Kawasaki disease (KD) is a systemic vasculitis syndrome with a predisposition for infants under four years of age, the cause of which remains unclear. A few cases of KD have been reported in infants undergoing burn treatment. Although toxic shock syndrome toxin-1 (TSST-1) produced by Staphylococcus aureus at the wound site is thought to be involved in the pathogenesis of KD, no case has been reported in which Staphylococcus aureus detected at the wound site was confirmed to be a non-producer of TSST-1. In this study, we report the first case of KD that developed during the treatment of a burn wound, in which the involvement of TSST-1 was ruled out. The patient was an 11-month-old male infant. The patient was admitted to the hospital on the same day of a second-degree burn injury, with a burn area of 10.5% due to exposure to boiling water. The patient was diagnosed with KD and was started on treatment with aspirin and immunoglobulin. Methicillin-resistant Staphylococcus aureus was detected in the wound, TSST-1 production was negative, and the neonatal toxic shock syndrome–like exanthematous disease (NTED) index was low. The patient’s symptoms improved after the start of treatment, and he was discharged from the hospital on the 18th day. Although damage-associated molecular patterns (DAMPs) are considered as a possible cause of the onset of the disease, we were not able to measure them, and this is an issue for the future.
Relationship between the burn area and number of days to KD onset.
Polycythemia vera is a myeloproliferative neoplasm that can cause opposite complications: thrombosis and bleeding. Since arterial or venous thrombosis is often fatal, prevention of thrombogenesis is the main treatment measure for polycythemia vera, both in daily life and perioperatively. However, reports of bleeding are less frequent than reports of thrombosis. Herein, we report a case of polycythemia vera in which significant postoperative bleeding was a perioperative complication. A 72-year-old woman with polycythemia vera had a subcutaneous hematoma after bruising her left lower leg, and was admitted to another hospital. As skin necrosis gradually appeared, the patient was transferred to our hospital. Following debridement and wound bed preparation, we applied a split-thickness skin graft using the right inguinal region as the donor site. After surgery, significant bleeding was observed at the donor and recipient sites, and this persisted until the next morning, which required transfusion of four units of blood. Hemostasis was difficult but finally achieved with strong and firm pressure. The skin graft survived, and the troublesome wound healed. Regarding the perioperative complications of polycythemia vera, not only thrombosis, but also bleeding should be considered. Strict control of patients' hematocrit and platelet count with phlebotomy and/or hydroxyurea as cytoreduction therapy is essential.
Infantile hemangiomas are benign vascular tumors that may require treatment if they cause significant disfigurement or functional disorders such as airway obstruction. Aggressive treatment, such as medication or surgery, is preferred, especially for infantile hemangiomas of the outer nose, which may be associated with tissue defects or deformities. In this case, we performed early reconstruction of an ulcerated extranasal infantile hemangioma based on defective tissues. Although the lesion regressed after propranolol therapy, the septal cartilage and major alar cartilage were partially damaged and the supporting tissue was disrupted. The nasal mucosa and skin were scarred. When the child reached 5 years and 4 months of age, we grafted a rib cartilage as supportive tissue and a free forearm flap as the nasal cavity lining. A median forehead flap surgery was performed for the skin defect in two stages, and the external nasal morphology improved moderately. External nasal reconstruction in children with infantile hemangiomas require reconstruction based on the defective tissue, as in adults. However, the optimal timing of external nasal reconstruction in children remains controversial, and further investigations are required.
(A) The rib cartilage is grafted as the alar margin graft, columella strut, and cap graft. (B) Grafted rib cartilage graft and raised median forehead flap. (C) The nose is covered with the median forehead flap.
A sterile abscess around a prosthesis or perigraft seroma is rare but sometimes occurs in a perigraft after reconstructive surgery. Removal of the causative graft is the favored treatment, but in some cases, this cannot be performed, and there is a reluctance to treat the abscess due to the risk to the patient. Herein, we report a case treated with total aortic replacement and omental flap reconstruction, after which the fistula-forming sterile abscess did not resolve. Major pectoral muscle flap reconstruction around the fistula was then conducted, but this surgery did not improve fistula discharge, and a new fistula appeared at the fragile site of the chest. This outcome suggests that fistula and perigraft repairs are required in such cases.
Cutaneous fistula and perigraft seroma after a negative pressure wound therapy.
Microorganisms infiltrate necrotic tissue over time, resulting in wound infections and odor. However, patients with odorous wounds occasionally cannot obtain adequate wound care regarding the odor owing to their systemic state. Although a variety of conservative or interventional wound treatments have been studied, the strategy for managing and caring for odorous wounds remains unknown. Odor can be reduced by preventing microbial colonization or infections that cause an objectionable odor. As a result, wounds are treated with systemic antibiotics and/or topical exudate-control dressings. The most effective method to eliminate wound odors is wound debridement. However, the debridement of necrotic tissue causing malodor is known to be painful unless performed under local or general anesthesia. This adds to physical and mental strain as well as the risk of interventional treatment as a whole. Therefore, an awareness of the fundamental mechanisms of odorous wounds and establishment of treatment strategies for optimal odor management, including aggressive debridement, is essential. The aim of this brief communication is to describe and suggest interventional odor treatment alternatives, focusing on topical surgical management.
Malodorous foot wounds in a patient with serious heart failure.