An outbreak of gangrenous syndrome among buffaloes and cattle in West Bengal: clinicopathological studies

Gangrenous syndrome/Degnala disease was recorded in a large number of buffaloes and cattle in Murshidabad district of West Bengal, India. Fusarium spp. had been isolated from the mouldy paddy straw which were fed to the animals. There was a reduction in the incidence of the disease following withdrawal of the mouldy paddy straw. Histopathological examination showed necrosis and loss of architectural details in the skin.

Transmetatarsal amputation of the toe: an analytic study of ischemic complications

Transmetatarsal amputations of the toes are very common procedures, particularly involving patients with diabetes mellitus and peripheral vascular disease. A complication of these operations is the onset of gangrene of an adjoining toe, which is usually ascribed to the underlying disease. It is suggested that another explanation may be responsible for this occurrence, namely, a combination of the variability of the bifurcation of the dorsal metatarsal arteries and the operative technique. The former is either not described or has different levels in different texts. The operation in nearly all texts is a classic racquet incision, without mention of the width of the racket. The combination of an incision widely diverging from the handle of the racket is in danger of severing the dorsal metatarsal artery, its bifurcation, or the digital branch to the adjacent toe. A patient with a good blood supply may be able to salvage the situation by way of the plantar vessels, but when the vascular status is parlous, which is the case in many amputations, the adjacent digit is at considerable risk. Clinical, radiological, and anatomic evidence is presented to support this contention. Based on the above, a safer operative technique is suggested to avoid possible complications.

Determining duration of antibiotic use in children with complicated appendicitis

BACKGROUND

The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician.

AIM

This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued.

METHODS

Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms).

RESULTS

Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1).

CONCLUSION

Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.

[Ischemic colitic in the elderly: predictive factors of gangrenous outcome]

OBJECTIVE

To better characterize the presentation of gangrenous and non-gangrenous ischemic colitis in subjects older than 60 years, and to identify risk factors of gangrenous outcome.

METHODS

Retrospective analysis of 80 cases of ischemic colitis (22 male, 58 female; mean age 76.9 +/- 8.7 years) with 64 and 16 non gangrenous and gangrenous forms, respectively.

RESULTS

Hematochezia and diarrhea were significantly less prevalent in gangrenous colitis compared to the non-gangrenous group (31.2% vs 81.2%, P < 0.0001 and 6.2% vs 53.1%, P < 0.0001, respectively), whereas nausea and vomiting, and hyperleukcocytosis were significantly more frequent in the former group (50.0% vs 18.7%, P < 0.01 and 93.7% vs 62.5%, P < 0.02 respectively). Hypertension (P < 0.03), angina (P < 0.05), history of cancer (P < 0.03) and age older than 90 (P < 0.002) were risk factors for gangrenous outcome. After multivariate analysis, only two independent factors were identified, i.e.: hypertension and history of cancer. These factors predicted gangrenous course in 85% of cases.

CONCLUSION

Patients older than 60 years suffering from ischemic colitis are at high risk of gangrenous course if they have hypertension or history of cancer.

Progeria (Hutchinson-Gilford): a case report

A new case with the typical features of progeria (Hutchinson-Gilford) occurred in India. Histopathology of the skin showed atrophic epidermis and diffuse fibrosis of dermis with loss of appendages. Roentgenographic findings were characteristic of progeria. The child also had a gangrenous ulcer over the left foot, a finding not highlighted in the literature.

[Accuracy of the term "diabetic angiopathy of the lower limbs". II. Possibilities of the morphological assessment of the stage of diabetic angiopathy of the lower limbs and the choice of treatment tactics]

In 40 patients with diabetic angiopathy of lower extremities of terminal stage the foot tissue biopsies were studied up using electron and light microscopy. A skin was supposed to be most acceptable substrate for biopsy because there was established morphological changes of tissues, occurring in a single direction and in a single type. Morphological criteria of the angiopathy stages were delineated, permitting to make a differentiative choice of the treatment tactics.

Arachidonic acid-induced hind limb gangrene: a new experimental rat model of peripheral vascular disease

The purpose of this study was to investigate the characteristics of arachidonic acid-induced peripheral vascular disease in rats. Injecting arachidonic acid (2 mg/leg) into the femoral artery caused hind limb gangrene. Histopathological examination revealed occlusive thrombi and marked vascular injury, including denudation of the endothelium and degeneration of the media in the paw arteries. Arachidonic acid injection markedly enhanced the platelet response to both U-46619 and collagen. Although the number of circulating platelets did not differ between sham-operation rats and arachidonic acid-injected rats, the numbers of circulating white blood cells and red blood cells were raised 10 d after arachidonic acid injection. Thrombocytopenia, induced before arachidonic acid injection, markedly suppressed arachidonic acid-induced hind limb gangrene in rats. In addition, the combined administration of aspirin (100 mg/kg/d, p.o.) and ticlopidine (300 mg/kg/d, p.o.) prevented the progression of arachidonic acid-induced hind limb gangrene. These results suggest that platelets are involved in the progression of arachidonic acid-induced hind limb gangrene. This experimental rat model may be suitable for developing novel drugs for the treatment of peripheral vascular disease.

[Streptococcal gangrene and so-called "flesh-eating bacteria disease". A rare and devastating disease]

Streptococcal gangrene, an unusual form of necrotizing fasciitis with fatal outcome, has been recently rediscovered and has gained popularity with the name "disease of flesh eating bacteria". The incidence of this and other severe diseases caused by Streptococcus pneumoniae has been suggested to be increasing. Only three patients with this disease have been studied at our institution in the last 12 years and in a review of a bacteremic infections caused by beta-hemolytic streptococci a significant increase of these infections was not observed. We report here the clinical and pathological characteristics of streptococcal gangrene as well as a review of the more recent literature.

Uremic small artery disease: calciphylaxis with penis involvement

Two male patients with chronic renal failure maintained on hemodialysis developed progressive clinical features of ischemic necrosis (so called calciphylaxis) of their extremities and penis. Both patients died. In one patient, penectomy provided tissue for histopathologic examination and there were changes of small artery calcification. A role of iron overload on the production of calciphylaxis is reviewed. This report is perhaps the first in nephrology literature on the occurrence of calciphylaxis involving penis and prepuce.

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.

Structure of the gangrene alpha-toxin: the beauty in the beast

The crystal and molecular structure of the Clostridium perfringens alpha-toxin crowns over a century-long research into the mechanisms of pathogenesis of gas gangrene. The structure reveals a two-domain enzyme, with a catalytic all-helical N-terminal domain, and a C-terminal domain similar in its jelly-roll topology to those found in pancreatic lipase and lipoxygenases.

Gangrene of Meckel's diverticulum secondary to axial torsion: a rare complication

A Meckel's diverticulum may result in a number of complications including hemorrhage, obstruction, and inflammation. We report a case of a gangrenous Meckel's diverticulum secondary to axial torsion, which has been reported only four times in adults and once in children in the past 28 years.

Successful treatment of gangrene in systemic necrotizing vasculitis with iloprost

Systemic necrotizing vasculitis is uncommon in children and may be rarely associated with gangrene. We describe a 3-yr-old girl with parvovirus B19-induced necrotizing vasculitis whose digital gangrene was successfully treated with iloprost, a prostacyclin analogue.

Video fluorescein imaging of the skin: description of an overviewing technique for functional evaluation of regional cutaneous blood perfusion in occlusive arterial disease of the limbs

In peripheral arterial occlusive disease (PAOD), and particularly in critical limb ischaemia, fluorescence recording of the skin after i.v. injection of sodium fluorescein provides an overviewing functional imaging of regional blood perfusion as revealed by a continuous, almost geographical, mapping of changes in the dynamic fluorescence pattern. Based on the previously used technique of rapid sequence flash photography introduced by Lund and Lund in 1973, a new video fluorescence imaging (VFI) technique has been developed and used in clinical routine. VFI has a broad versatility with non-touch access to areas of different size, such as the feet, hands or larger limb areas. Examples of application are the diagnosis of small artery disease, predictive prognosis of critical limb ischaemia, evaluation of distal outflow in connection with arterial reconstruction or pharmacotherapy of non-reconstructable critical ischaemia, as well as in decisions on amputation and assessment of amputation level. Thanks to its overviewing qualities with reproducible mapping of blood perfusion in standardized examination conditions, VFI would seem to have a well-justified role in angiology and above all in PAOD in both research and clinical routine work.

Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment

BACKGROUND

Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside.

METHODS

Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process.

RESULTS

These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis.

CONCLUSION

Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.

Digital necrosis in acquired immune deficiency syndrome vasculopathy treated with recombinant tissue plasminogen activator

Widespread digital ischemic changes and gangrene of the hands and feet is an uncommon but dramatic presentation in patients with human immunodeficiency virus (HIV) infection. We describe a patient in whom these clinical findings were associated with elevated serum endothelin levels. Because endothelin may affect the fibrinolytic system, we elected to treat with tissue plasminogen activator (tPA), which resulted in salvage of tissue of the fingers and toes. Patients with HIV infection with widespread ischemic necrosis and gangrene may require treatment with corticosteroids (in the event of possible vasculitis), thrombolytic agents (for the thrombotic component), or both, unless there are contraindications to either.

Adult T-cell leukemia/lymphoma presenting with digital gangrene

There have been only a few reports in the literature of lymphoma patients suffering from digital gangrene. The present case, a 40-year old man with adult T-cell leukemia/lymphoma (ATLL) showed marked edematous and dyshidrosis-like changes of the digital fingers. As a result of these changes, most of the fingertips of this patient were affected by gangrene. Histologically, lesions showed organized thrombi occluding veins in the middle dermis. In patients suffering from malignant lymphoma, digital swelling and pain associated with cyanosis should receive careful attention because of the possibility of digital gangrene. To our knowledge, this report is on the first ATLL case in the literature presenting with digital gangrene associated with occlusive thrombi.

Six cases positive for anti-centromere antibodies with ulcer and gangrene in the extremities

We report six cases that were positive for anti-centromere antibodies, with ulcer and gangrene in the extremities but mild or no skin thickening. The patients were five women and one man, and the mean age at onset of gangrene was 56 yr. Raynaud's phenomenon was found in five patients and calcinosis cutis in two patients. Three patients did not satisfy the criteria for systemic sclerosis and CREST syndrome in this study. Ulcer and gangrene occurred in the fingers in three patients, and in the fingers and toes in two patients. The gangrene was refractory to treatment, and amputation of fingers or toes was inevitable in five patients. Regardless of cutaneous lesion, the presence of anti-centromere antibodies may cause the same pathological presentation of vascular damage as seen in systemic sclerosis.