gms | German Medical Science

Objectives: Since traveling around the world is a mass phenomen, the confrontation with exotic and particulary rare symtoms of infections of the hands and upper extremity is inevitable.

Presentation of case: The patient (52 year old man) - with a severe pyarthros oft the right radiocarpal joint with massive destruction of soft tissue and a palmar abscess as well as a severe pyarthros oft the left elbow with neurotmesis N. radialis - was transfered from another hospital after multpile debridement and stabilisation oft the joints with an external fixateur. Secondary diagnoses: Colitis ulcerosa (i.d. 1994, therapy: Mesalazin, Predmisolon 7,5 mg / d), pulmonary sarcoidosis. The pathogen was Nocardia brasiliensis, gram-positive actinomycetes bacteria that causes Mycetoma, which is a chronic, frequently subcutaneous, granulomatous infection that commonly affects the feet. The disease usually occurs in tropical and subtropical areas and is endemic to Latin America, India, and Africa. Long-term infection is associated with multifocal osteomyelitis.

Interventions: The treatment consisted of multiple irrigation and debridement procedures including resection of the affected bone, soft tissue coverage by local rotational flap and the use of i.v. and oral antibiotics: Amikacin 1g 1-0-0-0, AmoxiClav 2,2 g 1-1-1-1, Imipenem 1g 1-1-1-1.

Results: After eradication of infection, intensive ergotherapy was necesseary to regain adequate function of the right hand and left elbow, the neurotmesis of the radial nerve was temporary.

Conclusions: Mycetoma of the upper extremity caused by Norcadia brasiliensis is very rare. Treatment consists of identifying the pathogen and then administrating the appropriate antibiotics and surgical débridement as required. To achive optimal results, interdisciplnary communication and treatment is mandatory. In some cases, amputation is necessary. Super-infection with other types of bacteria can result in sepsis and death.