Apoorv Goel

Fournier’s gangrene: a rare manifestation of Chikungunya fever

Fournier’s gangrene was first described by the venereologist Jean Alfred Fournier in 1883 as fulminant necrosis of the scrotum and penis following urogenital infection. It is a necrotising fasciitis of external genitalia. Predominantly seen in elderly men, diabetics and immunodeficient patients, it is a polymicrobial infection caused mainly by Escherichia coli, Klebsiella, Staphylococcus aureus, Streptococcus species and anaerobes. Fournier’s gangrene spreads extensively to the surrounding tissue and frequently results in septic shock and multi-organ failure. Active treatment includes broad spectrum intravenous antibiotics and radical surgical debridement of necrotic tissue. Chikungunya fever is caused by Chikungunya virus (family togaviridae, genus alphavirus) which is transmitted by the bite of infected Aedes aegypti and Aedes albopicusmosquitoes. Constitutional symptoms are high grade fever, a petechial or maculopapular rash of the trunk and occasionally limbs, and marked polyarthritis/ arthralgia, and intense headache, insomnia and extreme prostration. This disease is usually self-limiting but is associated with significant morbidity related to persistent arthritis and long-term anti-inflammatory therapy. Treatment is supportive. Mucocutaneous manifestations include facial flush, fine discrete morbilliform exanthema, pigmentary changes, apthous ulcers, desquamation, scrotal dermatitis and purpura. Though scrotal dermatitis or scrotal ulcers are rare manifestations, necrotising fasciitis may present in the form of Fournier’s gangrene. We hereby present such a case.

Can malaria trigger systemic lupus erythematosus

A 17-year-old girl presented with a 7-day history of fever and oliguria. There was no history of arthralgia, rash, haematuria, altered sensorium, convulsions, oral ulcers, alopecia or photosensitivity. Her family history was unremarkable. On examination she had tachypnoea, fever, anaemia, anasarca, bilateral basal crepitations in the chest and splenomegaly. Investigations on admission confirmed the anaemia (Hb: 8.6 g/dl), a normal white count (4100/mm), thrombocytopaenia (platelets: 19,000/mm), normal clotting (INR: 1.1), raised erythrocyte sedimentation (ESR: 55mm/1st h), abnormal renal function (urea: 29.6mmol/L, creatinine: 503.8 mmol/L). Liver function test was unremarkable, serum albumin was 0.078mmol/L and 24-h urinary protein excretion was 1 g. An immunochromatographic test for Plasmodium vivax was positive. Serological tests for dengue, leptospira, HIV, Hepatitis B and C virus and theMantoux test were all negative. An abdominal ultrasound scan showed a normal liver, a large spleen of 12.5 cm in length, bilateral hyperechoic kidneys, mild ascites and moderate bilateral pleural effusions. Our patient was treated with injectable artesunate and received haemodialysis in view of her oliguria, but continued to have persistent proteinuria and deranged renal function tests. Further evaluation revealed strongly positive antinuclear (ANA) and anti-double-stranded (ds) DNA antibody tests. Complement C3 levels were decreased. Polymerase chain reaction (PCR) testing for Cytomegalovirus (CMV) and Epstein–Barr virus (EBV) was negative. A renal biopsy showed diffuse proliferative glomerulonephritis (class IV lupus nephritis) with ‘full house’ immunofluorescence (Figures 1 and 2). A diagnosis of SLE (class IV) nephritis with plasmodium vivax malaria was made. Our patient was treated with pulsed methylprednisolone and cyclophosphamide monthly for 6 months together with oral prednisolone. Her renal function, proteinuria and 24-h urinary protein excretion normalized after 3 months of starting therapy.

Innovative Economical Surgical Suture Board

The aim of this study is to develop an economical suture board for practising suturing skills and techniques. Suture boards were made by using local electric boards, small leather patch, four suction buttons, six screws and a hook. These suture boards are multipurpose boards which are economical and available all the time in department for practicing. This board can also be placed in endotrainer for laparoscopic suturing skills. This economical suture board is cheap, easily available and helps in practicing various suturing and knot tying techniques.

Massive Lower Gastrointestinal Bleed caused by Typhoid Ulcer: Conservative Management

Typhoid fever is caused by gram-negative organism Salmonella typhi. The usual presentation is high-grade fever, but complications like gastrointestinal (GI) hemorrhage and perforation are also seen frequently. With the advent of antibiotics, these complications are rarely seen now. We present a case of a young female who was admitted with a diagnosis of typhoid fever presented with a massive GI bleed from ulcers in the terminal ileum and was managed conservatively without endotherapy and surgery. How to cite this article: Goel A, Bansal R. Massive Lower Gastrointestinal Bleed caused by Typhoid Ulcer: Conservative Management. Euroasian J Hepato-Gastroenterol 2017;7(2):176-177.

Retroperitoneal Spread of Fournier’s Gangrene: A Rare but Fatal Presentation

La gangrena de Fournier es una fascitis infectiva infecciosa necrotizante de los genitales externos predominantemente en varones ancianos. Generalmente se asocia con shock séptico y falla multiorgánica. Un varón de 55 años presentó edema escrotal, dolor y enrojecimiento sobre la pared abdominal inferior y ambos flancos con características de sepsis e íleo. Los hallazgos intraoperatorios sugieren una fascitis necrotizante extensa del escroto que se extiende tanto a la región inguinal como a la pared parietal lateral derecha y al músculo psoas derecho. Palabras claves: La fascitis necrotizante, La gangrena de fournier, Septicemia.