Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. Rick Robbins, M.D.

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

Read More
Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Necrotizing Soft Tissue Infection

Figure 1. Axial view showing extensive gluteal and perineal soft tissue inflammation with gas formation (arrow).

 

Figure 2. Saggital view showing gas formation (arrow).

 

A 70-year-old man with a history of coronary artery disease, chronic back pain, and general debilitation presented to the emergency department with complaints of fever, weakness and right buttock discomfort. Physical exam was remarkable for a temperature of 101.7º F, and for moderate erythema of the skin of the right inguinal area and right buttock, with associated tenderness. Laboratory exam was significant for a WBC of 22.7 K/ɥL, erythrocyte sedimentation rate of 82 mm, and serum creatinine phosphokinase of 2856 U/L. CAT of the abdomen and pelvis demonstrated extensive gluteal and perineal soft tissue inflammation with gas formation, consistent with a necrotizing soft tissue infection (Figures 1 and 2).

Three basic subsets of necrotizing soft tissue infections (NSTIs) have been described. Type I infections are the most common form and are characterized by a polymicrobial process typically involving gram positive cocci, gram negative rods, and anaerobes. Type I infections occur most commonly in diabetics, in patients with severe peripheral vascular disease, or in the presence of other immune compromising conditions.  Type II infections involve Group A Streptococcus, either alone or in combination with Staphylococcus aureus. Type II NSTI’s occur most commonly in immunocompetent hosts. Type III NSTI’s, caused by Vibrio vulnoficus, are found in patients with exposure to warm sea water, with liver disease being the most common predisposing condition (1-3). Fournier’s gangrene is a NSTI that involves the perineum (2).

Physical examination often reveals fever and local erythema or tenderness. Gas formation may be present on imaging studies, with CAT scans more sensitive than plain films (1). Treatment relies on early antibiotic therapy with anaerobic coverage, fluid resuscitation, and aggressive debridement. Hyperbaric oxygen therapy may have a role as well (1). Mortality is high, in the range of 40%, and recovery is often prolonged (1,3).

Angela Taylor MD, Milena Beer PA, and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

  1. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. [CrossRef] [PubMed]
  2. Pucket Y, Fisher B, Dissanaike S. Clinical comparison of Fournier's gangrene to other necrotizing soft tissue infections. Research Journal of Infectious Diseases. 2015;3:1. [CrossRef]
  3. Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy. 2015 Feb 16;8:1-7. [CrossRef] [PubMed] 

Cite as: Taylor A, Beer M, VanHook CJ. Medical image of the week: necrotizing soft tissue infection. Southwest J Pulm Crit Care. 2016 Mar;12(3):102-3. doi: http://dx.doi.org/10.13175/swjpcc005-16 PDF

Read More