tomography scans, PPD, gallium scan, ophthalmological examination, and serum calcium, alkaline phosphatase and angiotensin converting enzyme)- was ...
Journal of the Royal Society of Medicine Volume 84 January 1991 Table 1. Criteria for diagnosis (1) Temperature: >38.90C (2) Rash: erythematous rash (3) Desquamation: palms and soles about 2 weeks later (4) Hypotension and poor peripheral perfusion. (5) Clinical or laboratory abnormalities of at least 3 systems: (i) Gastrointestinal; diarrhoea and/or vomiting at the onset of illness (ii) Hepatic; raised liver enzymes (alanine and aspartate transaminases, triaditis and centrilobular necrosis (iii) Muscular; myalgia and/or raised creatine phosphokinase, arthralgias and synovitis (iv) Renal; raised urea and/or creatinine or pyuria without renal infection, acute renal failure (renal and pre-renal). (v) Cardiovascular; hypotension, shock and cardiomyopathy (vi) Neurological; deteriorating levels of consciousness and seizures (vii) Mucous membranes; ulceration of buccal mucosa, oesophagus, vagina, bladder, conxjunctival injection, subconjunctival haemorrhages and strawberry tongue (6) Negative results on blood and CSF cultures is suggestive in the presence of toxin-producing S. aureus grown from wound/ laceration/nasopharynx. Toxin-producing S. aureus grown from wound/laceration/nasopharynx. (7) No laboratory test is available for confirming the diagnosis of toxic shock syndrome. A significant rise in TSST-I serum antibody in association with clinical manifestation is strong retrospective support for diagnosis
disease, erythema multiformae, leptospirosis and typhus5. The pathogenetic mechanism of toxic shock syndrome is due to production of staphylococcal toxic shock syndrome toxin I(TSST-I). This toxin has been isolated in America and reproduces the disease in animal models6. TSST-I acts as an initiator for the in vivo release of endogenous shock-inducing mediators particularly Interleukin I (IL-I) and tumour
Fournier's gangrene of the scrotum following day case vasectomy
A Patel FRCS J W A Ramsay MS FRCS H N Whitfield MChir FRCS Department of Urology, St Bartholomew's Hospital, West Smithfield, London EC1 7BE Keywords: vasectomy; Fournier's gangrene
In 1883, Alfred Fournier, a French venereologist described five patients with unexplained gangrene of the male genitalia, a syndrome that has since borne his name'.
Case report A 31-year-old man underwent day case vasectomy under local anaesthesia (2% plain lignocaine) after preparation of the skin with aqueous chlorhexidine solution, through a midline incision, at his local hospital. The scrotum appeared red and swollen 3 hours later. The patient had suffered a mild diarrhoeal illness prior to operation. Delayed medical consultation despite the immediate appearances of the wound, allowed a systemic septic illness to become established over the next 48 h. On admission to this hospital there was established Gram-negative septicaemic shock, anuria and uraemia secondary to acute tubular necrosis, and Fournier's gangrene of the scrotum and penis. The patient
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necrosis factor (TNF)7. Anti-TSST-I antibody may be measured and levels greater than 1: 100 are thought to be protective. Antibody levels increase with age and more than 80% of adults 20 years and older have protective levels of antibody. Absence or inability to produce adequate levels of antibody may be an important risk factor in the development of the disease8. Children with endogenous strains of toxin-producing S. aureus and who produce adequate levels of anti-TSST-I antibody may be protected from the disease. References 1 Todd J, Fishaut M, Kapral F, Welch F. Toxic shock syndrome associated with phage group I staphylococcus. Lancet 1978; ii:1116-18 2 Davis JP, Chesney PJ, Ward PJ, et al. Toxic shock syndrome: epidemiologic features, risk factors and prevention. NEngi J Med 1980;303:1429-35 3 MacDonald K, Osterholm M, Hedberg C, et al. Toxic shock syndrome: a newly recognised complication of influenza and influenza-like illness. JAMA 1987;257:1053-58 4 Buchdahl R, Levin M, Wilkins B, et al. Toxic shock syndrome. Arch Dis Child 1985;60:563-7 5 Scully R, Mark E, McNeely B. Case records ofthe Massachusetts General Hospital. N Engl J Med 1986;314 1:302-9 6 de Azavedo J. Animal models for toxic shock syndrome: overview. Rev Infect Dis 1989;II,Supplement I:S205-S209 7 Parsonett J. Mediators in the pathogenesis of toxic shock syndrome: overview. Rev Infect Dis 1989;II,Supplement I: S263-S269 8 Jacobson J, Kasworm E, Daly J. Risk of developing toxic shock syndrome associated with toxic shock syndrome toxin I following non-genital staphylococcal infection. Rev Infect Dis 1989;II,
Supplement I:S8-S13 (Accepted 3 July 1990. Correspondence to Dr S R Hanafiah, Priority Services Unit, South Western Hospital, Landor Road, London SW9)
was admitted to intensive care, where inotropic support was provided, together with continuous arteriovenous haemofiltration. Parenteral antibiotic treatment with metronidazole, benzylpenicillin and Ceftazidime, was commenced prior to emergency radical debridement of the gangrenous tissues (Figure 1). Cardiorespiratory arrest occurred postoperatively, and after successful resuscitation there was pulmonary oedema, adult respiratory distress syndrome and disseminated intravascular coagulation. Histology of the penoscrotal tissues confirmed necrosis of the dermis and subcutaneous tissues, extensive vascular thrombosis and abundant Gram-positive cocci. Bacteriological specimens revealed the presence of (l-haemolytic streptococci. Gentamicin and vancomycin were added to the antibiotic regimen. The patient remained unconscious and required ventilation on the intensive care unit for 2 weeks. During this time, further surgical debridement was performed on four occasions with platelet cover. An EEG carried out for prognostic purposes was grossly abnormal and there was no response to external stimuli. A week later, the patient regained consciousness and the capacity for both speech and purposeful movement. In order to facilitate further dressings and aid skin coverage, a left orchidectomy was carried out, and the right testis was secured in the superficial inguinal pouch while the scrotum and penis were left to granulate. Complete re-epithelialization had occurred by 3 months.
Discussion Many common surgical procedures have been complicated by Fournier's gangrene including herniorrhaphy,
Case presented to Section of Urology, 28 April 1988
0141-0768/91/ 010049-02/$02.00/0 © 1991 The Royal Society of Medicine
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Journal of the Royal Society of Medicine Volume 84 January 1991
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Figure 1. Gangrenous penoscrotal tissue before and after debridement
haemorrhoidectomy, orchidectomy, circumcision and transrectal prostatic biopsy. Only two cases have been reported following vasectomy2'3 and only one of these required surgical intervention2. The formation of a scrotal haematoma is a recognized complication of vasectomy. In this case, the potential source of faecal pathogens was the patient's intercurrent diarrhoeal illness. Aerobic and anaerobic organisms on the perineal skin colonized the wound and subcutaneous tissues, spreading along loose fascial planes. The subsequent explosive onset of the severe toxaemic illness that ensued, and the rapid progression to gangrene, are consistent with Fournier's original description in 1883. Regular surgical debridement was maintained in spite of an apparently poor outlook in the presence of maior complications. These included cardiorespiratory arrest, adult respiratory distress syndrome, disseminated intravascular coagulation and acute tubular necrosis, requiring both dialysis and ventilatory support. In the presence of EEG changes which suggested little cortical brain activity or
response to external stimuli, this management policy was rewarded by the patient's eventual recovery. This case illustrates a rare but potentially fatal complication of day case local anaesthetic vasectomy. Patients undergoirg such procedures should be carefully assessed to exclude both those with scrotal or perineal lesions (boils and pustules) due to the risk of Staph. pyogenes infection, and those with intercurrent illnesses.
Gastric sarcoidosis
examination, electrocardiogram and chest radiograph were unremarkable. However, laboratory evaluation revealed a macrocytic anaemia (Hct=31.7%; MCV=98) with a low vitamin B12 level (less than 10 pg/ml). The Schilling test was compatible with pernicious anaemia (less than 1% excretion in 24 h) and normalized with the administration of intrinsic factor. Upper gastrointestinal barium study showed narrowing ofthe distal half ofthe stomach with lack of distensibility. Gastroduodenoscopy revealed prominent folds in the gastric antrum with pyloric friability and gastritis. Gastric biopsies contained acute and chronic inflammation and multiple non-caseatinggranulomata and were consistent with a diagnosis of sarcoidosis (stains for acid-fast bacilli and fungi were negative and no malignant cells were seen). Further evaluation of extent of disease (including colonoscopy, abdominal sonogram, computed tomography scans, PPD, gallium scan, ophthalmological examination, and serum calcium, alkaline phosphatase and angiotensin converting enzyme)- was unremarkable. The patient was presumed to have sarcoidosis involving only the stomach resulting in pernicious anaemia. The patient was begun on prednisolone therapy (40 mg orally daily initially 0141-0768/91/ for 6 months, followed by tapering doses over the next 010060021$02.00/0 1991 3 months). Re-evaluation at 9 months revealed a normal upper gastrointestinal barium study but a persistent- -The Royal macrocytic anaemia. Steroid therapy was discontinued and Society of Medicine vitamin B12 injections initiated.
R F Teichman MD MPH Group, Queens, New York P W Brandt-Rauf MD DrPH New York, USA
La Guardia Medical
Columbia University,
Keywords: sarcoidosis; stomach; pernicious anaemia; steroid therapy
Sarcoidosis is a systemic granulomatous disease of unknown cause that primarily involves the lungs, lymph nodes, skin, liver, spleen, eyes, phalangeal bones and parotid glands. Reviews of sarcoidosis1'2 reveal exceedingly few cases with gastric involvement, and even fewer with well-documented gastric involvement alone3 4. This is a case report of gastric sarcoidosis complicated by pernicious anaemia but with no extragastric manifestations of the disease. Case report In July 1986, a 51-year-old black woman presented for evaluation of intermittent tachycardia. History, physical
References 1 Fournier AJ. Gangrene foudroyante de la verge. Semaine Med 1883;3:345 2 Pryor JP, Yates-Bell AJ, Packham DA. Scrotal gangrene after male sterilisation. BMJ 1971;i:272 3 Squires JW, Barb MW, Pinch LW. The morbidity of vasectomy. Surg Gynecol Obstet 1976;143:237-40 (Accepted 30 April 1990. Correspondence to Mr A Patel, Department of Urology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF)
