imaging of fulminant infections in diabetic patients
TRANSCRIPT
![Page 1: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/1.jpg)
Imaging of fulminant Imaging of fulminant infections in diabetic infections in diabetic
patientspatients
Dr/Ahmed BahnassyDr/Ahmed Bahnassy
Assistant Professor of RadiologyAssistant Professor of Radiology
College of Medicine- Qassim College of Medicine- Qassim UniversityUniversity
![Page 2: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/2.jpg)
Diagnostic considerations in Diagnostic considerations in fulminant infections in diabetic fulminant infections in diabetic
patients.patients. Low immuneLow immune state of these patients. state of these patients. Susceptibility to infections ..including Susceptibility to infections ..including
fungifungi, and virulent , and virulent gram negativegram negative organismorganism
ExtensionExtension to surrounding soft tissues to surrounding soft tissues and bones .and bones .
Similarity to Similarity to malignantmalignant diseases . diseases . Potential Potential lethal outcomelethal outcome..
![Page 3: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/3.jpg)
Therefore :diagnostic evaluation of Therefore :diagnostic evaluation of an infection in diabetic patient is an infection in diabetic patient is three folds:three folds:
1.To locate the primary site of 1.To locate the primary site of infection.infection.
2.To study the local extension of this 2.To study the local extension of this infection.infection.
3.To suggest the causative organism 3.To suggest the causative organism to take into consideration its to take into consideration its behavior and its appropriate behavior and its appropriate treatment .treatment .
![Page 4: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/4.jpg)
I-Head and neck I-Head and neck infectionsinfections
![Page 5: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/5.jpg)
A-Malignant Otitis ExternaA-Malignant Otitis Externa
Severe life threatening infection of Severe life threatening infection of external auditory canal and surrounding external auditory canal and surrounding tissues.tissues.
Most common organism is Pseudomonas Most common organism is Pseudomonas AeruginosaAeruginosa
C/O: unrelenting C/O: unrelenting otalgia,headache.purulent otorrhea otalgia,headache.purulent otorrhea unresponsive to topical antibiotics.unresponsive to topical antibiotics.
Location : at bone cartilage junction of Location : at bone cartilage junction of EAC.EAC.
![Page 6: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/6.jpg)
Extension of infectionExtension of infection
Inferiorly into soft issues inferior to Inferiorly into soft issues inferior to temporal bone, parotid space and temporal bone, parotid space and nasopharyngeal masticator space nasopharyngeal masticator space
![Page 7: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/7.jpg)
Posteriorly into mastoidPosteriorly into mastoid
![Page 8: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/8.jpg)
Anteriorly into temporomandibular Anteriorly into temporomandibular joint .joint .
![Page 9: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/9.jpg)
And Medially into petrous apexAnd Medially into petrous apex
![Page 10: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/10.jpg)
Mucormycosis is an Mucormycosis is an aggressive, opportunistic aggressive, opportunistic infection caused by fungi .infection caused by fungi .
In individuals who are In individuals who are immunocompromised, immunocompromised, germination and hyphae germination and hyphae formation occur, and this formation occur, and this allows the organism to allows the organism to invade the patient's blood invade the patient's blood vessels. vessels.
B-MucormycosisB-Mucormycosis
![Page 11: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/11.jpg)
Extension of infectionExtension of infection
![Page 12: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/12.jpg)
Sinus Mucormycosis with Sinus Mucormycosis with orbital extensionorbital extension
![Page 13: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/13.jpg)
Pterygopalatine fossa Pterygopalatine fossa extensionextension
![Page 14: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/14.jpg)
Intraorbital Extension Intraorbital Extension
![Page 15: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/15.jpg)
Intracranial extension Intracranial extension
![Page 16: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/16.jpg)
cavernous sinus Thrombosis cavernous sinus Thrombosis
![Page 17: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/17.jpg)
C-Other fungal infections -C-Other fungal infections -Sinus AspergillosisSinus Aspergillosis
![Page 18: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/18.jpg)
D-Orbital infectionsD-Orbital infections
Orbital infections most often occur Orbital infections most often occur secondarily to an underlying paranasal secondarily to an underlying paranasal sinusitis; The two paranasal sinuses sinusitis; The two paranasal sinuses most often involved in orbital infections most often involved in orbital infections are the are the ethmoid and maxillary sinusesethmoid and maxillary sinuses. . Spread of infection from the sinuses to Spread of infection from the sinuses to the orbit may occur directly through the orbit may occur directly through extension via the osseous structures or extension via the osseous structures or indirectly through the valveless venous indirectly through the valveless venous plexus surrounding the orbit and plexus surrounding the orbit and paranasal sinuses . paranasal sinuses .
![Page 19: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/19.jpg)
Subperiosteal abscess Subperiosteal abscess
Infection from the sinus may extend Infection from the sinus may extend into and involve the subperiosteum, into and involve the subperiosteum, intraconal and extraconal spaces, intraconal and extraconal spaces, and the globe. and the globe.
A subperiosteal abscess (SPA) results A subperiosteal abscess (SPA) results from the development of purulent from the development of purulent material between the orbital bones material between the orbital bones and periorbita. and periorbita.
![Page 20: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/20.jpg)
Location of infection:Location of infection: Preseptal Preseptal =periorbital =periorbital
soft tissue.soft tissue. Subperiosteal Subperiosteal ;periph;periph
eral =eral =extraconal extraconal fat;extraocular fat;extraocular muscle;centralmuscle;central =intraconal fat;=intraconal fat;optic optic nerve nerve complexcomplex ; ;globe;lacriglobe;lacrimal glandmal gland . .
![Page 21: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/21.jpg)
II-Chest II-Chest InfectionsInfections
![Page 22: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/22.jpg)
A-AspergillosisA-Aspergillosis
Pulmonary aspergillosis is a spectrum of Pulmonary aspergillosis is a spectrum of mycotic diseases caused by mycotic diseases caused by AspergillusAspergillus species, usually species, usually Aspergillus fumigatus.Aspergillus fumigatus. This intensely antigenic and ubiquitous This intensely antigenic and ubiquitous soil fungus is commonly found in the soil fungus is commonly found in the sputum of healthy individuals. However, sputum of healthy individuals. However, in susceptible hosts, its ability to invade in susceptible hosts, its ability to invade the arteries and veins facilitates its the arteries and veins facilitates its hematogenous spread. hematogenous spread.
![Page 23: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/23.jpg)
FormsForms Pulmonary aspergillosis may take any of 4 forms: Pulmonary aspergillosis may take any of 4 forms: Allergic bronchopulmonary aspergillosis (ABPA) Allergic bronchopulmonary aspergillosis (ABPA)
is caused by a hypersensitivity reaction to the is caused by a hypersensitivity reaction to the fungus . fungus .
Saprophytic aspergillosis, or aspergilloma, is the Saprophytic aspergillosis, or aspergilloma, is the most common form. This form is noninvasive and most common form. This form is noninvasive and involves colonization of preexisting cavities. involves colonization of preexisting cavities.
Chronic necrotizing aspergillosis, also called Chronic necrotizing aspergillosis, also called semi-invasive aspergillosis, is a chronic cavitary semi-invasive aspergillosis, is a chronic cavitary pneumonic illness that often affect patients with pneumonic illness that often affect patients with preexisting chronic lung disease. preexisting chronic lung disease.
Angioinvasive aspergillosis which is often fatal.Angioinvasive aspergillosis which is often fatal.
![Page 24: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/24.jpg)
Aspegillosis :Invasive Aspegillosis :Invasive Aspergillosis -Halo Sign Aspergillosis -Halo Sign
Patchy Patchy consolidations consolidations with with surrounding surrounding area of ground area of ground glass opacity glass opacity describes the describes the halo sign in halo sign in Angio-invasive Angio-invasive form of form of aspergillosisaspergillosis
![Page 25: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/25.jpg)
Angio -invasive Aspergillosis Angio -invasive Aspergillosis with air crescent sign.with air crescent sign.
![Page 26: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/26.jpg)
Semi-Invasive AspegillosisSemi-Invasive Aspegillosis Mild Mild
immunocompimmunocompromiseromise
Consolidation Consolidation ,cavitation ,Pl,cavitation ,Pleural eural thickening ,thickening ,+/-mass +/-mass within the within the cavity )cavity )
![Page 27: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/27.jpg)
III-Abdominal III-Abdominal InfectionsInfections
![Page 28: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/28.jpg)
A-Emphysematous A-Emphysematous cholecystitischolecystitis
Ischaemia +infection Ischaemia +infection with gas producing with gas producing organisms.organisms.
Organism:ClostridiuOrganism:Clostridium Welchii,Ecoli.m Welchii,Ecoli.
1/3 show normal 1/3 show normal WBC.WBC.
Point tenderness is Point tenderness is rarerare due to diabetic due to diabetic neuropathyneuropathy
15% mortality15% mortality
![Page 29: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/29.jpg)
B-Emphysematous B-Emphysematous PyelonephritisPyelonephritis
Emphysematous Emphysematous pyelonephritis (EPN) is pyelonephritis (EPN) is a life-threatening, a life-threatening, fulminant, necrotizing fulminant, necrotizing upper urinary tract upper urinary tract infection associated infection associated with gas within the with gas within the kidney and/or kidney and/or perinephric space. perinephric space.
organisms : organisms : E. coliE. coli (68%), (68%), Klebsiella Klebsiella pneumoniaepneumoniae (9%), and (9%), and Proteus mirabilis.Proteus mirabilis.
![Page 30: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/30.jpg)
C-Emphysematous cystitisC-Emphysematous cystitis
UT infection by gas UT infection by gas forming organism forming organism almost almost pathognomonic of pathognomonic of poorly controlled poorly controlled diabetes .diabetes .
Organism: Organism: E.coli,E.aerogenes.E.coli,E.aerogenes.
CT is the most CT is the most sensitive sensitive examination.examination.
![Page 31: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/31.jpg)
D-Xanthogranulomatous D-Xanthogranulomatous PyelonephritisPyelonephritis
Xanthogranulomatous Xanthogranulomatous pyelonephritis (XGPN) pyelonephritis (XGPN) represents an unusual represents an unusual suppurative suppurative granulomatous reaction granulomatous reaction to chronic infection, to chronic infection, often in the presence of often in the presence of chronic obstruction .chronic obstruction .
Two forms of XGPN are Two forms of XGPN are described, namely, a described, namely, a diffuse or global form diffuse or global form (83-90% of patients) and (83-90% of patients) and a focal form (10-17%). a focal form (10-17%).
![Page 32: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/32.jpg)
a polymicrobial necrotizing fasciitis of a polymicrobial necrotizing fasciitis of the perineal, perirectal or genital the perineal, perirectal or genital areaarea . .
500 reported cases in literature .500 reported cases in literature .
E-Fournier Gangrene E-Fournier Gangrene
![Page 33: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/33.jpg)
Radiological diagnosisRadiological diagnosis
Radiographs can show the presence of soft Radiographs can show the presence of soft tissue gas in patients suspected of having tissue gas in patients suspected of having necrotizing fasciitis.necrotizing fasciitis.
SSonographic evaluation of the scrotum, onographic evaluation of the scrotum, scrotal contents, and surrounding structures scrotal contents, and surrounding structures shows a thickened and oedematous scrotal shows a thickened and oedematous scrotal wall, gas within the scrotal wall, and wall, gas within the scrotal wall, and unilateral or bilateral peritesticular fluid. unilateral or bilateral peritesticular fluid. Subcutaneous gas within the scrotal wall is Subcutaneous gas within the scrotal wall is the sonographic hallmark.the sonographic hallmark.
![Page 34: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/34.jpg)
Radiological findingsRadiological findings
Note gas lucencies Note gas lucencies in scrotal in scrotal subcutaneous subcutaneous tissuetissue
Air loculi seen as Air loculi seen as highly reflecting highly reflecting ring shadows.ring shadows.
![Page 35: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/35.jpg)
ConclusionConclusion
Infections in diabetic patients have Infections in diabetic patients have many many specificspecific considerations in their considerations in their diagnosis.diagnosis.
Their Their extensions extensions increase the increase the seriousness of the condition .seriousness of the condition .
The The potential lethalpotential lethal outcome of these outcome of these cases must prompt a rapid and cases must prompt a rapid and accurate diagnosis .accurate diagnosis .
![Page 36: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/36.jpg)
REFERENCESREFERENCES Al-Abdely HM: Management of rare fungal Al-Abdely HM: Management of rare fungal
infections. Curr Opin Infect Dis 2004 Dec; 17(6): infections. Curr Opin Infect Dis 2004 Dec; 17(6): 527-32[Medline]. 527-32[Medline].
Greenberg RN, Scott LJ, Vaughn HH: Zygomycosis Greenberg RN, Scott LJ, Vaughn HH: Zygomycosis (mucormycosis): emerging clinical importance and (mucormycosis): emerging clinical importance and new treatments. Curr Opin Infect Dis 2004 Dec; new treatments. Curr Opin Infect Dis 2004 Dec; 17(6): 517-25[Medline]. 17(6): 517-25[Medline].
Kontoyiannis DP, Wessel VC, Bodey GP, Rolston KV: Kontoyiannis DP, Wessel VC, Bodey GP, Rolston KV: Zygomycosis in the 1990s in a tertiary-care cancer Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000 Jun; 30(6): 851-center. Clin Infect Dis 2000 Jun; 30(6): 851-6[Medline]. 6[Medline].
McAdams HP, Rosado de Christenson M, Strollo DC, McAdams HP, Rosado de Christenson M, Strollo DC, Patz EF Jr: Pulmonary mucormycosis: radiologic Patz EF Jr: Pulmonary mucormycosis: radiologic findings in 32 cases. AJR Am J Roentgenol 1997 Jun; findings in 32 cases. AJR Am J Roentgenol 1997 Jun; 168(6): 1541-8[Medline]. 168(6): 1541-8[Medline].
![Page 37: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/37.jpg)
Sugar AM: Agents of mucormycosis and related species. In: Sugar AM: Agents of mucormycosis and related species. In: Mandell GL, Bennett GE, Dolin R, eds. Mandell, Douglas and Mandell GL, Bennett GE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 5th Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2005: 2973-ed. Philadelphia, Pa: Churchill Livingstone; 2005: 2973-2984. 2984.
Wingard JR, White MH, Anaissie E, et al: A randomized, Wingard JR, White MH, Anaissie E, et al: A randomized, double-blind comparative trial evaluating the safety of double-blind comparative trial evaluating the safety of liposomal amphotericin B versus amphotericin B lipid liposomal amphotericin B versus amphotericin B lipid complex in the empirical treatment of febrile neutropenia. L complex in the empirical treatment of febrile neutropenia. L Amph/ABLC Collaborative Study Group. Clin Infect Dis 2000 Amph/ABLC Collaborative Study Group. Clin Infect Dis 2000 Nov; 31(5): 1155-63[Medline]. Nov; 31(5): 1155-63[Medline].
Asci R, Sarikaya S, Buyukalpelli R, et al: Fournier's Asci R, Sarikaya S, Buyukalpelli R, et al: Fournier's gangrene: risk assessment and enzymatic debridement gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. Eur Urol 1998; with lyophilized collagenase application. Eur Urol 1998; 34(5): 411-8[Medline]. 34(5): 411-8[Medline].
Dahnert W.: Radiology review Dahnert W.: Radiology review manual.CNS.5thedition,Lippincot,Wiliams&Wilkins;2003:94.manual.CNS.5thedition,Lippincot,Wiliams&Wilkins;2003:94.
![Page 38: Imaging of fulminant infections in diabetic patients](https://reader036.vdocument.in/reader036/viewer/2022070313/554b2edab4c905a2058b4dfa/html5/thumbnails/38.jpg)