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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. C.S. 63M PANDACAN, MANILA. CHIEF COMPLAINT. Swelling, scrotal area. HISTORY OF PRESENT ILLNESS.

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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

slide2
C.S.

63M

PANDACAN, MANILA

chief complaint
CHIEF COMPLAINT

Swelling, scrotal area

history of present illness
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

slide5
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

physical examination
PHYSICAL EXAMINATION

GENERAL: CONSCIOUS, COHERENT, NICRD

BP: 130/90 CR= 90 RR=24 T=38.9 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

physical examination1
PHYSICAL EXAMINATION

>Perineum: (+) 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

salient features
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

slide9

SCROTAL MASS

NON-INFLAMMATORY

NON-INFLAMMATORY

INFLAMMATORY

INFLAMMATORY

TUMOR

TUMOR

RUBOR

DOLOR

MALIGNANT

MALIGNANT

BENIGN

BENIGN

TUMOR

CALLOR

slide10

INFLAMMATORY

UNCOMPLICATED

COMPLICATED

SKIN

-EPIDERMIS

-DERMIS

FOLLICULITIS

FURUNCLE

SSS

SUBCUTANEOUS

TISSUE

SUBCUTANEOUS

ABSCESS

CELLULITIS

NECROTIZING

FASCITIS

FASCIA

PYOMYOSITIS

MYONECROSIS

MUSCLE

MYOSITIS

do i need a paraclinical diagnostic procedure
DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?

NO.

  • I AM QUITE CERTAIN OF MY DIAGNOSIS
  • IT WILL NOT CHANGE MY TREATMENT PLAN
goals of treatment
GOALS OF TREATMENT
  • RESOLUTION OF INFECTION
  • PREVENT RECURRENCE OF INFECTION
pre treatment preparation
PRE-TREATMENT PREPARATION
  • PSYCHOSOCIAL SUPPORT
  • SCREENING FOR MEDICAL PROBLEMS:

- OPTIMIZE PHYSICAL CONDITION OF THE PATIENT

- ADEQUATE HYDRATION

- ANALGESICS FOR PAIN AND FEVER

treatment plan
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

operative technique
OPERATIVE TECHNIQUE
  • Patient supine under SAB
  • Asepsis, Antisepsis
  • Sterile drapes placed
  • Longitudinal scrotal incision carried down from skin to dartos fascia
  • Intraop Findings noted
intraop findings
Intraop Findings
  • Necrotic tissue
    • Skin
    • Subq
    • Fascia
  • Normal tissue overlying necrotic tissue over the perineal area
  • Foul smelling discharge
slide20
Radical debridement done
  • NSS Flushing
  • Correct Instrument, Needle, and Sponge Count
  • Wet to Dry sterile dressing
treatment
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
post treatment diagnosis
POST-TREATMENT DIAGNOSIS

Fournier’s Gangrene S/P Radical Wound Debribement

course in the ward
Course in the Ward
  • IV antibiotics given
  • Adequate pain control
  • 6 hours post op
    • Arrested
post treatment care
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
fournier s gangrene
Fournier’s 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

epidemiology
Epidemiology
  • According to CDC, 3/10,000 patient’s are diagnosed with Fournier’s Gangrene
  • Sex: M:F of 10:1
  • Age: Mostly <3 months and aged 30- 60 y.o.
predisposition to disease
Predisposition toDisease

Diabetes Mellitus- 60%

Chronic Alcoholism-25-50%

Immunosuppression

Cigarette Smoking

etiology and pathogenesis
Etiology and Pathogenesis
  • Polymicrobial infection
  • Mixed aerobic and anaerobic bacteria
  • Escherichia coli, Bacteroides, Clostridia, Staphylococci, Enterococci, Proteus and Pseudomonas
slide31
Common colorectal sources of infection

perirectal, perianal, ischiorectal abscess

perforation due to inflammatory disease

neoplastic disease, instrumentation or trauma

slide33
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
slide34
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
prognosis
Prognosis
  • Mortality rates ranging from 20-25%
  • High morbidity exists among survivors
  • M/M increase with

advanced age

primary anorectal infection

delayed treatment

slide36
shock or sepsis at presentation

renal failure

greater disease extent

DM

immunosuppression

management
Management
  • True surgical emergency that is rapidly progressive and potentially lethal
  • Once recognized: urgent surgical intervention with aggressive resuscitation
  • High dose parenteral antibiotics
slide38
Broad spectrum antibiotics

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

slide39
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
necrotizing fasciitis
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
necrotizing fasciitis1
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.
necrotizing fasciitis2
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. 
references
REFERENCES
  • Ameh EA, Dauda MM, Sabiu L, et. al. Fournier’s gangrene in neonates and infants. Eur J. Pediatr Surg 2004 Dec. 14 (6): 418-21.
  • Basoglu M, et. al. : Fournier’s 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. Fournier’s gangrene: a review of 1726 cases, BJS 2000; 87(6): 718-728.
  • Pathy R, Smith AD . Gangrene and Fournier’s gangrene. Urol Clin North Am 1992; 19: 149-62.
references1
REFERENCES
  • Pingul, JA, Joson, RJ, Needle Aspiration vs. Surgical Drainage for Uncomplicated cutaneous abscess; OMMC; Manila Philippines
slide45
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

slide46
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

slide47
MCQ
  • 2. The diagnosis of Fournier’s gangrene is based primarily on:

a. gas in the scrotal wall which is a sonographic hallmark of fournier’s gangrene.

b. CT scan which define extent of disease.

c. clinical findings

d. scrotal tissue edema on radiographs

slide48
2. The diagnosis of Fournier’s gangrene is based primarily on:

a. gas in the scrotal wall which is a sonographic hallmark of fournier’s gangrene.

b. CT scan which define extent of disease.

c. clinical findings

d. scrotal tissue edema on radiographs

slide49
MCQ
  • 3. The mortality rate for Fournier’s gangrene range from?
      • 3- 40%
      • 20-25%
      • 5-10%
      • 10-15%
slide51
MCQ
  • 4. Type II Necrotizing Fascitis is primarily caused by:
      • A. Staphylococcus aureus
      • B. E. coli
      • C. Streptococcus pyogenes
      • D. Pseudomonas
slide52
4. Type II Necrotizing Fascitis is primarily caused by:
      • A. Staphylococcus aureus
      • B. E. coli
      • C. Streptococcus pyogenes
      • D. Pseudomonas
slide53
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. Camper’s fascia

slide54
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. Camper’s fascia

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