Ludzkie koronawirusy - autor: Krzysztof Pyrć z Zakładu Mikrobiologii, Wydział Biochemii, Biofizyki i Biotechnologii, Uniwersytet Jagielloński, Kraków

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© Borgis - Nowa Medycyna 3/2016, s. 102-113 | DOI: 10.5604/17312485.1223279
*Jacek Wadełek
Diagnostic investigation and management of Fournier’s gangrene in intensive care unit
Diagnostyka i leczenie zgorzeli Fourniera w oddziale intensywnej terapii
Anaesthesiology and Intensive Care Unit, Saint Anna Traumatology Hospital, Mazowsze Rehabilitation Centre „STOCER”, Warsaw
Head of Department: Elżbieta Kurmin-Gryz, MD
Streszczenie
Zgorzel Fourniera (ZF) jest ostrym, szybko postępującym, potencjalnie śmiertelnym, infekcyjnym martwiczym zapaleniem powięzi okolic zewnętrznych narządów płciowych, krocza i okołoodbytniczej, które zwykle występuje u mężczyzn, ale może również mieć miejsce u kobiet i dzieci. Coraz częściej diagnozuje się schorzenia współistniejące u pacjentów ze ZF. Czynniki sprzyjające rozwojowi i etiologiczne ZF zapewniają dogodnie warunki do zakażenia poprzez obniżenie odporności gospodarza i prowadzą do powstania wrót zakażenia dla mikroorganizmów okolicy krocza – szczególnie u pacjentów z rozpoznaną cukrzycą i przewlekłym nadużywaniem alkoholu. ZF może również występować u pacjentów bez oczywistych niedoborów immunologicznych. Jest zakażeniem wywoływanym przez mieszaną tlenową i beztlenową florę bakteryjną działającą synergistycznie. Zakażenie jest wynikiem zaburzonej równowagi pomiędzy odpornością gospodarza a wirulencją wywołującego zakażenie mikroorganizmu. Objawy kliniczne rozwijają się w okresie kilku dni i charakteryzują się: uczuciem niepokoju, miejscowym obrzękiem i dyskomfortem, gorączką, krepitacją, zakażenie czasami prowadzi do wstrząsu septycznego. Rozpoznanie ZF stawiane jest w oparciu o obraz kliniczny. Niezależnie od szerokiego spektrum mikroorganizmów w etiologii ZF, jego leczenie jest takie samo we wszystkich przypadkach i polega na jak najszybszym usunięciu martwiczych tkanek, odpowiedniej resuscytacji i dożylnym podaniu antybiotyków o szerokim spektrum.
Summary
Fournier’s gangrene (FG) is an acute, rapidly progressive, and potentially fatal infective necrotizing fasciitis affecting the external genitalia, perineal or perianal regions, which commonly affects men, but can also occur in women and children. Comorbid systemic disorders are being increasingly identified in patients with FG. The predisposing and etiologic factors of FG provide a favourable environment for the infection by decreasing the host immunity and allowing a portal of entry for microorganisms into the perineum. Especially patients with diagnosed diabetes mellitus and long-standing alcohol misuse are at risk of FG. It can also affect patients with non-obvious immune compromise. It is secondary to polymicrobial infection by aerobic and anaerobic bacteria with a synergistic action. Infection represents an imbalance between host immunity and the virulence of the causative microorganisms. The clinical condition develops in a few days and is characterized by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. The diagnosis of Fournier’s gangrene is made clinically. In spite of the widely varying microorganisms in the etiology, the treatment of FG is common for all cases including emergency removal of the devitalized tissues, adequate resuscitation and intravenous administration of wide-spectrum antibiotics.
Introduction
Fournier’s gangrene (FG) is a necrotizing, life-threatening fasciitis of the perineal area, external genitalia and the anus, which may extend towards the abdominal cavity and result in soft tissue necrosis and the development of sepsis. As early as more than 200 years ago, in 1764, Baurienne described rapid inflammation of the perineum. In 1883 Jean Alfred Fournier, a French dermatologist and venereologist, described a gangrene in five young men without diagnosed etiologic factors (1, 2). The infection is usually caused by a mixed microbial flora. The prevalence of the disease is low; however, mortality still remains high. Certain diseases of the genitourinary and anorectal areas as well as diabetes and conditions associated with immunosuppression are conducive to the development of FG. The diagnosis of FG is made based on clinical symptoms with diagnostic imaging being useful for the evaluation of advancement of necrosis. Therapeutic management primarily involves aggressive surgical excision of necrotic tissues, the use of broad-spectrum antibiotics, anti-shock treatment and supporting therapy. The Fournier’s Gangrene Severity Index Score may be used to assess the condition of the patients (tab. 1). Due to its diversity and aggressive course FG is a very serious and complex medical problem that requires a multi-disciplinary therapeutic approach.
Tab. 1. Fournier’s Gangrene Severity Index Score; nine parameters are measured and the scores for all parameters are added to obtain a total score
ParameterScore
+4+3+2+10+1+2+3+4
Body temperature
[°C]
> 4139-40.938.5-35.936-38.434-35.9 32-33.930-31.9< 29.9
Heart rate
[breaths per minute]
> 180140-179110-13970-109 56-69 40-54< 39
Respiratory rate
[breaths per minute]
> 50 35-49 25-34 12-2410-11 6-9< 5
Serum sodium level
[mmol/l]
> 180160-179155-159150-154130-149120-129111-119< 110
Serum potassium level [mmol/l]> 7 6-6.95.5-5.93.5-5.43-3.42.5-2.9< 2.5
Serum creatinine level
[mg/dl]
> 3.5 2-3.41.5-1.90.6-1.4< 0.6
Hematocrit
[%]
> 60 50-5946-49.430-45.9 20-29.9< 20
White blood cell count
[103/μl]
> 40 20-3915-19.9 3-14.9 1-2.9< 1
Bicarbonate level
[mmol/l]
> 5241-51.932-40.922-31.9 18-21.915-17.9< 15
FG etiology
The etiologic factor for FG is successfully established in over 90% of cases. It should be sought since the treatment and prognosis are dependent on it (3). In some cases the etiologic factor cannot be determined due to necrotic lesions. Every process during which pathogens enter the subcutaneous tissue of the anorectal area may be the starting point for a severe infection. The infection may spread to the genitourinary organs, in the anal and rectal region, to the skin in these areas and in the retroperitoneal space. The area of the genitourinary organs is the most common location for the development of the etiologic factor, diseases of the urethra being the primary one. The knowledge of the anatomy of these regions is necessary to understand the etiology and pathogenesis of fulminant infections. The causes of FG are listed in table 2. Each of the listed areas may be the source of infection with a spread through interfascial spaces causing proliferative fasciitis (4-8). Although FG is found primarily in older men, it may occur at any age and only 10% of cases are found in women (7, 9). The FG causes specific for women include pudendal nerve block, episiotomy for a natural childbirth, septic miscarriage, hysterectomy, Bartholin’s gland abscess and vulvar abscess. In the vast majority of cases patients with FG have comorbidities that cause a compromised blood flow or immunity impairment, which increases their susceptibility to infection with a mixed flora (tab. 3). FG is often the result of a primary condition such as diabetes, genitourinary tuberculosis, syphilis and HIV infection. Diabetes is the most common comorbidity and is found in approximately 60% of patients with FG. Patients with diabetes suffer from urinary tract infections more frequently due to cystopathy and urinary stasis (4). Hyperglycaemia decreases cell immunity by reducing phagocytic activity. It compromises leukocyte chemotaxis to inflammation sites as well as reducing neutrophil adhesion and intracellular processes of pathogen destruction by oxygen. Wound healing is also impaired as a result of compromised epithelialisation and deposition of collagen (10-12). Apart from hyperglycaemia, diabetic patients also have impaired microcirculation, which contributes to a significant extent to the pathogenesis of PG. It is also noteworthy that diabetes increases the risk of PG, but does not increase its mortality (4, 13). Factors which increase the risk of FG include chronic alcoholism, malnutrition, cirrhosis and poor personal hygiene (tab. 3). Other factors which compromise immunity and may predispose individuals to the development of FG are chronic steroid therapy, organ transplant, chemotherapy for cancer such as leukaemia and HIV infection (14). The rising incidence of HIV is accompanied by an increase in the incidence of FG, especially in Africa. FG may be the first symptom of HIV infection (14, 15). Risk factors include CD4 count below 400, chemotherapy for Kaposi sarcoma and the placement of a femoral venous line for intravenous drug administration. Patients with HIV and FG are younger and have a broader spectrum of pathogenic bacterial flora.
Tab. 2. Causes of Fournier’s gangrene
Genitourinary system
Urethral stenosis
Prolonged presence of a urinary catheter in the urinary tract
Prolonged use of a condom
Kidney stones
Urethritis
Transurethral surgery
Inflammation of the periurethral glands and a periurethral abscess
Genitourinary tuberculosis
Urethral cancer
Prostate biopsy
Prostate massage
Prostate abscess
Placement of a penile implant
Erectile ring for the treatment of erectile dysfunction
Iatrogenic trauma
Genital warts burning
Circumcision
Prolonged priapism
Non-iatrogenic perineal trauma
Animal, insect and human bites
Scrotal abscess
Testicular hydrocele infection
Status post testicular hydrocele removal
Vasectomy
Balanitis
Paraphimosis
Colorectal causes
Intersphincteric, perianal and ischioanal abscess
Rectal mucosal biopsy
Hemorrhoid ligation
Anal dilation
Cancers of the rectum and sigmoid colon
Diverticulitis
Rectal perforation by foreign body
Colitis due to ischemia
Rectal stenosis
Skin causes
Exudative purulent dermatitis
Skin glands inflammation
Scrotal decubitus
Post-surgical scrotal wound infection
Scrotal cellulitis
Gangrenous purulent dermatitis
Abscess of the thigh associated with intravenous drug abuse
Retroperitoneal space
Psoas major muscle abscess
Perirenal abscess
Appendicitis and periappendiceal abscess
Pancreatitis with retroperitoneal fat necrosis
Other
Plastic surgery of inguinal hernia
Filariasis in endemic areas
Strangulated hernia
Tab. 3. Diseases predisposing patients to Fournier’s gangrene
Diabetes
Chronic alcoholism
Malnutrition
Obesity
Cirrhosis
Poor personal hygiene
Immunosuppression:
– chronic steroid therapy
– status post organ transplant
– chemotherapy for cancer
– HIV/AIDS
Tuberculosis
Syphilis
Fournier’s gangrene microbiology
One of the characteristic features of FG is infection with a mixed bacterial flora. On average four types of microorganisms are grown in a culture test (4). The broad spectrum of microbes includes aerobic and anaerobic bacteria, Gram-positive and Gram-negative strains, fungi and even mycobacteria (tab. 4). The most commonly found microbes include: Escherichia coli, Bacteroides, beta-haemolytic streptococci, staphylococci and Proteus. These bacteria colonise the gastrointestinal tract, skin and perineal hair follicles (3). Mixed bacterial flora acts synergistically in the development of fulminant necrotizing fasciitis. Anaerobic bacteria produce gas in subcutaneous tissues which causes a characteristic symptom of crepitus on palpation. A Clostridium infection is classically associated with the formation of gas; it is not a common infection, but must be taken into account in infections originating from the colon (4). It is very important to collect material for the identification of the organisms responsible for the infection so that an appropriate antibiotic may be selected. Due to the difficulties associated with growing anaerobic microbe cultures, during the first surgical debridement of the wound subcutaneous tissue fluid aspirate and a fragment of the infected tissue should be collected for microbiological testing for anaerobic bacteria. Microbiological testing should be extended to cover mycobacterium tuberculosis and fungal infections.
Tab. 4. Most common pathogens causing Fournier’s gangrene
Gram-negative
E. coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Proteus mirabilis
Enterobacteria
Gram-positive
Staphylococcus aureus
Beta-hemolytic streptococci
Streptococcus faecalis
Staphylococcus epidermidis
Anaerobic bacteria
Bacteroides fragilis
Peptococcus
Fusobacterium
Clostridium perfringens
Mycobacteria
Mycobacterium tuberculosis
Fungi
Candida albicans
Pathogenesis of FG

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Piśmiennictwo
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otrzymano: 2016-08-29
zaakceptowano do druku: 2016-09-13

Adres do korespondencji:
*Jacek Wadełek
Oddział Anestezjologii i Intensywnej Terapii Szpital Chirurgii Urazowej św. Anny w Warszawie Mazowieckie Centrum Rehabilitacji „STOCER” Sp. z o.o.
ul. Barska 16/20, 02-315 Warszawa
tel. +48 (22) 579-52-58
e-mail: WAD_jack@poczta.fm

Nowa Medycyna 3/2016
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