PMC6599410_01
Patient with Crouzon Syndrome, with cranio-cervico-facial involvement after a surgical procedure of cervicofacial advancement whit septic shock and acute and chronic osteomyelitis. A) Bilateral areas of ecchymosis were observed in the cervico-maxillary region. B) Necrotic areas in the cervical, frontal, temporal and occipital regions. C) Infected area with Pseudomonas aeruginosa. D) Once the infection was controlled after multiple surgical lavages and debridation, broad spectrum antibiotics, VAC and hyperbaric oxygen the skin grafts were placed. E) The patient was discharged from the hospital. F) Bone scintigraphy.- the bone scan images showed abnormal increased uptake of 111In in the right temporal region.
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Indurated skin and violaceous and well delimited lesions were noticed in some areas with scab formation (Fig. 1A). Over the next 48 h, necrotic areas developed in the occipital, frontal, parietal, cervical and upper back regions (Fig. 1B), a new head computed tomography scan of the head showed soft tissue edema and a subgaleal fluid collection with defined borders. In order to cover the skull and because of a very large uncovered area, an artificial skin graft was placed in the temporoparietal area, where after few days an infection developed presenting a green secretion under the graft where Pseudomonas aeruginosa was isolated, ciprofloxacin was added to the treatment according to the sensitivity pattern (Fig. 1C). The antibiotics, surgical lavages, VAC and hyperbaric oxygen continued until the cranial area was clean and autologous skin grafts from the leg were placed in the skull until the whole skull was covered with tissue and skin (Fig. 1D). After 2 months of intensive care, the patient was discharged from the hospital with oral ciprofloxacin to complete the treatment for cranial osteomyelitis in good general conditions (Fig. 1E). Technetium99 was performed; the bone scan images showed an abnormal increased uptake of the Indium111 in the right temporal region of the skull, confirming chronic osteomyelitis (Fig. 1F). The patient was admitted to the hospital for surgical resection of the affected bone, surgical lavage and skin graft; 2 strains of multi-resistant Pseudomonas aeruginosa with different patterns of sensitivity were isolated from the lesion; one was only sensitive to tobramycin which was not available in Mexico and the other one was sensitive to piperacillin/tazobactam.