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Fournier's gangrene or synergistic gengrene of scrotum and penis is a relatively rare but serious condition which can occur in any general or hospital practice. Early diagnosis with prompt aggressive treatment including antibiotics and surgical debridement are necessary to achieve patient survival. We report our clinical experience with three cases which occurred in three different hospitals in the Irish Republic. In two of these cases diabetes mellitus was an important predisposing factor. All three patients underwent surgery as well as antibiotic treatment in spite of which one patient failed to survive.

The method of treatment after Ilizarov was used in 28 patients with occlusion of lower extremity arteries, mainly of distal localization, with the III and IV degrees of ischemia. Osteotomy of mainly the tibial bone and distraction of the free osseous split was performed during 31-36 days. Two patients had fractures of the bone during operative interventions, after operation four patients had purulent complications or necrosis of the skin around the wire. The immediate positive result was noted in 20 patients. Their fate was followed-up in remote periods from 2 to 19 months, good results were observed in 18 patients. The use of the Ilizarov method was most justified in patients with the III and IV degrees of ischemia when other methods of treatment failed to give any effect and surgical reconstruction of the vessels is impossible. When treating patients with the IV degree, it is necessary to take into consideration the late appearance of revascularization and possibility of temporary deterioration. The use of the Ilizarov method foresees provision of the joint work of an angiosurgeon and a traumatologist-orthopedist.

A severe case of pyoderma gangrenosum in a Papua New Guinean girl aged 11 years in reported. Multiple lesions of the arms, legs, buttocks and mouth were present. There was no associated disease. She was treated with very high doses of prednisolone and slow resolution over 3 months in hospital was observed.

Nine cases of Fournier's gangrene diagnosed between 1982 and 1989 are reported. All were males with a mean age of 76 (47-82 years). Seven had a history of alcoholism and one had non insulin-dependent diabetes. Six patients also had an anal fistula which may have been the starting point of the infection. The causal agents were two anaerobes (Clostridium perfringens and Bacteroides fragilis) two gram-negatives (Morganella morgagni and Pseudomonas aeruginosa) and one, an unidentified gram-positive. In three patients a mixed intestinal flora was isolated and in another no germs were found. All were treated with broad-spectrum antibiotics and surgery. Seven patients survived and two died.

The diagnosis of Fournier's gangrene is usually simple. However, as this case illustrates, there are occasions when the clinician may be misled.

A 28-year-old man presented with painful progressive necrosis of the skin of his left leg which was associated with general toxicity and a high fever. A working diagnosis of necrotizing arachnidism was made, but no improvement followed two weeks of therapy with analgesics, antibiotics and antihistamines. His symptoms responded rapidly to prednisolone therapy, and a diagnosis of pyoderma gangrenosum was confirmed by biopsy. This subsequently proved to be associated with early acute myelomonocytic leukaemia.

Pathophysiological mechanisms of Fournier's gangrene are reported. Variety and progression of clinical manifestations are stressed as well. The importance of an accurate therapeutic protocol in the treatment of this peculiar and serious disease is therefore underlined.

Eighteen well-documented cases of pulmonary gangrene as a complication of bacterial pulmonary infections have been reported in the literature. These infections were due to Klebsiellapneumoniae, Streptococcus pneumoniae, and Hemophilus influenzae. We describe four patients with pulmonary tuberculosis who developed pulmonary gangrene. Vascular thrombosis and arteritis were found in three of these four patients, and this vascular complication seems to be necessary for the development of pulmonary gangrene.

An 11-month old male infant presented with dry idiopathic peripheral gangrene (IPG) of both feet. Subsequently spontaneous autoamputation occurred and the stump healed. Including this patient, 8 cases of IPG under 12 years of age seen at the Kenyatta National Hospital between 1978 and 1986 were analysed. 5 were males and 3 were females. All the 8 children except one had an illness preceding IPG. The literature is reviewed and the management is discussed.

Sonographic findings were analyzed in 19 patients with surgically proved gangrenous cholecystitis. In 8 patients (42%), there were no specific features that would allow differentiation from typical uncomplicated acute cholecystitis. However, in 11 patients (58%) atypical findings were present, including intraluminal membranes and/or marked irregularities of the gallbladder wall. These features are unusual in uncomplicated acute cholecystitis and should prompt close clinical observation for possible gangrenous cholecystitis.

The identification of gangrenous bowel in neonates with enterocolitis is essential for proper timing of surgical intervention. The use of sonography to identify the presence of gangrenous bowel is illustrated.

Fluorescein angiography (FA) was performed on 83 patients (68 diabetics) with foot ulcer or gangrene. Densitometric measurements were made on the FA images, and different FA parameters were defined. These parameters, as well as systolic ankle and toe blood pressures, were evaluated for predicting the future course, i.e., whether healing would occur or whether major amputation below or above the knee had to be performed. The toe slope (i.e., the rate of increase of fluorescence on the big toe during the first 10 seconds after its appearance on the toe) predicted healing correctly in 0.83 and major amputation in 0.88. The ankle and toe pressures had only slightly lower predictive value. The combination of ankle pressure and toe slope predicted healing correctly in 0.91 and major amputation in 0.88. When ankle pressure cannot be measured, FA is the method of choice. Further, FA provides information on regional blood flow unobtainable by any other method.

Fifty-two premature, low birth weight infants presented mainly in the first week of life with sudden manifestations of intestinal ileus and an x-ray picture of pneumatosis intestinalis. Twenty-two of 32 patients treated with gastric decompression, antibiotics, intensive supportive therapy and intravenous hyperalimentation survived. Twenty other patients had progression of their disease and required operation. Twelve of these patients survived. Review of this material indicated that some medically treated patients might have survived if they had been operated upon. Indications for operation included free perforation and clinical signs of deterioration. Abdominal physical findings and x-rays were not reliable except as signs of far advanced pathology. Confirmation of ascites by paracentesis and gram stain of fluid was helpful when present. If patients were adequately treated and then developed sudden hyponatremia or progressive acidosis, they invariably had gangrenous bowel and required operation. The most striking finding was that a sudden, profound drop in the platelet count to levels below 100,000 reliably predicted the presence of gangrenous bowel and the need for operation. Other clotting studies indicated that disseminated intravascular coagulation is an important accompaniment of NNE with the complication of bowel gangrene prior to perforation. Gastrostomy and resection of involved bowel with staged anastomosis proved to be the most successful form of surgical management. Overall suvival was 66 per cent.

Transcutaneous oxygen tension at 44 degree C and maximal isotope clearance (90m Tc-pretechnetate + histramine) just proximal to the 1st toe and systolic toe blood pressure (strain gauge) were studied on a tilt table in patients with various degrees of obstructive arteriosclerotic disease. In legs with moderate obstruction, the oxygen tension reached zero at a toe systolic blood pressure of 5--10 mmHg (tilt toe up) and reached arterial oxygen tension at about 50 to 70 mmHg (tilt toe down). In legs withsevere arterial obstruction and ischaemic rest pain, oxygen tension rose from zero not before systolic toe blood pressure reached 20--50 mmHg. Significant isotope clearance was seen at pressures below the limits just mentioned for both types of patients. This phenomenon here seen of a perfusion without oxygen supply is explained by a gas leak (rendered significant because of the slow flow rate) from the arterioles into the tissue sink and counter current gas shunting. The hypoxia in spite of a positive perfusion pressure up to 50 mmHg explains our experience that ischemic ulcers in feet such low pressures never heal.

This report discusses the role of digital subtraction angiography as well as noninvasive vascular testing in the evaluation of the ischemic foot. A case history is described presenting the diagnostic modalities and surgical management of an insulin-dependent diabetic man with gangrene.

Ten patients with pregangrenous and gangrenous changes of the toes in the presence of normal peripheral pulses are described. In the absence of diabetes this is an uncommon condition and is only rarely reported upon in the literature. Four patients had non occlusive arteriosclerotic changes in large arteries; three suffered from thrombocytosis and one from polycythemia vera; one patient had a monoclonal gamopathy and one was exposed to cold three months before the onset of gangrene. None of these patients smoked regularly. Severe pain usually preceded the gangrene. The process did not progress proximally in any patients, and in those who underwent toe amputations the healing was uneventful. Vasodilators and low-molecular dextran were not effective. Lumbar sympathectomy was performed in three patients, also with no effect on the course of the disease. Treatment of hematological disorders gave relief in three patients. Proximal arteriosclerotic changes should be corrected if possible to eliminate a source of emboli. In two patients anti-platelet aggregation agents provided relief. Toe amputation should be conservative and performed when definite demarcation appears between necrotic and viable tissue. This condition has a benign prognosis.

The authors stress the importance, in acute symmetric polygangrene of the extremities, of systemic disease accompanied by decreased perfusion with its physicochemical consequences on parietal structures and the liquid contents of vessels and tissues developing rapidly in the extremities. In the first chapter, they recall the various aetiologies proposed in the literature. They then describe 3 personal case studies which they have chosen for their extreme age range and their varying aetiology. They present the various pathogenic factors which can occur either in isolation or in combination: parietal factors, abnormalities of the various elements of the blood, plasma factors, all of which are responsible for rheological disturbances which, when combined with decreased perfusion, lead to the development of gangrene. Finally, they present their ideas about treatment which sould be a function of the aetiology and the stage of the disease at the time of diagnosis.

Amputation is a complex problem for a patient, the health care system, and the country. Every endeavor should be made to try to reduce the incidence of amputation. The only way this can be done is by identifying the causative problems and designing interventions to solve those problems. The new era of amputation prevention for the patient with diabetes includes the development of comprehensive wound or foot care programs that use state-of-the-art noninvasive vascular testing, quality angiography, distal vascular reconstruction procedures, aggressive infection control, total contact casting as appropriate, use of growth factors to enhance wound healing, use of orthotic shoes to prevent recurrence, and extensive patient education. By implementing these new systems into the health care system, data for amputation incidence hopefully will be reduced in the future.

A case of a 4-month-old girl with dermatitis gangrenosa infantum is reported. The lesions were seen on the cheeks and later at the site of blood examination on the earlobes. The patient was successfully treated with antibiotics and then by skin grafting.

A rapid non-invasive test for the presence of B. melaninogenicus in the wounds of crepitant non-clostridial gangrene is described. The wounds are viewed under an ultraviolet light, and the presence of bright red fluorescene indicates the probable presence of B. melaninogenicus.

This report is concerned with a short review of 3 reported cases in which rare successive complications occurred in various lapses of time after vascular reconstructive operations. In one, 38 year old man, in a 12 year period after primary endarterectomy of aortic bifurcation and common iliac arteries the following complications occurred consecutively: an aneurysmal formation in the iliac artery with urethero-aneurysmal fistula and severe bleeding from the urinary tract, entero-prosthetic fistula with severe gastro-intestinal bleeding, occlusion of the left iliac artery with severe left leg ischaemia. They were surgically corrected each time with a satisfactory result. In another, a 25 year old man, a traumatic lesion of the iliac artery with false aneurysmal formation took place. After an emergency excision of the aneurysm with graft replacement, early bleeding occurred from the operative wound. It was treated conservatively, which resulted in infection of the graft and crawling sepsis which lasted 6 months. Urethero-prosthetic fistula and occlusion of the femoral artery occurred. It was corrected surgically with a satisfactory result. The last case concerned a 53 year old man with atherosclerotic occlusion of the abdominal aorta, external iliac and femoral arteries. An aorto-bilateral femoral bypass graft was instituted in him. In 10 days, complete gangrene of the sigmoid colon with perforation occurred. Sigmoidectomy with colostomy were performed. After that, further complications developed: (1) massive venous thrombosis of the left leg and (2) progressive left buttock necrosis. The last complication resulted in septicemia and death of this patient after 3 months of treatment.

Detection of intestinal ischemia, prior to necrosis, is a major clinical problem. The lysosomal acid hydrolase, hexosaminidase (HEX), is known to be elevated in intestinal infarction. To determine if this enzyme could differentiate between partial intestinal ischemia and full-thickness intestinal gangrene, the following rat study was designed. Partial segmental intestinal ischemia was created by ligating alternate vascular bundles over a short (6 vessel) segment of the small-bowel mesentery, and complete segmental intestinal vascular occlusion was achieved by ligating the blood supply to the ileocecal segment. Preoperative serum HEX values were obtained from 15 animals. The rats were separated into one sham-operated and two intestinal ischemia groups. At four hours after surgery HEX values were determined. Total HEX activity was significantly elevated four hours after insult in both partial and complete intestinal ischemia, (P less than 0.005 and P less than 0.001 respectively). Total HEX activity was greater in complete intestinal ischemia than in partial ischemia, (P less than 0.05). Three neonates with intestinal perforation, secondary to necrotizing enterocolitis, were evaluated. The mean preoperative HEX activity was 1421 nmol/hr/mL serum and the mean post-resection HEX activity was 808 nmol/hr/mL serum. These data suggest that serum HEX activity may be a good marker for intestinal gangrene in neonates with necrotizing enterocolitis.

The challenge presented to the surgeon by infants with NEC is to time an operation to coincide with the finite interval between infarction of gut and perforation. This study describes a new technique for continuous monitoring of peritoneal fluid in a rabbit model of intestinal ischemia to aid in predicting this interval. Color change to brown appears to be a reliable indicator of infarction. A sudden dramatic rise in the WBC of this fluid may also be an easily obtained, useful parameter. Further clinical studies of this method seem warranted to help improve the still dismal outcome of this disease.

A retrospective and comparative study of 127 case reports of Meleney's postoperative progressive synergistic gangrene and of 62 examples of postoperative amoebic skin gangrene, showed that these two entities were clinically indistinguishable and that therefore a purely clinical diagnosis of Meleney's gangrene could not be made. Furthermore, a critical appraisal of the bacteriological data indicated that a certain diagnosis of Meleney's gangrene cannot be provided by the clinical bacteriologist. Finally, the histological features were entirely non-specific thus precluding a definitive diagnosis by the histopathologist. If Meleney's entity cannot be diagnosed its existence becomes debatable. The alternative diagnosis of cutaneous amoebiasis is advanced for consideration. Several of the outstanding features of Meleney's progressive gangrene, hitherto unexplained, are better understood if Entamoeba histolytica is accepted as the prime cause rather than bacteria.

Twelve cases of necrotizing infections of the perineum were seen over a 18 months period. The etiology was various. This serious affection seems to be more frequent now. The diagnosis is often late, particularly in the rectal injuries with a foreign body. Cellulitis was constant. Severe myonecrosis was present in 6 cases. Anaerobic organisms were found in 50% of the cases. Treatment consisted of initial radical debridement and repeated surgery, antibiotics, and hyperbaric oxygen which was systematically used in our cases. The importance of a diverting colostomy that was done in 10 cases was emphasized. The aggressiveness and advancing nature of the infection with myonecrosis, delayed diagnosis and delayed treatment, were the primary factors responsible for death. 4 of the 12 patients died.

We followed up 133 patients with claudication to determine the prognostic value of dependent rubor. Life tables analysis was used, with a threatened limb as the endpoint. A threatened limb was defined as the development of ischemic rest pain, skin ulceration, or gangrene. At four years, the rubor group had a limb-threat incidence of 25%, compared with only 9% in the nonrubor group. While not indicative of imminent limb loss, the presence of dependent rubor defines patients whose limb risk is greater than in those with claudication alone.

Twenty patients with acute dermal gangrene following surgery, trauma or sepsis are described. In 12 the skin became gangrenous secondary to a necrotizing process affecting the subdermal fascia, and in 8 the condition arose primarily in the skin. In the first group mortality was high unless radical excision of the necrotic fascia was performed at an early stage; in 3 of the recent patients the overlying skin was removed, defatted and stored for later grafting. In the second group, incision and adequate drainage combined with antibiotics seemed to suffice. Hyperbaric oxygen was of dubious value in the first group but appeared to contribute to arrest of the lesion in the second group.