- Email: [email protected]
Early recognition of potentially fatal necrotizing fasciitis
77
Abstracts
0 EARLY RECOGNITION OF POTENTIALLY FATAL NECROTIZING FASCIITIS. Stamenkovic I, Lew PD. NEngl JMed 1984; 310: 1689-1693. During a 13-year period from 1970 to 1983, 19 cases of histologically proven necrotizing fasciitis were retrospectively reviewed, with specific attention to those having had frozen section biopsies (8 patients). In the majority of cases the initiating lesion was found to be a minor cut or abrasion on the extremities. Microbiologic findings consisted of pure culture of Group A betahemolytic streptococcus in 14 cases and mixed aerobic, facultative, and anaerobic culture in five. Overall mortality was 47.4%. Frozen section biopsies were obtained within one to four days (average 21 hours) after the onset of symptoms in eight patients who had immediate surgical debridement. One patient in this group died as a result of congestive heart failure. In the 11 cases not having a frozen section biopsy, diagnosis and treatment were delayed an average of six days after the onset of symptoms; 8 of these 11 patients died. Erroneous diagnoses delaying surgery included erysipelas and cellulitis. The authors conclude that since prompt recognition and early surgical debridement are crucial to improving outcome, frozen section biopsies should be performed on all lesions suspicious for nec[David A. Frommer, MD] rotizing fasciitis.
0 SCORING SYSTEM TO AID IN DIAGNOSES OF APPENDICITIS. Teicher I, Landa B, Cohen M, et al. Ann Surg 1983; 198:753-758. The false positive diagnosis of appendicitis averages 20%. In an attempt to improve the diagnostic accuracy for this disease, the authors retrospectively compared 100 cases of surgically proven appendicitis with 100 cases of suspected appendicitis in which operation revealed a normal appendix. Of the 23 clinical variables tested, seven predictive factors were identified which could be assigned statistically significant differentiating weighted values: (1) sex: male + 2, female - 1; (2) age: 50 years + 3,20 to 39 years - 1; (3) duration of symptoms: 1% days +2, 2 days + 1, 3 days - 3; (4) urinary symptoms: - 3; (5) right lower quadrant muscle spasm: involuntary + 3, none - 3; (6) right-sided rectal mass: - 3; (7) white blood cell count: > 13,000 + 2, < 10,000 - 3. Values were then added to yield a diagnostic score for each patient with a
cumulative score of 5 - 3 indicating observation and a score > - 3 mandating prompt surgery. Applying this criteria retrospectively to the 200 study cases, the authors note that 38% of the negative laparotomies would have been avoided whereas only 5% of the cases of proven appendicitis would have first been observed. The authors conclude that although their simple scoring system can eliminate unnecessary laparotomies, close observation is mandatory in those patients not undergoing immediate surgical intervention. [John Neufeld, LID] Editor’s Note: This is a valuable article well worth every emergency physician’s review. The necessity of meticulous observation and prompt surgical intervention for progressive or unresolving signs and symptoms must be stressed.
0 ARRHYTHMIAS IN MITRAL VALVE PROLAPSE. Kramer HM, Kligfield P, Devereux RB, et al. Arch Intern Med 1984: 144:23602363.
It has been previously reported that patients with mitral valve prolapse (MVP) have an increased incidence of supraventricular tachycardia, ventricular arrhythmia, and sudden death. In this study symptomatic patients with MVP were compared with similarly symptomatic cardiac patients without MVP. Medications taken by the two groups were similar. Twenty-four hour ambulatory ECG monitoring revealed a trend toward more frequent paroxsysmal atria1 tachyarrhythmias in the MVP group, but overall there was no statistical difference in the incidence or complexity of atria1 and ventricular arrhythmias between the two groups. The authors conclude that compared with similar symptomatic controls, patients with MVP do not have as high an excess prevalence of dysrhythmias as previously described. [John Neufeld, MD]
0 HOW IMPORTANT ARE DENTAL PROCEDURES AS A CAUSE OF INFECTIVE ENDOCARDITIS? Guntheroth WC. /lm J Curdi-
01 1984; 54:797-801.
The author reviews studies relating dental procedures to the occurrence of infective endocarditis (IE). The prevalence of dental extractions preceding IE was only 3.6% in a review of 1,322 cases. Bacteremia was associated with 40% of 2,403 extractions, was found in 38% of
Abstracts
0 EARLY RECOGNITION OF POTENTIALLY FATAL NECROTIZING FASCIITIS. Stamenkovic I, Lew PD. NEngl JMed 1984; 310: 1689-1693. During a 13-year period from 1970 to 1983, 19 cases of histologically proven necrotizing fasciitis were retrospectively reviewed, with specific attention to those having had frozen section biopsies (8 patients). In the majority of cases the initiating lesion was found to be a minor cut or abrasion on the extremities. Microbiologic findings consisted of pure culture of Group A betahemolytic streptococcus in 14 cases and mixed aerobic, facultative, and anaerobic culture in five. Overall mortality was 47.4%. Frozen section biopsies were obtained within one to four days (average 21 hours) after the onset of symptoms in eight patients who had immediate surgical debridement. One patient in this group died as a result of congestive heart failure. In the 11 cases not having a frozen section biopsy, diagnosis and treatment were delayed an average of six days after the onset of symptoms; 8 of these 11 patients died. Erroneous diagnoses delaying surgery included erysipelas and cellulitis. The authors conclude that since prompt recognition and early surgical debridement are crucial to improving outcome, frozen section biopsies should be performed on all lesions suspicious for nec[David A. Frommer, MD] rotizing fasciitis.
0 SCORING SYSTEM TO AID IN DIAGNOSES OF APPENDICITIS. Teicher I, Landa B, Cohen M, et al. Ann Surg 1983; 198:753-758. The false positive diagnosis of appendicitis averages 20%. In an attempt to improve the diagnostic accuracy for this disease, the authors retrospectively compared 100 cases of surgically proven appendicitis with 100 cases of suspected appendicitis in which operation revealed a normal appendix. Of the 23 clinical variables tested, seven predictive factors were identified which could be assigned statistically significant differentiating weighted values: (1) sex: male + 2, female - 1; (2) age: 50 years + 3,20 to 39 years - 1; (3) duration of symptoms: 1% days +2, 2 days + 1, 3 days - 3; (4) urinary symptoms: - 3; (5) right lower quadrant muscle spasm: involuntary + 3, none - 3; (6) right-sided rectal mass: - 3; (7) white blood cell count: > 13,000 + 2, < 10,000 - 3. Values were then added to yield a diagnostic score for each patient with a
cumulative score of 5 - 3 indicating observation and a score > - 3 mandating prompt surgery. Applying this criteria retrospectively to the 200 study cases, the authors note that 38% of the negative laparotomies would have been avoided whereas only 5% of the cases of proven appendicitis would have first been observed. The authors conclude that although their simple scoring system can eliminate unnecessary laparotomies, close observation is mandatory in those patients not undergoing immediate surgical intervention. [John Neufeld, LID] Editor’s Note: This is a valuable article well worth every emergency physician’s review. The necessity of meticulous observation and prompt surgical intervention for progressive or unresolving signs and symptoms must be stressed.
0 ARRHYTHMIAS IN MITRAL VALVE PROLAPSE. Kramer HM, Kligfield P, Devereux RB, et al. Arch Intern Med 1984: 144:23602363.
It has been previously reported that patients with mitral valve prolapse (MVP) have an increased incidence of supraventricular tachycardia, ventricular arrhythmia, and sudden death. In this study symptomatic patients with MVP were compared with similarly symptomatic cardiac patients without MVP. Medications taken by the two groups were similar. Twenty-four hour ambulatory ECG monitoring revealed a trend toward more frequent paroxsysmal atria1 tachyarrhythmias in the MVP group, but overall there was no statistical difference in the incidence or complexity of atria1 and ventricular arrhythmias between the two groups. The authors conclude that compared with similar symptomatic controls, patients with MVP do not have as high an excess prevalence of dysrhythmias as previously described. [John Neufeld, MD]
0 HOW IMPORTANT ARE DENTAL PROCEDURES AS A CAUSE OF INFECTIVE ENDOCARDITIS? Guntheroth WC. /lm J Curdi-
01 1984; 54:797-801.
The author reviews studies relating dental procedures to the occurrence of infective endocarditis (IE). The prevalence of dental extractions preceding IE was only 3.6% in a review of 1,322 cases. Bacteremia was associated with 40% of 2,403 extractions, was found in 38% of