Medical Image of the Week: Fournier’s Gangrene with a Twist

Figure 1. A: Coronal view of abdominal CT scan showing extensive gas formation from the site of trauma (scrotum) ascending along fascial planes, encompassing abdominal wall and chest wall (arrows). B: Close up view of the scrotum and perineum showing tissue necrosis with gas formation. C: Sagittal view of the thoracic CT scan showing gas formation tracking along the chest wall and superior mediastinum (arrows).

Figure 2. Status post incision and debridement of scrotum and perineum.

A 37-year-old man presented with worsening left testicular pain, swelling and redness within 3 days of being poked by a safety-pin during foreplay. Over 24 hours, his left scrotum doubled in size with significant erythema, edema, crepitus and induration. Imaging of scrotum and legs revealed extensive gas formation extending to the retroperitoneum and ascending along fascial planes. Subcutaneous emphysema of abdominal wall, chest wall with mediastinal gas was noted. Investigation showed a shite blood cell count of 22,000 cells/mcL with 12% bands and HIV testing was negative. Intravenous vancomycin and ertapenem were administered on presentation followed by emergent bilateral debridement of the scrotum. Wound/tissue cultures grew methicillin sensitive Staphylococcus aureus, group B Streptococcus and anaerobic Bacteroides. Antibiotics were de-escalated to ciprofloxacin and metronidazole and the patient showed adequate recovery at 30 days of follow up.

Improved survival of Fournier’s gangrene can only be achieved by prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics.

Our case brings forward the act of piquerism, a paraphilia which led to rapidly progressive perineal tissue necrosis with bacterial synergism of non-clostridial micro-organisms causing extensive gas formation.

Padmastuti Akella, MD¹, Himmat Grewal MD¹, Imola Daniel MD²

¹Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA

²Division of Infectious Diseases, Saint Vincent Hospital, Worcester, MA

References 

1. Archer CB, Rosenberg WM, Scott GW, MacDonald DM. Progressive bacterial synergistic gangrene in patient with diabetes mellitus. J R Soc Med. 1984;77 Suppl 4:1-3. [PubMed]
2. Yasuda K, Hayashi M, Takeda N, Goshima E, Miura K. A survived case of diabetic nonclostridial gas gangrene and the review of the literatures on microbiological findings. Jpn J Med. 1986 May;25(2):171-4. [CrossRef] [PubMed]
3. Takazawa K, Otsuka H, Nakagawa Y, Inokuchi S. Clinical features of non-clostridial gas gangrene and risk factors for in-hospital mortality. Tokai J Exp Clin Med. 2015 Sep 20;40(3):124-9. [PubMed]
4. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-65. [CrossRef] [PubMed]

Cite as: Akella P, Grewal H, Daniel I. Medical image of the week: Fournier's gangrene with a twist. Southwest J Pulm Crit Care. 2018;17(1):28-9. doi: https://doi.org/10.13175/swjpcc083-18 PDF

Medical Image of the Week: Staphylococcal Pneumonia in a Patient with Influenza

Figure 1. Thoracic CT scan axial view demonstrating bilateral cavitary infiltrates.

A 63-year-old, obese diabetic man presented to his primary care physician with complaints of fever, headache, myalgias, and cough. A nasal swab specimen was positive for influenza A by fluorescent immunoassay. Therapy with oseltamivir was initiated. The patient’s symptoms progressed and he was transported to the emergency department , where he was found to have a room air oxygen saturation of 74%, bilateral basilar infiltrates on chest radiograph, a white blood count of 24.2 K/uL and a procalcitonin level of 12.66 ng/ml. He was placed on BIPAP with high flow supplemental oxygen,  started on empiric intravenous antibiotic therapy with vancomycin and piperacillin/tazobactam, and admitted to the intensive care unit.  Blood and sputum cultures were eventually positive for methicillin-sensitive Staphylococcus aureus, and the patient’s antibiotic therapy was de-escalated to nafcillin. On hospital day 5, a CT of the chest obtained to evaluate pleuritic pain revealed extensive bilateral cavitary infiltrates (Figure 1). The patient’s discomfort resolved without further intervention, he continued to improve, and was uneventfully transitioned to oral therapy. 

S. aureus pneumonia is characterized by high fever, productive cough, and a radiographic pattern of patchy, often multilobar, infiltrates which may exhibit cavitary change.  In the USA, approximately 2% of patients admitted to the hospital for treatment of community-acquired pneumonia demonstrate microbiologic evidence of S. aureus infection (1). There is a slight predominance of methicillin sensitive species (MSSA) compared to methicillin resistant species (MRSA).  Morbidity and mortality are both high, with over 80% of patients requiring care in the ICU, and a fatality rate of 13% (2).

Among patients admitted to the intensive care unit with a primary diagnosis of influenza, there is a 15% incidence of S. aureus pneumonia. Risk factors for co-infection in this setting  include obesity, HIV infection, and immunosuppressive medication. There is a robust association between bacteremia and mortality (3).  Early empiric antibiotic therapy with an agent active against S. aureus should be strongly considered for patients admitted to the ICU with influenza complicated by pneumonia, pending the return of blood and respiratory cultures.

¹Charles VanHook, ²Kristin Dahlem, and ¹Angela Taylor

¹Longmont United Hospital, Longmont, Colorado USA

²Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts USA

References

1. Jain S, Self WH, Wunderink R, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015 Jul 30;373(5):415-27. [CrossRef] [PubMed]
2. Self WH, Wunderink RG, Williams DJ, et al. Staphylococcus aureus community-acquired pneumonia: prevalence, clinical characteristics, and outcomes. Clin Infect Dis. 2016 Aug 1;63(3):300-9. [CrossRef] [PubMed]
3. Martin-Loeches I, J Schultz M, et al. Increased incidence of co-infection in critically ill patients with influenza. Intensive Care Med. 2017 Jan;43(1):48-58. [CrossRef] [PubMed]

Cite as: VanHook C, Dahlem K, Taylor A. Medical image of the week: staphylococcal pneumonia in a patient with influenza. Southwest J Pulm Crit Care 2017:14(4):170-1. doi: https://doi.org/10.13175/swjpcc045-17 PDF

Medical Image Of The Week: Tricuspid Valve Vegetation with Septic Pulmonary Emboli

Figure 1. Chest radiograph on presentation consistent with septic pulmonary embolic and cavitation.

Figure 2. Echocardiogram demonstrating a highly mobile echo-dense vegetation attached to the atrial side of the tricuspid valve.

A 28-year-old woman with a history of extensive intravenous heroin use presented to the hospital with generalized chest and abdominal pain. Vital signs were remarkable for hypotension, tachypnea, and tachycardia. Laboratory studies revealed leukocytosis, hyponatremia, acute kidney injury, and lactic acidosis. A radiograph of the chest demonstrated multiple airspace opacities throughout the bilateral lungs with associated cavitary lesions and a small right-sided pleural effusion (Figure 1). A transthoracic echocardiogram was obtained, which demonstrated a 3.6 cm x 2.0 cm tricuspid valve vegetation (Figure 2). Blood cultures identified methicillin-sensitive Staphylococcus aureus.

Infective endocarditis, valvular vegetation, and septic pulmonary emboli are common complications of intravenous drug use. Staphylococcus aureus is the most common bacterial cause of infective endocarditis among intravenous drug users (1). Like endocarditis, patients with septic pulmonary emboli often present with non-specific clinical manifestations such as fever (86%), dyspnea (48%), and chest pain (49%) (2). Management may be surgical or medical, and determining the best course is complicated by social and psychiatric factors affecting adherence to treatment. Cardiac valve surgery has been advocated early for large right-sided vegetations but carries high morbidity and expense, as well as risk of compromised recovery, in the setting of ongoing IV drug use. Even for patients with valvular vegetations ≥ 1cm, medical therapy alone may be a safe option under some circumstances in the absence of other surgical indications (3).

Sarah Harris BA¹, Kady Goldlist MD², Maria Tumanik DO², Cameron Hypes MD MPH^3,4

¹ University of Arizona College of Medicine

² Department of Internal Medicine, Banner University Medical Center – South Campus

³ Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

 ⁴Department of Emergency Medicine

University of Arizona

Tucson, AZ USA

References

1. Ortiz-Bautista C, López J, García-Granja PE, et al. Current profile of infective endocarditis in intravenous drug users: The prognostic relevance of the valves involved. Int J Cardiol. 2015;187:472-4. [CrossRef] [PubMed]
2. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med. 2014 Jan;108(1):1-8. [CrossRef] [PubMed]
3. Otome O, Guy S, Tramontana A, Lane G, Karunajeewa H. A retrospective review: significance of vegetation size in injection drug users with right-sided infective endocarditis. Heart Lung Circ. 2016 May;25(5):466-70. [CrossRef] [PubMed] 

Cite as: Harris S, Goldlist K, Tumanik M, Hypes C. Medical image of the week: tricuspid valve vegetation with septic pulmonary emboli. Southwest J Pulm Crit Care. 2016:12(6):253-4. doi: http://dx.doi.org/10.13175/swjpcc042-16 PDF