[Acute genital gangrene (Fournier's gangrene)].
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Aged↗
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[Gangrene of the gall bladder. A case of gall bladder gangrene due to embolism of the hepatic artery (author's transl)].
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Acute Disease↗
Harlequin gangrene: a case report of unilateral gangrene of the leg and arm with myxedema, septicemia and disseminated intravascular coagulation.
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Arm↗
[Current aspects of gas gangrene, apropos of 47 cases collected over a 3-year period (1974-1976)].
On the basis of 47 cases of gas gangrene collected over the three year period between 1974 and 1976, the authors review the circumstances surrounding its development, the clinical features and the prognosis of the disorder which remains grave despite a well-defined therapeutic protocol combining surgery, antibiotics and hyperbaric oxygen. There would appear to be a real resurgence of the disease at the present time. Post-traumatic and surgical aetiologies predominate, giving rise to two types of gangrene: clostridial gas gangrene secondary to contamined wounds, with a quasi-constant vascular element, affecting predominantly the limbs, and nonclostridrial gangrene, the increasing prevalence of which involves essentially spetic abdomino-pelvic surgery. In the light of this study, prognosis would appear to be related to the underlying terrain in which the gangrene occurs, to certain features of the clinical picture and, above all, to the possibilities of early application of the complete therapeutic protocol. Strict prophylactic measures would alone seem capable of preventign the worrying increase in the number of cases of gas gangrene.
Adult↗
[Clostridium infections with and without manifest gas gangrene. Report on 77 infections in 76 patients].
Systematic microbiological research and correlation of the histopathological findings obtained from random autopsies revealed 23 hitherto undetected clostridial infections including 11 cases of gas gangrene, 4 of septicemia, 3 of bacteremia, and 5 other clostridial infections. The knowledge gained from this study led to clinical diagnosis of several cases of gas gangrene which were confirmed bacteriologically and histologically. Of 8 hospital patients who were thus diagnosed in this surgical clinic, 7 recovered, including a case of gas gangrene of the abdominal wall. The problem in gas gangrene is timely clinical diagnosis. Little is known about gas edema illnesses which are not traumatically conditioned. Recognition of the local and general symptoms (local, violent, yet inappropriate pain in the wound, "unexplained" postoperative secondary bleeding, appearance of tachycardia wholly unrelated to the patient's temperature, sudden shock, rapid deterioration of patient's general condition, jaundice and rise in CPK) makes it possible to diagnose postoperative gas edema in time. 77 infections with isolation of clostridia, seen in 76 patients, are reported. On the basis of clinical and histopathological criteria they have been classified as follows: 22 cases with gas gangrene (clostridial myonecrosis), 16 cases with anaerobic cellulitis, 20 wound infections, 8 cases of septicemia, 5 of bacteriemia, 1 of tetanus, and 5 other clostridial infections.
Adolescent↗
Gas gangrene: review of 34 cases.
High morbidity and mortality continue to result from gas gangrene, despite the use of aggressive modes of therapy. Between 1967 and 1973, 34 patients with gas gangrene were seen at the University of Maryland Hospital; 11 (32.3%) died. Clostridium perfringens was recovered from the wounds in 79% of the cases and from the blood in 15%. Eighty-five percent of the wounds contained one or more organisms in addition to C perfringens, with as many as seven organisms recovered from some wounds. Twenty-nine patients received hyperbaric oxygen treatments, as well as the more conventional antibiotic drugs; it was not possible to assess the value of this added therapy. Gangrene of the abdominal wall resulted in a higher (50%) mortality than gangrene of an extremity (24%). Presence of normal or depressed white blood cell counts, decreased platelet counts, and abnormal renal or liver functions all denoted a poor prognosis.
Adolescent↗
Nonclostridial gas gangrene. Report of 48 cases and review of the literature.
Gangrenous lesions accompanied by evidence of subcutaneous gas usually are diagnosed as "clostridial gas gangrene." The occurrence of nonclostridial gas gangrene has been infrequently reported and is thought to be relatively rare. Review of 278 admissions of diabetic patients with orthopedic vascular problems disclosed a 17% (48 patients) incidence of nonclostridial gas infections and a 3% (one patient) occurrence of clostridial gas gangrene. Clinical characteristics ranged from severe to benign toxicity. Appreciation of the causative organisms (usually mixed Gram-negative rod and enterococcus) of this syndrome is essential, especially in the diabetic patient, since appropriate antibiotic therapy and surgery can result in a low mortality (4%) and a high incidence (80%) of ambulatory, independent patients.
Acute Disease↗
Paracentesis and lavage for diagnosis of intestinal gangrene in neonatal necrotizing enterocolitis.
A study to evaluate peritoneal fluid as an index of intestinal gangrene in infants with necrotizing entercolitis (NEC) was begun in 1974. Twenty samples of peritoneal fluid were obtained by paracentesis or lavage from 15 infants with nonperforated NEC. A brown color in the peritoneal fluid was noted in all 8 patients found to have intestinal gangrene at subsequent operation. Gram stain showed bacteria in 6 of these 8 patients and bacterial cultures were confimatory in all but one. In 12 samples of peritoneal fluid in patients without intestinal gangrene, the fluid was straw-colored or pink and Gram stain showed no bacteria. The decision to operate on an infant with intestinal gangrene and impending perforation may be aided by analysis of the peritoneal fluid.
Ascitic Fluid↗
Marlex mesh in gas gangrene.
Clostridial gas gangrene is a well recognized complication of traumatic and surgical wounds, and is associated with an overall mortality rate of 25% (5, 22). Gas gangrene of a limb results in a mortality rate approximately half that of gas gangrene of the trunk (4, 7, 8, 9, 11, 12, 13, 15, 16, 19, 24). Radical debridement and antibiotic therapy or high amputation of involved limbs are accepted traditional approaches to the problem. The role and value of hyperbaric oxygenation (OHP) remains controversial despite intense study over the past few decades. Patients with gas gangrene involving all layers of the abdominal wall as well as an extremity pose major resuscitative, operative, supportive, and rehabilitative problems. A report is presented of two such patients with comments on the therapeutic modalities employed.
Abdominal Injuries↗
[Nitrosoguanidine-induced attenuated Clostridium perfringens type A mutant in gas gangrene].
A fully virulent classical type A strain of Clostridium perfringens was treated during its logarithmic growth phase with 100 mug/ml of N-méthyl-N'-nitro-N-nitrosoguanidine, the bacteria being exposed to the mutagen for 30 min at 37 degrees C in a phosphate buffer adjusted to pH 6.2; after treatment the suspension was streaked on sheep blood agar plates, and colonies that showed an alteration in the theta-hemolysis pattern were selected for isolation. The virulence of two mutants, thus altered in their theta-hemolysis, was studied. One, designated LNG 5, was still capable of killing most of the inoculated guinea pigs in less than 24 h with all the clinical, macroscopic, and bacteriological signs of gas gangrene; however, histological sections showed that tissue damage was not as marked as with the wild strain. On the contrary, the second mutant, labelled LNG 11, was completely avirulent as far as gas gangrene was concerned; indeed, the injection of fluid cultures containing 1 times 10(8) - 10(9)/ml viable bacteria, was not followed by any clinical, bacteriological, or histological signs of gas gangrene. However, strain LNG 11 did give rise to a firm swelling of the inoculated thigh with a corresponding acute inflammatory response of the connective tissue, although the muscle fiber was unaltered. Eventually, this local reaction was followed by necrosis of the skin accompanied by an acute or subacute inflammation with fibroblastic proliferation. These superficial lesions healed spontaneously. They could not be reproduced with crude filtrate alone or with washed bacilli. Strain LNG 11 was therefore considered to be soletly an attenuated strain since, although avirulent as far as gas gangrene is concerned. it is still capable of producing low levels of toxic material. This appears to be the first time that such a strain of C. perfringens type A has been obtained by nitrosoguanidine treatment.
Animals↗
Peripheral gangrene as the initial manifestation of polycythaemia vera.
Peripheral gangrene is an uncommon initial manifestation of polycythaemia vera, especially if it is not associated with occlusive disease of larger vessels of the limbs. A 57-year-old Chinese male with polycythaemia vera presenting with recurrent gangrene of the toes is described. Absence of occlusive arterial disease of larger vessels was shown by the presence of peripheral pulses. The digital gangrene was due most probably to impaired perfusion resulting from hyperviscosity. Correction of hyperviscosity in this case by venesection and treatment with the cytotoxic drug, busulphan, not only corrected the polycythaemia vera, but also cured the digital gangrene.
Gangrene↗
[Experiences in the treatment of gas gangrene in accident surgery (author's transl)].
It is reported on 105 patients with gas gangrene. 68 cases were caused by accident, 7 of them died. Only the gas chromatographic identification of toxin in blood was needed to assure diagnosis. In 46 cases of gas gangrene localized in the lower limbs, amputation was necessary in 12 cases; in 5 cases gangrene in the lower leg, in 7 cases in the thigh. In ten cases of disease in the upper limbs three amputations were necessary. If OHP is implicated as soon as possible in the therapy of gas gangrene, in most cases local necrectomy with maintenance of the limb will be sufficient, if amputation was necessary, it was localized in the region of infection.
Adolescent↗
Conversion of chronic staphylococcal mastitis to acute gangrenous mastitis after neutropenia in blood and bone marrow produced by an equine anti-bovine leukocyte serum.
A stock strain of Staphylococcus aureus of mastitis origin, characterized by alpha-, beta-, and delta-toxins, was used to produce chronic mastitis of 20 to 300 days' duration in 6 lactating mammary quarters of 4 cows. Early acute Streptococcus agalactiae mastitis was produced in 1 additional mammary quarter of 1 cow. Equine anti-bovine leukocyte serum (EABLS) was administered to all cows by continuous intravascular drip for 12 to 32 hours. Neutropenia in blood and partial depletion of neutrophil reserve in bone marrow were produced. Chronic subclinical staphylococcal mastitis in 2 quarters of 1 cow changed to gangrenous mastitis by the 40th hour after EABLS administration and led to death of the cow. The disappearance of neutrophil leukocytes from the milk was followed by uninhibited multiplication of S aureus. Probably, staphylococcal leukocidins accelerated the destruction of neutrophils in the milk as S aureus multiplication became intensified. In another quarter of the same cow that was infected with Str agalactiae, neutrophil leukocytes were present in milk as long as 3 days after their disappearance from blood and bone marrow. This may give some indication of the extravascular life-span of the neutrophil in the udder in mastitis. The 2nd cow died at the 16th hour from the start of EABLS administration and at a time when gangrenous mastitis was in the initial stages of development. The S aureus-infected quarters of the 2 remaining cows did not become gangrenous. Administration of EABLS to these 2 cows did not significantly reduce the numbers of neutrophil leukocytes entering the milk of the 3 S aureus-infected quarters. It is concluded that continuous diapedesis of neutrophil leukocytes into the milk in chronic staphylococcal mastitis protects the gland against the development of gangrenous mastitis in the presence of a strain of S aureus capable of alpha-toxin production.
Agranulocytosis↗
[Studies of oral microbiogenesis. II. Significance of staphylocci present in periodontal lesions, pulp gangrene and in the alveolus after tooth extraction].
A study was carried out on the properties and significance of staphylococci isolated from the alveoli after dental extraction (12 strains), from parodontal pus (19 strains) and pulpar gangrene (15 strains). By their frequency, staphylococci of the Staphylococcus aureus have an etiologic significance in pulpar gangrene. Of particular importance for the diagnosis and epidemiology was the predominance of lysotype 80 among the staphylococci isolated from pulpar gangrene and lysotype 77 in healthy carriers. In 2 of 11 patients the coexistence of the same lysotype was found in the pulpar gangrene and nasal secretion.
Alveolar Process↗
Gas gangrene and related infection: classification, clinical features and aetiology, management and mortality. A report of 88 cases.
The clinical features of gas gangrene and related infection seen in 88 patients over a 10-year period are described. It is suggested that clostridial infection could be simply classified as either 'gas-forming' or 'non-gas-forming'. The gas-forming group represents the more severe form of infection. Non-clostridial gas gangrene may present in a variety of forms. The anaerobic streptococcus was the organism most frequently responsible, but these cases were indistinguishable from clostridial infection on clinical grounds. The treatment of gas gangrene in this series of patients is reported. Emphasis is laid on the importance of adequate prophylaxis with penicillin in patients at risk. The value of antibiotics in established infection remains equivocal. The evidence supporting the value of hyperbaric oxygen therapy is assessed and an attempt made to quantify the response to this treatment. Benefit was apparent in only a proportion of patients. A favourable response indicated clostridial infection and guaranteed immediate survival. Extensive debridement or amputation is unnecessary in this group. No response following hyperbaric oxygen therapy indicated widespread mixed clostridial and non-clostridial infection, or infection due to organisms other than clostridia. Urgent and extensive debridement and amputation remain the predominant measures in this group.
Adolescent↗
A current appraisal of problems with gangrenous bowel.
Gangrenous bowel most often results from hernia, adhesions and mesenteric insufficiency. The overall mortality rate for 151 cases was 37%. This figure was 20% for hernia, 23% for adhesions and 74% for mesenteric insufficiency. In the latter category where bowel resection was feasable the mortality rate was 40%. Other causes of bowel gangrene had a mortality rate of 28%. In many instances the pathophysiologic processes were of such a nature that current medical expertise has not reached a level of development to effectively cope with the situation. There were, however, a significant number of cases where survival may have been achieved had it not been for deficiences on the part of the patient, the primary health care personnel or those in attendence at the referral center. The basic keystone for a successful outcome in the management of patients with the gangrenous bowel problem is early surgical intervention. All will be lost if patient exposure to this source of lethal toxins is allowed to proceed to an irreversible stage. Liberal antibiotic administration probably postpones the arrival of intractable hypotension. Other factors which can be expected to improve the survival rate include minimization of technical errors, repair of incidental hernias, elemination of dependence upon nasogastric tubes for the definitive management of patients with complete bowel obstruction (with one or two exceptions), and a firm commitment to the diligent pursuit and early definitive management of postoperative complications.
Anti-Bacterial Agents↗
Gangrene of toes with normal peripheral pulses.
Ten patients with pregangrenous and gangrenous changes of the toes in the presence of normal peripheral pulses are described. In the absence of diabetes this is an uncommon condition and is only rarely reported upon in the literature. Four patients had non occlusive arteriosclerotic changes in large arteries; three suffered from thrombocytosis and one from polycythemia vera; one patient had a monoclonal gamopathy and one was exposed to cold three months before the onset of gangrene. None of these patients smoked regularly. Severe pain usually preceded the gangrene. The process did not progress proximally in any patients, and in those who underwent toe amputations the healing was uneventful. Vasodilators and low-molecular dextran were not effective. Lumbar sympathectomy was performed in three patients, also with no effect on the course of the disease. Treatment of hematological disorders gave relief in three patients. Proximal arteriosclerotic changes should be corrected if possible to eliminate a source of emboli. In two patients anti-platelet aggregation agents provided relief. Toe amputation should be conservative and performed when definite demarcation appears between necrotic and viable tissue. This condition has a benign prognosis.
Adult↗
Gangrene following intra-arterial injection of procaine penicillin.
Irreversible ischaemic gangrene of the upper limb developed in a one-year-old child after an unintentional intra-arterial injection of procaine penicillin. The hand needed amputation. Arterial embolization phenomenon along with intense vasospasm appears to have been responsible for this rare complication. Unintentional intra-arterial injection of penicillin intended for intra-muscular use may lead to disastrous consequences. Regional tissue necrosis has been described previously but ischaemia leading to gangrene of an extremity has not been reported. The following is a case report of a child who developed such a gangrene in his hand which had to be amputated.
Adolescent↗