Les gangrènes des organes génitaux externes: à propos de 102 cas

Objectives

To describe the epidemiological, clinical, biological and therapeutic features of Fournier’s gangrene and identify the prognostic factors.

Patients and methods

We conducted a retrospective study on 102 cases of Fournier’s gangrene treated at the urology department of the university teaching hospital Aristide- Le-Dantec (Dakar) between January 2001 and December 2007.

Results

The mean age of the patients was 50.0 ± 15.7 years (range: 20–93 years). The mean duration of hospital stay was 8.0 ± 7.1 days (range: 1–33 days). The lesions were located on the scrotum in 61.7% of cases, on the scrotum and penis in 17.6% of cases and on the penis alone in 3.9% of the cases. Perineal involvement was found in 14.7% of the cases. No etiologic factors (idiopathic) were found in 26 cases (25.5%) and 70 patients (68.6%) had Fournier’s gangrene secondary to urethral stricture. The most common predisposing factors were diabetes mellitus (13.7%), hypertension (5.9%), and renal failure (5.9%). Biological examination revealed that 79.4% of patients had a leukocytosis higher than 12,000/ml and the mean rate of haemoglobin was 9.8 ± 2.8 g/dl (range: 3.3–13.9 g/dl). The most common antibiotherapy associated a third generation cephalosporin, aminoside and metronidazole (46.1%). Twenty-one patients (20.6%) underwent extensive debridement only and eighty-one (79.4%) underwent extensive debridement and cystostomy. The death rate was 15.7%. Among the patients whose Fournier’s gangrene was idiopathic or secondary to urethral stricture, the statistically significant factors for a poor outcome were age, the secondary character of the gangrene, the extent of the lesions, and association with diabetes mellitus and/or hypertension.

Conclusion

Fournier’s gangrene is still a frequent and lethal disease. Its good management requires a multidisciplinary approach.     

Les urgences urologiques au centre hospitalier national de Nouakchott : aspects épidémiologiques, cliniques et thérapeutiques

Objective

To present the epidemiological, clinical and therapeutic features of urological emergencies in Mauritania, West Africa.

Material and methods

The authors conducted a 5-year retrospective study that analyzed the epidemiological, clinical and therapeutic features of all urological emergencies admitted to the urology department of Nouakchott Central Hospital.

Results

There were 1,200 urological emergencies. The mean age of the patients was 58.8 years (range one month-94 years). These patients had an age ≥60 years in 50.7% of the cases The sex ratio (M: F) was 20: 32. The most frequent illnesses were urinary retention (53%) and genitourinary system infections, which represented 16.8% of the cases. The gangrenes of male external genitalia (Fournier’s gangrene) accounted for 4.3% of the cases and priapism 1.8%. In emergency, 300 surgical operations were performed. The most performed procedures were the installation of a suprapubic catheter (59.7%) and debridement of a gangrene of male external genitalia (16%).

Conclusion

The most frequent urological emergency in our country was acute urinary retention. Serious illnesses, like gangrene of male external genitalia (Fournier’s gangrene) and priapism, are not rare there.     

Gangrène des organes génitaux externes (GOGE): traitement chirurgical et reconstruction plastique

Objective

To present the various types of surgical reconstruction of Fournier’s gangrene and their outcome.

Patients and methods

It is a retrospective study conducted on 14 patients with Fournier’s gangrene treated at the Urology Department of Teaching Hospital of Cocody (Abidjan-Côte d’Ivoire) between January 2000 and June 2009.

Results

The mean age of the patients was 39 years (range: 20–67 years). All the patients were black and presented infectious symptoms, which were treated by hydroelectrolytic reanimation and ant biotherapy. The lesions reached down all the penis and the scrotum in 64.29% of the cases (N = 9) and on the scrotum and perinea in 35.71% of the cases (N = 5). The lesions require extensive debridement and local bandages. All of the patients were cured (100%). In three patients (21.43%), the lesions with bandages only to tiny scrotum lesions healed spontaneously. In nine patients (64.29%), it got healed after debridement suture without tension of the scrotum skin, and in the two patients (14,28%), the one with wide wound of penis, scotum and perinea, then the other with penile skin loss, were healed after skin graft taken with inner face of the thigh.

Conclusion

Fourniers gangrene still remains a severe disease. Management of this gangrene requires a multidisciplinary approach. The plastic surgical reconstruction restores an adequate environment to penis and scrotum, which does not compromise the quality of the sexual relations and the reproductive function of the testicles, especially in young men.     

La gangrène des organes génitaux externes de I’homme: Facteurs de risque et de pronostic

The objective of this study, based on 20 cases of necrotizing fasciitis of the male genitalia, is to identify the risk factors and prognostic factors of this disease. Most cases of necrotizing fasciitis of the male genitalia occurred in elderly men with a poor socio-economic level including 9 diabetics. There was no identifiable cause in 8 cases (Fournier’s gangrene). All patients underwent surgical excision and systematic antibiotic therapy. This series comprised 5 deaths (25%) in patients over the age of 69 years with extensive lesions and a very poor general state on admission. The outcome of survivors was favourable after a prolonged hospital stay (mean stay: 1 month). The clinical context therefore appears to play an essential role in the development of this disease and its subsequent prognosis, which could be improved by rapid and appropriate prevention and treatment.     

Effect of continuous sub-culturing on infectivity of <Emphasis Type="Italic">Clostridium perfringens</Emphasis> ATCC13124 in mouse gas gangrene model

Clostridium perfringens is a Validated Biological Agent and a pathogen of medical, veterinary, and military significance. Gas gangrene is the most destructive of all the clostridial diseases and is caused by C. perfringens type A strains wherein the infection spreads quickly (several inches per hour) with production of gas. Influence of repeated in vitro cultivation on the infectivity of C. perfringens was investigated by comparing the surface proteins of laboratory strain and repository strains of the bacterium using 2DE-MS approach. In order to optimize host-pathogen interaction during experimental gas gangrene infection, we also explored the role of particulate matrix on ability of C. perfringens to cause gas gangrene.     

Solitary Candida albicans Infection Causing Fournier Gangrene and Review of Fungal Etiologies

Polymicrobial bacterial infections are commonly found in cases of Fournier gangrene (FG), although fungal growth may occur occasionally. Solitary fungal organisms causing FG have rarely been reported. The authors describe a case of an elderly man with a history of diabetes who presented with a necrotizing scrotal and perineal soft tissue infection. He underwent emergent surgical debridement with findings of diffuse urethral stricture disease and urinary extravasation requiring suprapubic tube placement. Candida albicans was found to be the single causative organism on culture, and the patient recovered well following antifungal treatment. Fungal infections should be considered as rare causes of necrotizing fasciitis and antifungal treatment considered in at-risk immunodeficient individuals.Key words: Fournier gangrene, Fournier’s Gangrene Severity Index, Candida albicansFournier gangrene (FG) is a rare, rapidly progressive, necrotizing infection of the perineum and genital area that was first described in 1883 by Jean Alfred Fournier in five young male patients.¹ The infectious flora causing necrotizing fasciitis are typically polymicrobial, involving aerobic and anaerobic bacteria derived from gastrointestinal, genitourinary, and cutaneous sources.^2,3 Certain predisposing conditions increase the risk of developing FG, including diabetes, chronic kidney disease, immunosuppression, local trauma, urethral stricture, or genitourinary infections.^4–6It is essential to diagnose FG early and treat it emergently because the infection can quickly progress, with mortality rates of 7.5% to 50% cited in various series.^7,8 Aggressive management involves hemodynamic stabilization, broad spectrum antibiotics to empirically cover all potential organisms, and wide surgical debridement.^3–5 Early surgical debridement with excision of all nonviable tissue is the most important component of treatment. Multiple surgical debridements are often required, as the areas of cutaneous involvement may not indicate the full extent of subcutaneous disease.⁵Rapid initiation of broad spectrum antibiotic coverage is also necessary to stabilize the presenting patient with FG before and after surgical management. The infection is generally caused by three or more microorganisms, most commonly Escherichia coli, Proteus, Enterococcus, and anaerobes.⁴ Fungal etiologies of necrotizing infections are rare but have been increasingly reported in the literature.^9–12 Candida species are commonly part of the normal flora in the gastrointestinal and genitourinary tracts of humans but may cause acute disease in the setting of compromised host immunity. This report describes a case of primary C albicans necrotizing fasciitis of the genitalia and reviews the literature regarding fungal FG to determine possible predisposing factors.     

The effect of soil- and tuber-borne inoculum on the incidence of potato gangrene

Under optimum growing conditions neither tuber- nor soil-borne Phoma exigua var. foveata inoculum appreciably affected stand or yield of the subsequent potato crop. Seed tubers with gangrene rots caused high levels of stem and tuber symptoms when planted in var. foveata contaminated or uncontaminated land; contaminated seed tubers with no rots also produced progeny with a high gangrene potential. Sufficient soil-borne inoculum was carried over in land that produced a gangrene affected crop in the previous year to override the effect of tuber disinfection. Effective gangrene control was achieved by a combination of tuber disinfection shortly after harvest over successive years with a 1 in 5 yr potato crop rotation. Gangrene rots usually developed through injuries to the tuber periderm, rots in other tubers being associated with pustules of powdery scab (Spon-gospora subterranea).     

Control of potato gangrene by thiabendazole in relation to time of harvest after haulm destruction and site of production

The efficiency of thiabendazole in controlling gangrene on potato tubers harvested on different dates was assessed over two years in Scotland (East Craigs) and England (Rothamsted). At East Craigs the incidence of gangrene on wounded and cold-stored tubers was greater than on those tubers kept at ambient store temperatures and graded in January, but the assessments were correlated. The incidence of gangrene increased with delay in harvest after haulm destruction although the pattern differed with year and site. Dipping tubers in thiabendazole or sodium hypochlorite almost eliminated gangrene on all harvest dates at Rothamsted but at East Craigs the incidence of gangrene on dipped tubers was much greater and tended to increase the longer the interval between haulm destruction and harvest. Furthermore, dipping tubers in thiabendazole was much more effective than spraying even though the fungicide residues were twice as large with the latter treatment. All 43 isolates of Phoma foveata collected in Scotland were sensitive to thiabendazole in agar plate tests. The results are discussed in relation to disease development at each of the sites.     

Effects of fungicides applied to seed potato tubers at harvest or after grading on fungal storage diseases and plant development

An assessment was made over 3 years of the efficacy of thiabendazole, 2–aminobutane and a formulation of a mixture of thiabendazole and 2–aminobutane in controlling gangrene, skin spot and dry rot when applied either at harvest or after grading at different dates during the storage season.
After harvest applications, the incidence of gangrene was least on tubers treated with the mixture and generally greatest with thiabendazole. When applied after grading the efficacy of the fungicides was not affected by date of grading. Although 2–aminobutane applications at harvest or after grading were equally effective in controlling gangrene, thiabendazole and the mixture were less effective after grading where gangrene was prevalent in a stock. Thiabendazole and the mixture gave good control of dry rot when applied at harvest but were less effective when applied after grading, particularly late in the storage season. Dry rot was sometimes more prevalent on tubers fumigated with 2–aminobutane, especially those treated after grading. Skin spot was more effectively controlled by the mixture and 2–aminobutane than by thiabendazole but, with applications after grading, the efficacy of all fungicides declined the later the date of grading.
Plants grown from tubers treated with the mixture or its 2–aminobutane glycollate constituent exhibited characteristics associated with genetic variation.     

Virulence studies on chromosomal α-toxin and Θ-toxin mutants constructed by allelic exchange provide genetic evidence for the essential role of α-toxin in Clostridium perfringens-mediated gas gangrene

The pathogenesis of clostridial myonecrosis, or gas gangrene, involves the growth of the anaerobic bacterium Clostridium perfringens in the infected tissues and the elaboration of numerous extracellular toxins and enzymes. The precise role of each of these toxins in tissue invasion and necrosis has not been determined. To enable genetic approaches to be used to study C. perfringens pathogenesis we developed an allelic exchange method which involved the transformation of C. perfringens cells with a suicide plasmid carrying a gene insertionally inactivated with an erythromycin-resistance determinant. The frequency with which double reciprocal crossover events were observed was increased to a workable level by increasing the amount of homologous DNA located on either side of the inactivated gene. Allelic exchange was used to isolate mutations in the‘chromosomal pfoA gene, which encodes an oxygen-labile haemolysin known as Θ-toxin or perfringolysin O. and in the chromosomal pic gene, which encodes the α-toxin or phospholipase C. The resultant mutants failed to produce detectable Θ-toxin or α-toxin activity, respectively, and could be complemented by recombinant plasmids that carried the respective wild-type genes. The resultant strains were virulence tested in a mouse myonecrosis model. The results showed that the pic mutants had demonstrably reduced virulence and therefore provided definitive genetic evidence for the essential role of α-toxin in gas gangrene or clostridial myonecrosis.     

Peripheral gangrene in patients with severe falciparum malaria: report of 3 cases

Peripheral gangrene, characterized by distal ischemia of the extremities, is a rare complication in patients with falciparum malaria. Patients with this complication have generally undergone early amputation of the affected areas. In this report, we describe 3 adult Thai patients presented at the Hospital for Tropical Diseases, Bangkok, with high grade of fever ranged 6-9 days, jaundice, acute renal failure, respiratory failure, alteration of consciousness and shock. Two patients had gangrene developed at the lower extremities on day 1 of hospitalization and 1 patient had gangrene developed on day 3. Blood smears revealed hyperparasitemia with Plasmodium falciparum. These patients were diagnosed as having severe malaria with peripheral gangrene. The resolution of gangrene was successfully achieved by treatment with artesunate and conservative treatment in 2 of 3 cases.     

The role of seed-tuber and stem inoculum in the development of gangrene in potatoes

To determine the relative importance of seed tubers and stems as sources of inoculum for potato gangrene in progeny tubers, different levels of inoculum of Phoma exigua var. foveata were established in field experiments by planting rotting or contaminated seed tubers and by inoculating stems shortly before haulm desiccation. The pathogen was only occasionally detected by isolation from inside green stems in June and July on plants growing from contaminated but unrotted seed. The incidence of pycnidia on desiccated stems increased with increasing concentration of inoculum contaminating seed tubers and with increasing time interval between desiccation and harvest. Stem infection was probably derived from inoculum on seed tubers spreading via the soil to the stem bases. Stem inoculation of plants growing from uninoculated or uncontaminated seed greatly increased both the gangrene potential of progeny tubers (defined as % wounds with gangrene after uniformly damaging tubers and storing them at 5°C for 12 wk), and tuber contamination (defined as % wounds with gangrene after spreading tuber-borne soil onto test tuber slices and storing them at 5°C for 8 wk). However, when stems of plants growing from rotting or contaminated seed were cut at ground level and removed before desiccation, gangrene potential of progeny tubers was only slightly less than that of tubers from untreated plots. There was no evidence that soil inoculum or aerial spread played a significant role in disease development. Gangrene potential and contamination of progeny tubers were related to Contamination levels on seed tubers. Some transmission also occurred from rotted seed tubers to progeny. Inoculum levels around progeny tubers increased rapidly after desiccation even in plots where stems had previously been cut at soil level and removed to eliminate pycnidial development above ground as a source of inoculum. Both gangrene potential and contamination of progeny tubers were greater on cv. Ulster Sceptre than on cv. Pentland Crown. The results showed that the inoculum on seed tubers, whether from rots or surface contamination, contributed more to the contamination of progeny tubers at harvest than did the inoculum from pycnidia on stems following desiccation of the haulm.     

Effects of delaying fungicide treatment on the incidence of gangrene in stored potato tubers

Potato titbers infested with Phoma exigua var. foveata were uniformly wounded and sprayed or dipped in fungicide suspensions either immediately or after periods of up to 21 days' storage at 5, 10, 15 or 20 °C. Tubers were then stored at 5 °C and gangrene assessed after 12 wk. Incidence of gangrene on untreated tubers was progressively decreased by increasing the length of storage at 15 or 20° (curing) but was not affected by 3 days' storage at any temperature. Fungicide treatment immediately after wounding gave best control of the disease; treatment after 3 days' delay was less effective and after 14 or 21 days was usually ineffective. Gangrene was decreased by fungicides more on tubers stored for 3 or 7 days at 5 °C than at higher temperatures. Control of gangrene by curing or fungicides diminished when the amount of inoculum on tubers was increased. Increasing the amount of fungicide applied improved control and fungicides were more effective in decreasing gangrene on cut and crush wounds than on cut wounds. At the arbitrary concentrations used in these experiments imazalil gave better disease control than thiabendazole, prochloraz, carbendazim plus quinolin 8-ol or triadimefon.     

A recombinant carboxy‐terminal domain of alpha‐toxin protects mice against Clostridium perfringens

Clostridium perfringens alpha‐toxin (CP, 370 residues) is one of the main agents involved in the development of gas gangrene. In this study, the immunogenicity and protective efficacy of the C‐terminal domain (CP251‐370) of the toxin and phospholipase C (PLC; CB, 372 residues) of Clostridum bifermentans isolated from cases of clostridium necrosis were examined. The recombinant proteins were expressed as glutathione S‐transferase (GST) fusion proteins. Antibodies that cross‐reacted with alpha‐toxin were produced after immunization with recombinant proteins including GST‐CP251‐370, GST‐CP281‐370, GST‐CP311‐370, CB1‐372 and GST‐CB251‐372. Anti‐GST‐CP251‐370, anti‐GST‐CP281‐370 and anti‐GST‐CP311‐370 sera neutralized both the PLC and hemolytic activities of alpha‐toxin, whereas anti‐CB1‐372 and anti‐GST‐CB251‐372 weakly neutralized these activities. Immunization with GST‐CP251‐370 and GST‐CP281‐370 provided protection against the lethal effects of the toxin and C. perfringens type A NCTC8237. Partial protection from the toxin and C. perfringens was elicited by immunization with GST‐CP311‐370 and CB1‐372. GST‐CP251‐370 and GST‐CP281‐370 are promising candidates for vaccines for clostridial‐induced gas gangrene.     

The role of neutrophils and monocytic cells in controlling the initiation of Clostridium perfringens gas gangrene

Clostridium perfringens is a common cause of the fatal disease gas gangrene (myonecrosis). Established gas gangrene is notable for a profound absence of neutrophils and monocytic cells (phagocytes), and it has been suggested that the bactericidal activities of these cells play an insignificant role in controlling the progression of the infection. However, large inocula of bacteria are needed to establish an infection in experimental animals, suggesting phagocytes may play a role in inhibiting the initiation of gangrene. Examination of tissue sections of mice infected with a lethal (1 x 10(9)) or sublethal (1 x 10(6)) inoculum of C. perfringens revealed that phagocyte infiltration in the first 3 h postinfection was inhibited with a lethal dose but not with a sublethal dose, indicating that exclusion of phagocytes begins very early in the infection cycle. Experiments in which mice were depleted of either circulating monocytes or neutrophils before infection with C. perfringens showed that monocytes play a role in inhibiting the onset of gas gangrene at intermediate inocula but, although neutrophils can slow the onset of the infection, they are not protective. These results suggest that treatments designed to increase monocyte infiltration and activate macrophages may lead to increased resistance to the initiation of gas gangrene.     

Nitrosoguanidine-induced attenuated Clostridium perfringens type A mutant in gas gangrene]

A fully virulent classical type A strain of Clostridium perfringens was treated during its logarithmic growth phase with 100 mug/ml of N-méthyl-N'-nitro-N-nitrosoguanidine, the bacteria being exposed to the mutagen for 30 min at 37 degrees C in a phosphate buffer adjusted to pH 6.2; after treatment the suspension was streaked on sheep blood agar plates, and colonies that showed an alteration in the theta-hemolysis pattern were selected for isolation. The virulence of two mutants, thus altered in their theta-hemolysis, was studied. One, designated LNG 5, was still capable of killing most of the inoculated guinea pigs in less than 24 h with all the clinical, macroscopic, and bacteriological signs of gas gangrene; however, histological sections showed that tissue damage was not as marked as with the wild strain. On the contrary, the second mutant, labelled LNG 11, was completely avirulent as far as gas gangrene was concerned; indeed, the injection of fluid cultures containing 1 times 10(8) - 10(9)/ml viable bacteria, was not followed by any clinical, bacteriological, or histological signs of gas gangrene. However, strain LNG 11 did give rise to a firm swelling of the inoculated thigh with a corresponding acute inflammatory response of the connective tissue, although the muscle fiber was unaltered. Eventually, this local reaction was followed by necrosis of the skin accompanied by an acute or subacute inflammation with fibroblastic proliferation. These superficial lesions healed spontaneously. They could not be reproduced with crude filtrate alone or with washed bacilli. Strain LNG 11 was therefore considered to be soletly an attenuated strain since, although avirulent as far as gas gangrene is concerned. it is still capable of producing low levels of toxic material. This appears to be the first time that such a strain of C. perfringens type A has been obtained by nitrosoguanidine treatment.     

Factors affecting the occurrence of gangrene (Phoma exigua) in potatoes

The presence in soil from Scotland and England of Phoma exigua f. sp. exigua and P. exigua f.sp. foveata, which cause gangrene, is confirmed by isolation, and it is established that infection of tubers occurs before lifting, and after lifting from soil adhering to tubers. The distribution of the disease is related to soil moisture, gangrene being most prevalent in tubers from the north-eastern counties of Scotland where the moisture content of arable soils remains high throughout the growing season. The incidence of the disease may be affected by the haulm, either as a source of infection—though not an important source—or by its effect on the maturity of the tubers. The incidence of gangrene is less where haulm destruction is rapid. The incidence of gangrene in a crop is not related to its incidence in the seed tubers planted and, unless infection is severe, the effect on yield is not serious. Symptoms of skin necrosis were associated with tubers from acid soils, infected with P. exigua f.sp. foveata and stored at low temperature.     

The influence of potato harvesting and grading machinery on contact spread of Phoma exigua var. foveata on tubers

The incidence of wounds infected by Phoma exigua var. foveata was increased if freshly damaged tubers (recipients) were shaken in a bag with diseased tubers (donors) to simulate the tuber-to-tuber contact that occurs during potato handling. An increase in the number of gangrene rots on damage points also occurred if the recipient tubers were wounded after contact with the diseased tubers, rather than before, and when the donor tubers were heavily infested with P. exigua var. foveata but were free of gangrene lesions. Increasing the proportion of donor to recipient tubers increased the percentage of infected wounds on recipients. Increased incidences of infection in recipient tubers also occurred after they had been passed over an elevator digger when it was lifting stocks of tubers heavily infested with P. exigua var. foveata. When spores of an E +ve isolate of P. exigua var. foveata were sprayed onto the webs of manned potato harvesters, tubers harvested immediately after developed gangrene rots from many of which the E +ve isolate was cultured. An E +ve isolate was also used to demonstrate the transfer of P. exigua var. foveata inoculum from tubers onto soil on riddles of a potato grader and from these soil-coated surfaces onto other tubers during grading.