Depp's Daughter Recovering After Foot Puncture Infection

The Associated Press is reporting that Johnny Depp's 7-year-old daughter with longterm partner Vanessa Paradis is "doing much better" after a nine day hospital stay in London.


Several articles report that Lilly Rose was originally admitted for "blood poisoning" after stepping on a rusty nail at Depp's country home.


'Blood poisoning?' Another one of our favorite media pseudo-medical phrases. Why can't they use bacteremia, or infection, or even blood infection.


We decipher "blood poisoning" to mean bacterial infection disseminated to the blood causing a sepsis like picture. And considering the circumstances, i.e. rusty nail, one would have to assume that the offending bug would be Clostridium tetani, or tetanus. Or is it?


Actually, probably not. While more than 90% of pedal puncture wounds result from stepping on a nail. The most common organisms implicated in penetrating wounds are Staph aureus, beta-hemolytic streptococci, and then various anaerobic bacteria. Also, Pseudomonas aeruginosa is often responsible for infection when the injury is due to object penetration through shoes and socks.


Importantly, puncture wounds have the capability to infect deep spaces of the foot, including bones, joints, tendons, and deep fascia, and serious complications can arise. Therefore, the depth of penetration is hugely important.


The signs of more extensive injury are those typical of any infection, i.e. redness, warmth, pain, and swelling. If the offending object is still partly in there, e.g. broken glass or sea shell, it must be removed and the wound must be extensively debrided. Empiric ABx should be started to cover the most common bugs, i.e. S. aureus but anti-pseduomonals should be strongly considered as psudomonal osteomyelitis/-chondritis can be catastrophic.


It is our suspicion that Depp's daughter probably was treated inadequately or conservatively at first or perhaps even his the injury from her parents as kids can do and then presented 2-3 days after the injury with a warm, red, swollen foot. Imaging studies were performed for sure which included plain old x-rays to look for air and possibly a CT. CBC, Chem, and ESR were quite important in documenting infection and blood cultures were probably being sent every time the little one spiked a fever.



When she manifested systemic evidence of infection, broad spectrum IV antibiotics were certainly started and the wound was opened, any pus was removed, and the wound was most likely left open to heal on its own rather than sew it shut again.


Typically, in systemic bacterial infection, i.e. bacteria in the blood (bacteremia) patients will experience signs of sepsis: hypotension, tachycardia, fever, increased WBC. In addition to stroing anti-microbial therapy, IV fluids were probably used and maybe even pressors for blood pressure support.


This is a very scary situation for a little girl and her parents. We are happy to hear that she is out of the hospital and recovering. An interesting infectious disease topic nevertheless which proves our mantra: It sucks to be an interesting patient, but it's great to have an uneventful recovery.







Baldwin G, Colbourne M: Puncture wounds. Pediatr Rev 1999 Jan; 20(1): 21-3[Medline].


Patzakis MJ, Wilkins J, Brien WW, Carter VS: Wound site as a predictor of complications following deep nail punctures to the foot. West J Med 1989 May; 150(5): 545-7[Medline].

Deep Chene Thrombosis

Add another item to Dick Cheney's long list of medical issues. In addition to his 4 heart attacks (first being at a sprite 37 yrs of age), 2 bypass surgeries, multiple coronary interventions, popliteal aneurysms, ischemic cardiomyopathy, and subsequent implantation of a cardiac defibrillator - the vasculopath has staved off death yet again.

The cat-like veep has amazing luck or a ridiculously attentive medical staff. Following an around-the-world trip which included more than 60 hrs of air travel, Cheney complained of slight calf pain which elucidated the DVT.

Cheney visited his doc at George Washington University hospital and a duplex revealed the clot, prompting his MD to start him on warfarin. In a statement today, Mr. Cheney’s office said he would be treated with “blood thinning medication for several months.”

We can only assume that Cheney is already on standard anti-platelet therapy, aspirin and Plavix, considering his multiple stent history. Throw in some warfarin for this latest diagnosis and his blood will be "thinner" than Nicole Richie. Speaking of "thin blood", why do we use this euphemism and who came up with it? The blood's viscosity does not change at all. Is it really that hard to explain or understand that platelets help clots to form and these medications prevent the bonding of platelets to each other? It is due time that the media and PR flack start speaking of medical treatments in real terms rather than 3rd grade metaphors. If advertisors can advertise directly to consumers than consumers should understand medical terminology rather than psedo-scientific analogies.

Back to Cheney's hard-to-believe medical history, Dr. Cameron Akbari, a senior vascular surgeon at Washington Hospital Center in the District of Columbia, said Mr. Cheney’s history of heart disease puts him at only “a very slightly increased risk” of developing a deep venous thrombosis.

“Reasons No. 1, 2, 3, 4 and 5 why he developed this are he was on a very long plane ride,” Dr. Akbari said.

Ok. But why does he keep clotting every portion of his vascular bed. I am quite sure that Cheney has had the over-ordered hypercoagulable work-up, but he should also be tested for aspirin and clopidogrel resistance.

To clarify, it is unlikely that the clot lodged in Cheney's left leg is actually sitting in his calf. The vast majority of these thrombi sit in the larger, more proximal venous system. And lastly, Coumadin or Warfarin, will prevent further propagation of this clot but will not dissolve the clot - so the risk of PE is still there all you anti-Chenites.

One more interesting historical note: Warfarin was named in honor of the Wisconsin Alumni Research Foundation who discovered that coumarin, a byproduct of moldy silage, was a potent anticoagulant and the cause of bleeding cows. Warfarin was first registered for use as a rodenticide in the US in 1952, but its true mechanism of action, the inhibtion of vitamin K-dependent cofactors was not elucidated until 1978.

Hepatitis A Scare for Beyonce's Party

An unlucky employee of Wolfgang Puck Catering diagnosed with hepatitis A may have donated his virus to guests at several high-profile functions, including Sports Illustrated's swimsuit issue party attended by Beyonce Knowles and other pseudo-celebs, officials said.

The risk of illness was 'quite low,' but anyone who ate raw food at the magazine's Feb. 14 party was urged to receive a preventive shot by Wednesday, the LA County Department of Public Health said Tuesday.

The affected employee was placed on medical leave, said Carl Schuster, president of Wolfgang Puck Catering.

'We immediately worked to take every precaution to further safeguard our patrons and other employees,' Schuster said in a statement.

Sports Illustrated said in a statement that it was taking the situation very seriously and was working directly with county health authorities.

'We are alerting our guests and staff as quickly as possible to ensure they receive the relevant health warnings,' the statement said.

Hep A (HAV) is usually spread via the fecal-oral route, i.e. infected people share the yellowing virus through food and water that they handle – after touching their ass. It is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection.

To get technical on your ass, (and for those of you prepping for Boards) Hepatitis A is a 27 nm, nonenveloped, icosahedral, positive-stranded RNA virus classified in the Heparnavirus genus of the Picornaviridae. But you knew that.

According to our favorite medical resource, UpToDate.com, community outbreaks due to contaminated water or food have also been described, shellfish being the most popular offender. However, several outbreaks related to consumption of “contaminated” green onions have been reported in the literature.

HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure.

The two most common physical examination findings are jaundice and hepatomegaly, which occur in 70% and 80% of symptomatic patients, respectively. Less common findings include splenomegaly, cervical lymphadenopathy, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.

Laboratory findings in symptomatic patients are notable for marked elevations of LFTs (usually >1000 IU/dL), serum total and direct bili, and alk phos. Typically, ALT is higher than the AST and bilirubin levels above 10 mg/dL are not uncommon.

The diagnosis of acute HAV infection is made by the detection of anti-HAV antibodies in a patient with the typical clinical presentation. Serum IgM anti-HAV is the gold standard for the detection of acute illness.

Because the disease is usually self-limited, the treatment is supportive.

But believe us, it would be a lot more than supportive if one of the celebs turned yellow.