropical areas and 75% of cases in temperate countries) [1]. In 20-50% of cases there is a history of trauma to the affected muscles [2]. Recent data indicate that up to 75% cases in temperate areas are immunocompromised. Transient bacteraemia, not contiguous spread from surrounding tissues, is suspected to be the source of infection because there is no external injury or portal of entry that can usually be identified [3].

Primary lid tuberculosis after lid surgery is a very rare condition and is likely caused by the introduction of bacilli through epithelial injury. Secondary infection, due to direct hematogenous spread or contiguous spread from adjacent structures are more common presentations of lid tuberculosis. The authors experienced a case of primary lid tuberculosis occurring in a 19 year old female after blepharoplasty for making a eyelid crease. Her upper lid skin showed a reddish and non-tender mass lesion measured 3x1 cm, which was diagnosed as the tuberculosis through typical histopathological findings (caseous necrosis), acid-fast bacilli stain and PCR, and treated with anti-tuberculosis medications.

Glomus tumors are uncommon soft tissue tumors. Rare occurrences in visceral organs including the respiratory tract have been reported. The vast majority of these tumors are biologically benign. We report a case of primary pulmonary glomus tumor with atypical features characterized by mild nuclear atypia, local infiltration, and contiguous spread to a peribronchial lymph node. The current literature is reviewed.

There are reports that complex regional pain syndrome, type I (reflex sympathetic dystrophy; CRPS-I/RSD) can spread from the initial site of presentation, but there are no detailed descriptions of the pattern(s) of such spread. We describe a retrospective analysis of 27 CRPS-I/RSD patients who experienced a significant spread of pain. Three patterns of spread were identified. 'Contiguous spread (CS)' was noted in all 27 cases and was characterized by a gradual and significant enlargement of the area affected initially. 'Independent spread (IS)' was noted in 19 patients (70%) and was characterized by the appearance of CRPS-I in a location that was distant and non-contiguous with the initial site (e.g. CRPS-I/RSD appearing first in a foot, then in a hand). 'Mirror-image spread (MS)' was noted in four patients (15%) and was characterized by the appearance of symptoms on the opposite side in an area that closely matched in size and location the site of initial presentation. Only five patients (19%) suffered from CS alone; 70% also had IS, 11% also had MS, and one patient had all three kinds of spread. Our results suggest that CRPS-I/RSD spread may not be a unitary phenomenon. In some it may be due to a local spread of pathology (CS); in others it may be a consequence of a generalized susceptibility (IS). In the MS case, spread may be due to abnormal neural functioning spreading via commissural pathways. Alternatively, we discuss the possibility that all three kinds of spread may be due to aberrant CNS regulation of neurogenic inflammation.

A wide spectrum of diseases may involve the clivus, such as primary neoplasms, metastatic disease, and inflammatory, vascular, hematopoietic, and infectious processes. Of these, osteomyelitis of the skull base and/or clival-petrous abscess are unusual, but may occur as a result of contiguous spread from the paranasal sinuses, namely, the posterior ethmoid and sphenoid, as was demonstrated by this patient. In this case report we discuss the pertinent anatomy, imaging studies, pathogenesis, and medical and surgical management of this case.

Background: Lupus vulgaris is the most common form of cutaneous tuberculosis in adults. Lupus vulgaris is caused by hematogenous, lymphatic, or contiguous spread from elsewhere in the body. histologically it is charecterised by typical tubercles with or without caseation, surrounded by epitheloid histiocytes and multinucleate giant cells in the superfi cial epidermis with prominent peripheral lymphocytes. Materials and Method: All cases of clinically and histopathologicaly diagnosed lupus vulgaris over the previous five years were included in the study. Results: Fourteen cases of lupus vulgaris cases reported during the study period with eaqual incidence among males and females. Discussion: Plaque type of lupus vulgaris was the most common type. Histopathologically tubercular granulomas were seen in all cases as compared to other studies. Conclusion: Different patterns of lupus vulgaris are reported

Abscesses may form in brain parenchyma as a result either of metastatic spread from infection elsewhere in the body or of contiguous spread from structures in close proximity, such as the paranasal sinuses, ears, and nose. Trauma and surgical procedures may introduce infectious agents to vulnerable cerebral tissue. Since brain abscess is a curable condition, prompt recognition of predisposing factors and knowledge of the varied clinical presentations, as well as of the diagnostic and therapeutic approaches, are essential for cure.

Purpose The hypothesis is tested in 297 patients with Hodgkin's disease, that it does arise in one site and spreads in a predictable manner in the lymphatic system before hematogenous dissemination. Materials and methods 70 PS I, 66 PS II, 137 PS III. and 15 PS IV Hodgkin's disease patients. 188 A, 109 B. 236 presented cervical lymphomas: 80 left-, 92 right- and 64 bilateral-cervical. They were grouped according to the number of involved sites. Results A characteristical pattern was observed in 88%. The accuracy of the hypothesis is significant for the 236 patients with cervical lymphoma (P = 0.01; T-test). Conclusion HD spreads from the right cervical side via the upper me diastinum and hili to the upper abdominal nodes and the spleen whereas left cervical lymphoma leads to direct abdominal involvement bypassing the mediastinum. Abdominal involvement precedes upward spread via the pulmonary hili and upper mediastinum on the left side or on both sides to the cervical or axillary or inguinal nodes.

Summary Most clostridial infections arise by direct inoculation of soil or feces into tissues or by contiguous spread from the gastrointestinal tract or vagina usually after an injury. We report a case of spontaneous bifocal clostridial myonecrosis associated with acute leukemia.

Between January 1970 and August 1986, 3051 total hip arthroplasties (THAs) were performed at the authors' institution. Forty-seven hips in 43 patients developed deep infection. Using clinical and laboratory criteria, patients were classified into four modes of infection: (1) surgical contamination, which included hips (N = 13) with a suspicious clinical course (e.g., persistent elevation of sedimentation rate, early radiographic signs of loosening) without another identifiable source; (2) hematogenous spread, which included septic hips (N = 19) with a temporally related infectious source and an organism consistent with that source; (3) recurrent sepsis, septic failure in a previously infected hip (N = 13); and finally, (4) infection from direct or contiguous spread, which occurred in an additional two patients. Thus the majority of infections were nonsurgical. Patients with surgically acquired infections tended to present earlier, were less likely to require a Girdlestone procedure for salvage, and were more likely to be reimplanted (p = 0.024). The incidence of surgical infections decreased with the use of improved antiseptic techniques. The incidence of hematogenous infection, however, increased during the time that a cohort was followed. Additionally, in a previously septic hip, septic failure may occur as late as seven years after THA.

Actinomycosis is a chronic suppurative and granulomatous bacterial infection characterized by contiguous spread, abcess formation and sinus tract formation. There are four clinical forms according to the lesional site, as 1) cervicofacial, 2) thoracic, 3) abdominal, and 4) disseminated form. Recently, we experienced a case of 54 year-old patient with left mandibular actinomycosis. The pathognomonic findings of actinomycosis is sulfur granule with multiple filaments in Gram-stain and the treatment of actinomycosis is surgical excision of mass or sinus tract with massive antibiotics(esp. Penicillin) therapy for 6 to 12 months.

Neuroblastoma, a malignant tumor of neural crest origin, is the most common extracranial solid tumor in children. In 1971 Evans et al. introduced a clinical staging for neuroblastoma. Over sixty percent of patients present with neuroblastoma beyond stage I. Despite more aggressive therapy there has been only minimal improvement in survival. Since 1978, all patients with neuroblastoma have had CT scanning as part of their initial evaluation at our institution. Children with abdominal neuroblastoma beyond stage I form the basis of this report. Selected cases illustrating the permeative nature of neuroblastoma and the mechanism of direct abdominal spread by CT scanning are presented. The tumor originates in the retroperitoneum and spreads to the abdominal aorta where it gains access to the subperitoneal space via the celiac axis and superior mesenteric artery. These vessels course from the aorta to their ultimate destination within their peritoneal folds. These folds form the interconnecting space (subperitoneal space) between the retroperitoneum and the peritoneal organs. Such scanning is extremely sensitive in detecting neuroblastoma with early infiltration into adjacent tissues and contiguous spread through abdominal spaces. The clinical implications of the permeative nature of neuroblastoma and the mechanism of contiguous abdominal spread are discussed.

Reactive duodenal changes including marked mucosal friability and nodularity were seen endoscopically in a patient with chronic pancreatitis and pseudocysts. These changes simulated the contiguous spread of cancer of the pancreas. In addition, their presence led to an unusual complication of endoscopic retrograde cholangiopancreatography (ERCP), a submucosal injection producing a portal venogram. The presence of marked mucosal friability may be a relative contraindication to performing ERCP in such patients.

Four cases of Aspergillus osteomyelitis are presented and the world literature is reviewed, for a total of 19 cases. Aspergillus osteomyelitis is largely a disease of immunosuppressed hosts, although wound and other infections in "normal" hosts are seen. In children, contiguous spread from an adjacent pulmonary infection is most common, whereas in adults hematogenous spread is the rule. The survival rate in immunocompromised patients is poor, whereas the cure rate is uniform in "normal" hosts. A combined medical-surgical therapeutic approach has been used most often and seems appropriate.

Several points can be made from analysis of the published cases of cutaneous mycobacteriosis and those in our series: 1) mycobacterial cutaneous infections are probably more common than is reported-we collected 34 cases over a 10-year period; 2) most patients with cutaneous infections caused by nontuberculous mycobacteria have significant underlying disease; 3) there is a relative lack of classic histologic features in patients with cutaneous mycobacteriosis, and there appear to be diverse forms of clinical presentation; 4) a high index of suspicion is needed in evaluating patients with possible cutaneous mycobacteriosis, and appropriate cultures must be done to establish the diagnosis. In attempting to provide a practical classification of cutaneous mycobacteriosis which includes infection by nontuberculous mycobacteria, we propose the following grouping, which uses simple terms, avoids confusing nomenclature, and incorporates pathophysiologic descriptions and prognostic information: 1) Mycobacteriosis caused by inoculation from an exogenous source. 2) Cutaneous mycobacteriosis caused by spread from an endogenous source. Contiguous spread originates most often with osteomyelitis, but also occurs through autoinoculation of the perirectal, oral, or vaginal skin as organisms are passed or expectorated from pulmonary or genitourinary tuberculosis. 3) Cutaneous mycobacteriosis caused by hematogenous spread. This group includes lupus vulgaris, nodules and abscesses, and acute disease with hemorrhagic pustules. Some mycobacterioses will be difficult to classify when inoculation or hematogenous spread cannot be ruled out. However, the system of classification we have proposed should help clinicians understand and diagnose the diverse forms of cutaneous mycobacterial infections.

Sixteen patients with primary thyroid lymphoma were studied with computed tomography (CT) and ultrasonography (US), and findings were compared. In 13 of 16 patients, detection of the primary tumor with US and CT were comparable. US was superior in one case, and CT in another. One tumor was not detected with either technique. Thyroid lymphomas appeared as extremely hypoechoic masses intermingled with echogenic structures. Although echogenicity of unaffected thyroid tissue was also low because of coexisting Hashimoto thyroiditis, thyroid lymphomas were relatively well differentiated as markedly hypoechoic areas. Five tumors showed contiguous spread into both thyroid lobes. US and CT were equally sensitive in detection of superficial lymphomatous nodes (seven of 16 cases). CT was superior to US in the definition of tumor extent in two patients with intrathoracic tumor extension and in one with laryngeal invasion. In patients with suspected thyroid lymphoma, CT should be the primary radiologic technique used for diagnosis and staging; US will be useful in local follow-up.

Mycobacteria other than M. tuberculosis have been classified into four groups: (I) photochromogens, (II) scotochromogens, (III) nonchromogens, and (IV) rapid growers (16). Most of the reported cases of nontuberculous mycobacterial disease of the lung were caused by Mycobacterium kansasii (Group I) and the Battey bacillus (Group III) (2–5, 9, 11, 12, 15, 17). Scotochromogens (Group II) (21), and M. fortuitum (Group IV) (1, 7) were responsible for the remaining few. The clinical, pathologic, and radiographic aspects of mycobacteriosis are generally indistinguishable from those of tuberculosis (2, 4, 6, 8, 9, 12, 15, 17, 19). Certain features, however, have been described as more suggestive of mycobacteriosis (4, 5, 15), i.e.: (a) thin-walled cavities with little surrounding reaction, (b) rarity of hilar elevation, (c) lack of diaphragmatic pleural change, (d) infrequency of bronchogenic spread and more evidence of contiguous spread, (e) absence of calcification, (f) lack of nodule formation or heavy fibrosi...

A 58-year-old man developed herpes zoster ophthalmicus with delayed hemiparesis. Temporal artery biopsy confirmed the presence of a vasculitis. Electron microscopy of the temporal artery failed to reveal viral particles. Herpes zoster ophthalmicus with delayed arteritis appeared to be a contiguous spread of vasculitis to the carotid system and not a direct viral invasion.

Vascular complications of tuberculous infections are rare and occur even less frequently in the pediatric population. Tuberculous pseudoaneurysms can occur either as a result of contiguous spread from a neighboring focus—invariably infected lymph nodes—or by hematogenous spread and seeding of acid-fast bacilli that lodge in the adventitia or media via the vasa vasorum. We report a case of turberculous right common iliac artery pseudoaneurysm in a 12-year-old and review the relevant literature.

Primary thyroid lymphoma (PTL) is defined as a lymphoma involving only the thyroid gland or both thyroid gland and neck lymph nodes, without contiguous spread or distant metastases from other areas of involvement at diagnosis. Despite its rarity, PTL should be promptly recognized because its management is quite different from the treatment of other neoplasms of the thyroid gland. In the present study, we report a case of PTL treated by surgery and adjuvant chemotherapy. Otherwise, literature review allowed us to define main characteristics of this located lymphoma.