ID Case Conference
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Transcript of ID Case Conference
ID Case ConferenceID Case Conference
Yvonne L. Ballard, MDYvonne L. Ballard, MD
26 March 200826 March 2008
CC: weakness/dizzinessCC: weakness/dizziness
44yo AAM with no known PMH 44yo AAM with no known PMH admitted 3/15 for a 2-week h/o blurry admitted 3/15 for a 2-week h/o blurry vision, weakness, dizziness, polyuria, vision, weakness, dizziness, polyuria, polydipsia, and SOB.polydipsia, and SOB.
On admission, found to be in DKAOn admission, found to be in DKA Also had leukocytosis and fever, but Also had leukocytosis and fever, but
denied localizing symptomsdenied localizing symptoms
History…History…
3 weeks ago, pt experienced hematuria 3 weeks ago, pt experienced hematuria that resolved spontaneouslythat resolved spontaneously
Reports history of recurrent abcesses, Reports history of recurrent abcesses, beginning 10 years ago (groin, axilla, beginning 10 years ago (groin, axilla, thigh)thigh)
Sexually active, monogamous with wifeSexually active, monogamous with wife No history of STDsNo history of STDs No history of HIVNo history of HIV
PMH:PMH:- HTNHTN- Diabetes Mellitus Diabetes Mellitus
(HgA1c = 12.3%)(HgA1c = 12.3%)- Large Subcut CystLarge Subcut Cyst
FamHx:FamHx:- Mom – healthyMom – healthy- Dad – DMDad – DM- ““my whole family has my whole family has
sugar”sugar”
Social Hx:Social Hx:- Lives in Moncure Lives in Moncure
with Momwith Mom- Married, wife lives in Married, wife lives in
Chapel HillChapel Hill- Construction workerConstruction worker- 1ppd smoker 1ppd smoker - Previously heavy Previously heavy
EtohEtoh- No illicits, No IVDANo illicits, No IVDA
History, cont…History, cont…
On the evening of admission, pt began to On the evening of admission, pt began to complain of right-sided groin pain that quickly complain of right-sided groin pain that quickly progressed overnightprogressed overnight
Also noted new onset of a large swelling in Also noted new onset of a large swelling in suprapubic areasuprapubic area
Worsened overnight, and began to have Worsened overnight, and began to have drainage from the scrotum the following daydrainage from the scrotum the following day
Denies testicular pain, urethral dischargeDenies testicular pain, urethral discharge No dysuria or pain with defecationNo dysuria or pain with defecation
Physical ExamPhysical Exam Temp 36.8, P 86, RR 14, BP 99/71, Pox 98% on RATemp 36.8, P 86, RR 14, BP 99/71, Pox 98% on RA Gen: WD, WN, NAD. Large cyst over right eyeGen: WD, WN, NAD. Large cyst over right eye HEENT: Peerla, Eomi, anicteric, conj pink. OP clear. HEENT: Peerla, Eomi, anicteric, conj pink. OP clear. Axilla: No LAD. Under right axilla, ~1cm area of induration Axilla: No LAD. Under right axilla, ~1cm area of induration
without fluctuance, erythema. Nontender.without fluctuance, erythema. Nontender. CV: RRR, Nrml S1S2, No m/g/rCV: RRR, Nrml S1S2, No m/g/r Pulm: CTA b/l, no w/w/rPulm: CTA b/l, no w/w/r Abd: Soft, ND, NT, NABS. No organomegalyAbd: Soft, ND, NT, NABS. No organomegaly GU: GU: Very firm indurated area superior to iliac crest, above the Very firm indurated area superior to iliac crest, above the
penis. No erythema or warmth. His penis appears normal, penis. No erythema or warmth. His penis appears normal, without lesion. No urethral drainage. The testicles are normal on without lesion. No urethral drainage. The testicles are normal on palpation, without mass or tenderness. In the middle of his palpation, without mass or tenderness. In the middle of his scrotum, he has an area of thickened skin, and central in that scrotum, he has an area of thickened skin, and central in that area is a small area of draining purulent yellow fluid. There are area is a small area of draining purulent yellow fluid. There are no abcesses palpated.no abcesses palpated.
Rectal: No masses, abcesses, or ulcers.Rectal: No masses, abcesses, or ulcers. Ext: No c/c/eExt: No c/c/e
Laboratory DataLaboratory Data
138
3.2
107
20
11
1.2142
15.519.5
299
8.6
3.2
2.1
6.7UA - 163 WBCs, 5 RBCs, 2+ LE, UA - 163 WBCs, 5 RBCs, 2+ LE, No Nitr, No blood. 4+ glu, 2+ ket. No Nitr, No blood. 4+ glu, 2+ ket.
CT Scan, 3/17:CT Scan, 3/17:
Repeat CT Scan, 3/18:Repeat CT Scan, 3/18:
Discussion…Discussion…
Fournier’s GangreneFournier’s Gangrene
HistoryHistory Reported by Bauriene in 1764Reported by Bauriene in 1764
- Affliction of King Herod the Great of Judaea (whom Affliction of King Herod the Great of Judaea (whom had DM)had DM)
Credited to Professor Jean-Alfred Fournier, a Credited to Professor Jean-Alfred Fournier, a Parisian Dermatologist and Venereologist, who Parisian Dermatologist and Venereologist, who described it in 1883described it in 1883
““Fulminant gangrene of the penis and scrotum”Fulminant gangrene of the penis and scrotum”- (1) sudden onset in a hitherto healthy young man(1) sudden onset in a hitherto healthy young man- (2) rapid progression to gangrene(2) rapid progression to gangrene- (3) absence of a definite cause(3) absence of a definite cause
Redefined in 1998: “an infective necrotizing Redefined in 1998: “an infective necrotizing fasciitis of the perineal, genital, or perianal fasciitis of the perineal, genital, or perianal regions”regions”
EtiologyEtiology Local Skin InfectionLocal Skin Infection Urinary Tract InfectionUrinary Tract Infection
- Renal AbcessesRenal Abcesses- Urethral StonesUrethral Stones- Urethral StricturesUrethral Strictures
Colorectal InfectionsColorectal Infections- Ruptured AppendicitisRuptured Appendicitis- Colonic CarcinomaColonic Carcinoma- DiverticulitisDiverticulitis
British Journal of Surgery 2000, 87, 718-728
J Microbiol Immunol Infect. 2007; 40:500-506
Comorbid and Predisposing Comorbid and Predisposing ConditionsConditions
Diabetes MellitusDiabetes Mellitus AlcoholismAlcoholism HTNHTN Chronic Liver Chronic Liver
DiseaseDisease HIVHIV MalignancyMalignancy Trauma/SurgeryTrauma/Surgery
Am Surg. 2002 Aug;68(8):709-13.
J Microbiol Immunol Infect. 2007; 40:500-506
BacteriologyBacteriology Classically a MIXED infectionClassically a MIXED infection Most common organisms:Most common organisms:
- Escherichia coliEscherichia coli- Bacteroides fragilisBacteroides fragilis- StreptococcusStreptococcus- StaphylococcusStaphylococcus- Enterococcus spp.Enterococcus spp.- Klebsiella pneumoniaeKlebsiella pneumoniae- CorynebacteriaCorynebacteria- ClostridiumClostridium- Proteus mirabilisProteus mirabilis
Synergistic RelationshipsSynergistic Relationships
J Microbiol Immunol Infect. 2007; 40:500-506
BacteriologyBacteriology
Increase in atypical organisms Increase in atypical organisms suggested in one studysuggested in one study- Shewanella putrefaciens, Vibrio vulnificus, Shewanella putrefaciens, Vibrio vulnificus,
Candida albicansCandida albicans- Decrease in anaerobic infections, as Decrease in anaerobic infections, as
evidenced by decrease in use of evidenced by decrease in use of hyperbaric oxygen chamber for treatment?hyperbaric oxygen chamber for treatment?
BJU Int. 2007 Dec;100(6):1218-20.
Clinical PresentationClinical Presentation
Early – swelling, erythema, tendernessEarly – swelling, erythema, tenderness Spreading – pain, fever, systemic toxicitySpreading – pain, fever, systemic toxicity Late – swelling and crepitus of the Late – swelling and crepitus of the
scrotum rapidly progresses, dark purple scrotum rapidly progresses, dark purple areas develop and progress to extensive areas develop and progress to extensive scrotal gangrenescrotal gangrene
Abdominal wall usually involved last…but Abdominal wall usually involved last…but accelerated spread in patients with accelerated spread in patients with DiabetesDiabetes
British Journal of Surgery 2000, 87, 718-728
Morbidity and MortalityMorbidity and Mortality Hospital stays from 2 to 278 daysHospital stays from 2 to 278 days ComplicationsComplications
- Resp failure, Renal failure, Shock, DKA, Resp failure, Renal failure, Shock, DKA, Pneumonia, Hepatic failure, DIC, UGIBPneumonia, Hepatic failure, DIC, UGIB
Mortality 0-45%Mortality 0-45% EARLY, aggressive treatment EARLY, aggressive treatment
associated with a reduced mortality rateassociated with a reduced mortality rate
Am Surg. 2002 Aug;68(8):709-13.
TreatmentTreatment
Broad-spectrum antibiotics – triple therapy Broad-spectrum antibiotics – triple therapy favored in most studiesfavored in most studies- Penicillins – StreptococciPenicillins – Streptococci- Metronidazole – AnaerobesMetronidazole – Anaerobes- 33rdrd gen. Cephalosporin (with/without Gent) gen. Cephalosporin (with/without Gent)
• Enteric organisms and staphylococciEnteric organisms and staphylococci
Surgical debridementSurgical debridement Unprocessed honeyUnprocessed honey Hyperbaric OxygenHyperbaric Oxygen
Hyperbaric OxygenHyperbaric Oxygen
Initially used for presumed clostridial Initially used for presumed clostridial infection when crepitus was observedinfection when crepitus was observed
Increases tissue oxygenation to a level Increases tissue oxygenation to a level that inhibits and kills anaerobesthat inhibits and kills anaerobes
Reduces systemic toxicityReduces systemic toxicity- Improvement in neutrophil functionImprovement in neutrophil function- Increased fibroblast proliferationIncreased fibroblast proliferation- Promotes angiogenesisPromotes angiogenesis
Hospital CourseHospital Course
Urology Consult – Bedside I&DUrology Consult – Bedside I&D Cultures: Beta-hemolytic Group B Cultures: Beta-hemolytic Group B
Streptococci and AnaerobesStreptococci and Anaerobes Treatment: Vanc, Zosyn, Clinda Treatment: Vanc, Zosyn, Clinda
Ceftriaxone and ClindamycinCeftriaxone and Clindamycin Fever resolved, continued drainageFever resolved, continued drainage Superior aspect - ? Hematoma?Superior aspect - ? Hematoma?
Have a Have a Great Day!!!Great Day!!!