CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION

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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND
SHARING OF INFORMATION ON COMPLICATED SKIN AND
SOFT TISSUE INFECTION

• JONATHAN R. MALABANAN,MD
• DEPARTMENT OF SURGERY
• OSPITAL NG MAYNILA

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• C.S.
• 63M
• PANDACAN, MANILA

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CHIEF COMPLAINT

• Swelling, scrotal area

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HISTORY OF PRESENT ILLNESS

• 10 DAYS PTC ? SWELLING AND ERYTHEMA OF THE
  SCROTAL AREA
• PAIN AND TENDERNESS
• CRUSTING SKIN LESIONS
• (-) CONSULT OMMC OPD
• 1 DAY PTC? INCREASED SEVERITY OF SWELLING ,
  ERYTHEMA, PAIN AND TENDERNESS
• FEVER AND CHILLS
• () CONSULT OMMC SURGERY ER

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• PAST MEDICAL HISTORY
• - HPN X 20YRS, Metoprolol 50 mg tab BID
• - () DM
• FAMILY HISTORY
• - UNREMARKABLE
• PERSONAL/SOCIAL HISTORY
• - SMOKER, 25 pack years
• -NON- ALCOHOLIC BEVERAGE DRINKER

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PHYSICAL EXAMINATION

• GENERAL CONSCIOUS, COHERENT, NICRD
• BP 130/90 CR 90 RR24 T38.9 WT 57 kg
• HEENT PINK PALPEBRAL CONJUNCTIVA, ANICTERIC
  SCLERA, NO TPC, (-) CLAD,
• CHEST/LUNGS SCE, NO RETRACTIONS, CLEAR BREATH
  SOUNDS
• HEART ADYNAMIC PRECORDIUM, NRRR, NO MURMUR

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PHYSICAL EXAMINATION

• gtPerineum () erythematous swelling scrotal area
• crusting skin lesion of the scrotum
• Tenderness
• Foul smelling d/c
• DRE () hemorrhoidectomy site good sphincteric
  tone, tenderness Right anterolateral area

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SALIENT FEATURES

• 63/M, DM
• 2. () erythematous swelling on the scrotal area,
  crusting skin lesion of the scrotum
• Tenderness
• Foul smelling d/c
• 3. FEVER AND CHILLS

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SCROTAL MASS
INFLAMMATORY
NON-INFLAMMATORY
INFLAMMATORY
NON-INFLAMMATORY
TUMOR
TUMOR
RUBOR
BENIGN
MALIGNANT
BENIGN
MALIGNANT
DOLOR
TUMOR
CALLOR
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INFLAMMATORY
UNCOMPLICATED
COMPLICATED
SKIN -EPIDERMIS -DERMIS
FOLLICULITIS
FURUNCLE
SSS
SUBCUTANEOUS TISSUE
SUBCUTANEOUS ABSCESS
CELLULITIS
NECROTIZING FASCITIS
FASCIA
PYOMYOSITIS
MYONECROSIS
MUSCLE
MYOSITIS
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CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS DEGREE OF CERTAINTY TREATMENT
DIAGNOSIS FOURNIERS GANGRENE 90 SURGICAL
SCROTAL ABSCESS 10 SURGICAL
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DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?

• NO.
• I AM QUITE CERTAIN OF MY DIAGNOSIS
• IT WILL NOT CHANGE MY TREATMENT PLAN

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GOALS OF TREATMENT

• RESOLUTION OF INFECTION
• PREVENT RECURRENCE OF INFECTION

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PRE-TREATMENT DIAGNOSIS
DIAGNOSIS FOURNIERS GANGRENE 90 DEGREE OF CERTAINTY
SCROTAL ABSCESS 10 OF CERTAINTY
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TREATMENT OPTIONS
TREATMENT OPTION BENEFIT RISK COST AVAILABILITY
SURGICAL Radical Wound Debribement plus IV Antibiotics 75 Success Rate Bleeding Risk of Operation Allergy to parenteral Antibiotics PF 25- 50 thou Antibiotic Pen G P815 per 5 M units Metro P350 per vial Available
SURGICAL Radical Wound Debribement plus IV Antibiotics plus Hyperbaric Oxygen Mortality Rate 3-40 Bleeding Risk of Operation Allergy to parenteral Antibiotics ? Not Available
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PRE-TREATMENT PREPARATION

• PSYCHOSOCIAL SUPPORT
• SCREENING FOR MEDICAL PROBLEMS
• - OPTIMIZE PHYSICAL CONDITION OF THE PATIENT
• - ADEQUATE HYDRATION
• - ANALGESICS FOR PAIN AND FEVER

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TREATMENT PLAN

• Emergency Radical Wound Debribement
• Parenteral Antibiotic with coverage involving
  Streptococcus pyogenes
• benzylpenicillin 100,000 IU/kg i.v. every 6
  hours
• And Metronidazole 500 mg Q8
• Tetanus Prophylaxis 6,000 units TIM ( ) ANST
• Tetanus toxoid .5 ml TIM

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OPERATIVE TECHNIQUE

• Patient supine under SAB
• Asepsis, Antisepsis
• Sterile drapes placed
• Longitudinal scrotal incision carried down from
  skin to dartos fascia
• Intraop Findings noted

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Intraop Findings

• Necrotic tissue
• Skin
• Subq
• Fascia
• Normal tissue overlying necrotic tissue over the
  perineal area
• Foul smelling discharge

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• Radical debridement done
• NSS Flushing
• Correct Instrument, Needle, and Sponge Count
• Wet to Dry sterile dressing

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TREATMENT

• Radical Wound Debribement
• MEDICAL
• Penicillin G 5 M units TIV q6
• Metronidazole 500 mg Q8
• Ketorolac 75 mg TIV q8 for pain and swelling
• Intermediate Insulin

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POST-TREATMENT DIAGNOSIS

• Fourniers Gangrene S/P Radical Wound Debribement

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Course in the Ward

• IV antibiotics given
• Adequate pain control
• 6 hours post op
• Arrested

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Cause of Death Pathophysiologic analysis Interval between onset death
Immediate Cause Septic shock 1 hr
Antecedent Cause Sepsis 6 hrs
Underlying Cause Fourniers Gangrene gt24 hrs
Other factors contributing to death S/P Hemorrhoidectomy 10 days
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POST-TREATMENT CARE

• SUPPLY THE BASIC NEEDS OF THE PATIENT
• COMFORT
• ANALGESICS
• MEDICATIONS ANTIBIOTICS
• ADEQUATE SUGAR CONTROL
• SUPPORT ORGAN FUNCTION
• MONITORING FOR COMPLICATIONS
• TISSUE COVERAGE
• ADVICE ON
• HOME CARE
• FOLLOW-UP PLAN

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Sharing of Information
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Fourniers gangrene

• Polymicrobial necrotizing fasciitis of the
• perineal- 21
• perirectal-33
• genital area-45
• that extend rapidly along fascial planes to
  involve the groin, thighs, and abdominal wall

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Epidemiology

• According to CDC, 3/10,000 patients are
  diagnosed with Fourniers Gangrene
• Sex MF of 101
• Age Mostly lt3 months and aged 30- 60 y.o.

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Predisposition to Disease

• Diabetes Mellitus- 60
• Chronic Alcoholism-25-50
• Immunosuppression
• Cigarette Smoking

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Etiology and Pathogenesis

• Polymicrobial infection
• Mixed aerobic and anaerobic bacteria
• Escherichia coli, Bacteroides, Clostridia,
  Staphylococci, Enterococci, Proteus and
  Pseudomonas

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• Common colorectal sources of infection
• perirectal, perianal, ischiorectal abscess
• perforation due to inflammatory disease
• neoplastic disease, instrumentation or trauma

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Causes of Fourniers gangrene
Genitourinary Gastrointestinal Obstetrical / Gynecological
Pathological Infection Trauma Urethral stricture Periurethral abscess Epidydymitis Paraphimosis Soft tissue injuries Post coital Anorectal abscess Ischiorectal abscess Perianal fistula Hemorrhhoids Perforated rectal carcinoma Rectal perforation by foreign body Perforated sigmoid diverticulitis Post coital Vulvar abscess Bartholins gland abscess Septic abortion
Procedural Post-op TURP Traumatic catherization Anoscopy / sigmoidoscopy Colonoscopy Post-op anastomotic dehiscence Hysterectomy Cervical / pudendal nerve block Post-op episiotomy Pelvic exenteration
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• Regardless of portal of entry
• Local infection causes marked inflammatory
  reaction that extends to the deep fascial planes
• Progresses to obliterative endarteritis and local
  ischemia

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• Direction of disease spread determined by the
  attachments of various fascial planes in the
  pelvis and perineum
• Testes, epidydymes, bladder, and rectum are
  spared from necrosis because of the separate
  nonperineal blood supply

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Prognosis

• Mortality rates ranging from 20-25
• High morbidity exists among survivors
• M/M increase with
• advanced age
• primary anorectal infection
• delayed treatment

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• shock or sepsis at presentation
• renal failure
• greater disease extent
• DM
• immunosuppression

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Management

• True surgical emergency that is rapidly
  progressive and potentially lethal
• Once recognized urgent surgical intervention
  with aggressive resuscitation
• High dose parenteral antibiotics

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• Broad spectrum antibiotics
• ampisulbactam, ticarcillin/clavulanate,
  piperacillin/tazobactam, or imipinem,
  penicilinase-resistant, synthetic penicillin plus
  clindamycin plus antipseudomonal aminoglycoside

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SSSS

• Staphylococcal scalded-skin syndrome (SSSS)
  occurs predominantly in neonates and is caused by
  an exotoxin from phage group II S aureus
• Punch biopsy with frozen section is useful since
  the cleavage plane in SSSS is the stratum corneum

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NECROTIZING FASCIITIS

• Necrotizing fasciitis is a deep-seated infection
  of the subcutaneous tissue that results in the
  progressive destruction of fascia and fat
• Predisposing factors for the development of
  necrotizing fasciitis due to Strep. pyogenes
  include varicella ,penetrating injuries, minor
  cuts, burns, splinters, surgical procedures,
  childbirth, blunt trauma, and muscle strain

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NECROTIZING FASCIITIS

•    Type I necrotizing fasciitis is a mixed
  infection caused by aerobic and anaerobic
  bacteria and occurs most commonly after surgical
  procedures and in patients with diabetes.  90 of
  nec fasc falls into this polymicrobial category.
•    Type II necrotizing fasciitis is caused by
  group A streptococcus (GAS, Streptococcus
  pyogenes).  This is the much feared flesh eating
  bacteria which can progress and cause death
  within 24hrs.  Approx. 50 of these cases produce
  TSS toxin.

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NECROTIZING FASCIITIS

• Treatment consists of early and aggressive
  surgical exploration and debridement of necrotic
  tissue, antibiotic therapy, and hemodynamic
  support as needed.
• In addition, the various types of infection
  require some specific modalities (such as the use
  of PCN clindamycin for suspected GAS infectionà
  the clinda will block protein synthesis of the
  TSS toxin).
• The best indication for surgical intervention is
  severe pain, toxicity, fever and elevated CPK
  with or without radiographic findings.  

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REFERENCES

• Ameh EA, Dauda MM, Sabiu L, et. al. Fourniers
  gangrene in neonates and infants. Eur J. Pediatr
  Surg 2004 Dec. 14 (6) 418-21.
• Basoglu M, et. al. Fourniers gangrene review
  of 15 cases. Am Surg 1997Nov 63(11)1019-21.
• Capeeli, TS, Schelfeffer M. Gerber GS The use of
  hyperbaric oxygen in urology. J Urol 1999 Sept
  162 (3 Pt 1) 647-54.
• Eke, N. Fourniers gangrene a review of 1726
  cases, BJS 2000 87(6) 718-728.
• Pathy R, Smith AD . Gangrene and Fourniers
  gangrene. Urol Clin North Am 1992 19 149-62.

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REFERENCES

• Pingul, JA, Joson, RJ, Needle Aspiration vs.
  Surgical Drainage for Uncomplicated cutaneous
  abscess OMMC Manila Philippines

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MCQ

• 1. Staphylococcal scalded skin syndrome
• a. is caused by an exotoxin
• b. is most frequently found in adolescent males
• c. is a toxic reaction to antibiotics used in
  treating abscess
• d. usually begins around a neglected carbuncle

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• 1. Staphylococcal scalded skin syndrome
• a. is caused by an exotoxin
• b. is most frequently found in adolescent males
• c. is a toxic reaction to antibiotics used in
  treating abscess
• d. usually begins around a neglected carbuncle

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MCQ

• 2. The diagnosis of Fourniers gangrene is based
  primarily on
• a. gas in the scrotal wall which is a
  sonographic hallmark of fourniers gangrene.
• b. CT scan which define extent of disease.
• c. clinical findings
• d. scrotal tissue edema on radiographs

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• 2. The diagnosis of Fourniers gangrene is based
  primarily on
• a. gas in the scrotal wall which is a
  sonographic hallmark of fourniers gangrene.
• b. CT scan which define extent of disease.
• c. clinical findings
• d. scrotal tissue edema on radiographs

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MCQ

• 3. The mortality rate for Fourniers gangrene
  range from?
• 3- 40
• 20-25
• 5-10
• 10-15

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• 3. The mortality rate for Fourniers gangrene
  range from?
• 3- 40
• 20-25
• 5-10
• 10-15

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MCQ

• 4. Type II Necrotizing Fascitis is primarily
  caused by
• A. Staphylococcus aureus
• B. E. coli
• C. Streptococcus pyogenes
• D. Pseudomonas

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• 4. Type II Necrotizing Fascitis is primarily
  caused by
• A. Staphylococcus aureus
• B. E. coli
• C. Streptococcus pyogenes
• D. Pseudomonas

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MCQ

• 5. Infection of the superficial perineal fascia
  may spread to the penis and scrotum via
• A. Colles fascia
• b. Scarpa fascia
• c. Dartos fascia
• d. Campers fascia

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• 5. Infection of the superficial perineal fascia
  may spread to the penis and scrotum via
• A. Colles fascia
• b. Scarpa fascia
• c. Dartos fascia
• d. Campers fascia

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Thank You