Primary bacterial gluteal pyomyositis: a rare disease in temperate climates presenting as suspected septic arthritis of the hip.

Ghazala CG, Fatone E, Bentley R, Rajeev A
J Emerg Med. 2016 Sep;51(3):319-321

In nations with temperate climates, primary polymyositis is a rare, life-threatening bacterial infection that can mimic various clinical diseases depending on the area involved, leading to delayed diagnosis and management.

We describe a young postpartum woman who presented to the emergency department with hip pain that was initially suspected to be caused by septic arthritis. However, hip arthrocentesis was negative, and a magnetic resonance imaging scan revealed extensive pyomyositis of the gluteal muscles. She underwent surgical debridement and was given parenteral antibiotics with good clinical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We emphasize that cases of pyomyositis in temperate countries are often diagnosed late and therefore delay life- and potentially limb-saving treatment. For patients who present with hip and thigh pain and clinical features of sepsis, pyomyositis should be considered in the differential diagnosis and an early magnetic resonance imaging scan should be performed to confirm the diagnosis and reduce the high morbidity and mortality associated with this emerging disease.

Myxofibrosarcoma of the extremity and trunk.

Ghazala CG, Agni NR, Ragbir M, Dildey P, Lee D, Rankin KS, Beckingsale TB, Gerrand CH
Bone J J 2016; 98-B: 1682-1688

Myxofibrosarcomas (MFSs) are malignant soft-tissue sarcomas characteristically presenting
as painless slowly growing masses in the extremities. Locally infiltrative growth means that
the risk of local recurrence is high. We reviewed our experience to make recommendations
about resection strategies and the role of the multidisciplinary team in the management of
these tumours.

Patients with a primary or recurrent MFS who were treated surgically in our unit between
1997 and 2012 were included in the study. Clinical records and imaging were reviewed. A
total of 50 patients with a median age of 68.4 years (interquartile range 61.6 to 81.8) were
included. There were 35 men; 49 underwent surgery in our unit.

The lower limb was the most common site (32/50, 64%). The mean size of the tumours was
8.95 cm (1.5 to 27.0); 26 (52%) were French Fédération Nationale des Centres de Lutte Contre
le Cancer grade III. A total of 21 (43%) had positive margins after the initial excision; 11
underwent further excision. Histology showed microscopic spread of up to 29 mm beyond
macroscopic tumour. Local recurrence occurred in seven patients (14%) at a mean of 21
months (3 to 33) and 15 (30%) developed metastases at a mean of 17 months (3 to 30) postoperatively.

High rates of positive margins and the need for further excision makes this tumour
particularly suited to management by multidisciplinary surgical teams. Microscopic tumour
can be present up to 29 mm from the macroscopic tumour in fascially-based tumours.

Popliteal artery pseudoaneurysm with secondary chronic common peroneal nerve neuropathy and foot drop after total knee replacement.

Ghazala CG, Elsaid TA, Mudawi A
Ann Vasc Surg. 2015 29(7): 1453.e5-8

Total knee replacements (TKRs) are performed to treat debilitating arthritis and are one of the most routinely performed surgical procedures in the United Kingdom. Complications of infection and deep vein thrombosis are well recognized and managed, whereas neurovascular injuries are rarely reported although should not be disregarded. We report on the case of a 72-year-old man who presented 5 weeks after a TKR with symptoms of a progressively worsening ipsilateral foot drop. A diagnosis of common peroneal nerve neuropathy secondary to the compressive effects of a popliteal pseudoaneurysm was made, and he underwent uneventful patch repair of the pseudoaneurysm. Unique to the literature is the chronicity of the foot drop, which still persisted at follow-up 6 weeks later.

Endovascular management of a penetrating abdominal aortic injury.

Ghazala CG, Green BR, Williams R, Wyatt MG.
Ann Vasc Surg. 2014; 28(7):1790.e9-1790.e11.

Penetrating aortic trauma is associated with high mortality rates. We report the case of a 24-year-old man who presented with a self-inflicted abdominal aortic penetration injury, resulting in a pseudoaneurysm. Rather uniquely, he was managed through prophylactic stenting to his abdominal aorta; this case was also rare in that there were remarkably no associated visceral injuries. Stenting was preferred because of risks of an aortic graft in a young man. A 14-mm Atrium Advanta™ stent was deployed, and angiography confirmed adequate exclusion of the pseudoaneurysm. He had no complications at follow-up.

Functional capacity is significantly impaired in primary biliary cirrhosis and is related to orthostatic symptoms.

Newton JL, Elliott C, Frith J, Ghazala C, Pairman J, Jones DE.
Eur J Gastroenterol Hepatol 2011; 23(7): 566-72.

OBJECTIVE:

To assess patient-reported functional ability and its relationship with symptoms in primary biliary cirrhosis (PBC).

METHODS:

Functional status was assessed in a representative cohort of 75 patients with PBC using the Patient-Reported Outcome Measure Information System Health-Assessment Questionnaire (PROMIS-HAQ) functional assessment tool and was related to both symptom severity at the point of assessment (assessed using the PBC-40 and Orthostatic Grading Scale) and symptom severity change over the previous 4 years. Functional status in the PBC group was compared with primary sclerosing cholangitis (cholestatic liver disease) and community controls.

RESULTS:

Functional impairment at follow-up (PROMIS-HAQ) was substantial in PBC significantly higher than that in both primary sclerosing cholangitis and community controls. PROMIS-HAQ domain scores confirmed that patients with PBC had significant impairment in arising, eating, walking, reach and grip and activity, but not dressing or hygiene. Functional impairment correlated positively with greater PBC-40 Fatigue, Cognitive and Social and Emotional domains and higher orthostatic symptoms. Over 4 years, total symptom burden increased significantly (P=0.03). The predominant factor was rise in Cognitive domain scores indicating worsening cognitive symptoms (P<0.0001). Change in PBC-40 Cognitive, Social and Emotional scores (2005-2009) strongly predicted functional ability in 2009. Multivariate analysis confirmed that PROMIS-HAQ scores were predicted independently by PBC-40 Social and Emotional scores (P=0.02; β=0.3) and orthostatic symptoms (P=0.04; β=0.3).

CONCLUSION:

PBC associates with substantial functional impairment. PBC symptom distribution evolves over time, with cognitive symptoms making ever-greater contribution to overall symptom burden. The major potentially modifiable determinant responsible for the functional impairment appears to be orthostatic symptoms.

Primary biliary cirrhosis is associated with falls and significant fall related injury.

Frith J, Kerr S, Robinson L, Elliott C, Ghazala C, Wilton K, Pairman J, Jones DE, Newton JL.
QJM 2010;103(3):153-61.

BACKGROUND:

Osteoporosis and autonomic dysfunction are prevalent in the autoimmune liver disease primary biliary cirrhosis (PBC). Postural hypotension is one consequence of autonomic dysfunction and is a recognized risk factor for falls, which, alongside osteoporosis could lead to significant injury and fractures.

AIM:

To determine the prevalence and sequelae of falls in PBC and to identify modifiable risk factors.

DESIGN:

Cross-sectional, geographical, population census of PBC and two control groups: primary sclerosing cholangitis and a community dwelling population. Multidisciplinary falls assessment of a representative group of PBC.

METHODS:

Symptom assessment tools, completed by the three cohorts, determined the prevalence of falls, injuries and associated symptoms. Multidisciplinary assessments, adhering to NICE guidelines, identified modifiable fall associations.

RESULTS:

Significantly more of the PBC population had fallen (72% P < 0.001) than both control groups. Fifty-five percent had fallen in the last year (P < 0.001), and 22% more than once in the last year (P < 0.01). Seventy percent of PBC fallers were injured, 27% fractured a bone and 19% were admitted to hospital, all significantly more common than controls. Postural dizziness was significantly worse in fallers (P < 0.001), as were balance (P < 0.001) and lower limb strength (P = 0.002). Lower limb strength was independently associated with number of falls in previous year (beta = 0.184, P < 0.001).

CONCLUSION:

Falls and resultant injury are prevalent in PBC and more common than previously recognized. Addressing postural dizziness, poor balance and lower limb weakness using a multidisciplinary approach has the potential to reduce falls, morbidity and mortality and as a result improve quality of life.