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| chandru1294 Total Posts: 19 | Posted: Tue Oct 20, 2009 04:03 pm which of the following is not a life threatening complication of diabetes? 1.malignant otitis externa 2.emphysematous pyelonephritis 3.emph............... nephritis 4.emph................ appendicitis 5.rhinocerebral mucormycosis.. pls somebody tell whats the correct answer n explain... |
| Admin Total Posts: 890 | Posted: Thu Oct 22, 2009 12:53 am The most probably answer for this question would be D) Emphysematous Appendicitis. A) Malignant otitis externa - uncommon form of external otitis occurs mainly in elderly diabetics, being somewhat more likely and more severe when the diabetes is poorly controlled. Even less commonly, it can develop due to a severely compromised immune system. Beginning as infection of the external ear canal, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. The hallmark of malignant otitis externa is unrelenting pain that interferes with sleep and persists even after swelling of the external ear canal may have resolved with topical antibiotic treatment. It follows a more chronic course than ordinary acute otitis externa. There may be granulation involving the floor of the external ear canal, most often at the bony-cartilaginous junction. Paradoxically, the physical findings of MOE, at least in its early stages, are often much less dramatic than those of ordinary acute otitis externa. In later stages there can be soft tissue swelling around the ear, even in the absence of significant canal swelling. Treatment requires oral or intravenous antibiotics, diabetes control. Unrecognized and untreated, the infection continues to smolder and over weeks or months can spread deeper into the head and involve the bones of the skull base, constituting skull base osteomyelitis (SBO). The infecting organism is almost always pseudomonas aeruginosa, but it can instead be fungal (aspergillus or mucor). MOE and SBO are not amenable to surgery, but exploratory surgery may facilitate culture of unusual organism(s) that are not responding to empirically used anti-pseudomonal antibiotics. The usual surgical finding is diffuse cellulitis without localized abscess formation. SBO can extend into the petrous apex of the temporal bone or more inferiorly into the opposite side of the skull base. As the skull base is progressively involved, the adjacent exiting cranial nerves and their branches, especially the facial nerve and the vagus nerve, may be affected, resulting in facial paralysis and hoarseness, respectively. If both of the recurrent laryngeal nerves are paralyzed, shortness of breath may develop and necessitate tracheotomy. Profound deafness can occur, usually later in the disease course due to relative resistance of the inner ear structures. Gallium scans are sometimes used to document the extent of the infection but are not essential to disease management. Skull base osteomyelitis is a chronic disease that can require months of IV antibiotic treatment, tends to recur, and has a significant mortality rate. B) Emphysematous pyelonephritis - is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. The condition presents with abdominal pain, septic shock, vomiting, fever, lethargy and confusion. The majority of cases reported are unilateral, occur in patients with diabetes mellitus or urinary tract obstruction, and more commonly affect on the left kidney. EPN was first described in 1898, in association with pneumaturia as a result of gas forming pathogens. The most common pathogen is Escherichia Coli (70%), followed by Klebsiella pneumoniae (29%) and Proteus. These bacteria ferment sugars within the urine producing gases including nitrogen, hydrogen, carbon dioxide, and oxygen. EPN occurs nearly exclusively (90%) in people with diabetes. The exact pathophysiology of EPN is still unclear. This is evidenced on the observation that UTIs are very common in diabetic patients, and only a small proportion of these patients develop EPN. The factors that predispose to EPN in people with diabetes may include uncontrolled diabetes, high levels of glycosylated hemoglobin, and impaired host immune mechanisms caused by local factors such as renal tract obstruction (tumours or lithiasis). With regard to imaging the AXR, although reported as normal, demonstrated gas in the collecting system of the right kidney and a calculus at the PUJ. In the acute abdomen, the AXR should specifically be reviewed to exclude signs of all general surgical diagnoses, as well as vascular (aneurysms) and urological differential diagnoses. Renal USS can confirm the presence of EPN in approximately 80% of cases whereas CT is 100% sensitive. Thus, a CT scan is mandatory to diagnose EPN if the index of suspicion is high. The most recent CT classification of EPN is described by Huang et al, with minor adjustments from the previously proposed classification by Michaeli et al (1984). It essentially describes the anatomical location of gas on CT scan: • Class 1 – Gas confined to the collecting system • Class 2 – Gas confined to the renal parenchyma alone • Class 3a – Perinephric extension of gas or abscess • Class 3b – Extension of gas beyond the Gerota fascia • Class 4 – Bilateral EPN or unilateral EPN with a solitary kidney It is now largely accepted that nephrectomy is the treatment of choice in most patients with EPN. When treated with antibiotics alone, EPN is associated with a high mortality rate (40%). Huang et al concluded that Class 1 and Class 2 EPN could be managed with percutaneous drainage and antibiotics. In class 3 and class 4 EPN, the presence of fewer than two risk factors (thrombocytopenia, acute renal failure, stupor/coma and shock) indicated that percutaneous drainage and antibiotics could also be used (successful in less than 64% of cases). However, in the presence of three or more of the above risk factors, nephrectomy yielded better results. Mortality rates were 15–20% in two other case series in which nephrectomy was the treatment of choice. C) Emphysematous nephritis - Emphysematous pyelonephritis is a severe necrotizing form of acute multifocal bacterial NEPHRITIS that results in the presence of gas forming organisms in the renal parenchyma. D) Emphysematous appendicitis - Intraluminal appendiceal air is seen in 57% of normal appendices and 31% of cases of appendicitis on appendiceal CT and is a nonspecific finding when taken in isolation. Gangrenous (Emphysematous) appendicitis is associated with an ectopic appendix, diagnostic delay, perforation, and postoperative antibiotic therapy. E) Rhinocerebral mucormycosis - is a rare opportunistic infection of the sinuses and brain caused by saprophytic fungi. The infection can rapidly result in death. Rhinocerebral mucormycosis commonly affects individuals with diabetes and those in immunocompromised states. |