- Email: [email protected]
A Fatal Complication of Gynecological Surgery*
Department of Case Reports New Instruments, Etc. A FATAL COMPLICATION OF GYNECOLOGICAL SURGERY* SHELDON
G.
ALTMAN, M.D., AND MURRAY
l{EW YORK, :t'~.
L.
BRANDT, M.D., F.A.C.S.,
Y.
(From the Obstetrical-Gynecological Service of Fordham Hospital, Bronx, New York)
HE purpose of this paper is to present the recent syndrome of acute staphylococcal pseudomembranous enterocolitis following antibiotic therapy, and to add a case of our own which occurred incidentally to gynecological surgery. About twenty cases of this syndrome have been reported in the literature, not all of them following surgery.
T
A 21-year-old white woman, gravida 0, married nine months, was admitted to the Gynecological Service of Fordham Hospital with the chief complaint of lower abdominal pain. On the day prior to admission the patient suddenly developed severe pain in the right lower quadrant, followed by diarrhea and flatulence for which a physician gave her penicillin and Terramycin. Despite this therapy the pain persisted and became progressively more severe. The diarrhea continued, and vomiting developed on the day of admission. Appendectomy had been performed nine years before. Nevertheless, she complained of recurrent episodes of right lower quadrant pain. A history of recurrent purulent vaginal discharge and therapy for chronic cervicitis was elicited. Terramycin, 2 Gm. daily, without medical supervision had been taken sporadically for a six-month period. The physical examination revealed a well-developed, well-nourished woman in no acute distress. The temperature was 102lh F.; the blood pressure was 132/76. Eye, ear, nose and throat examination was completely normal. No nuchal rigidity or lymphadenop· athy was found. A regular sinus rhythm was present, and there were no murmurs. The lungs were clear. The abdomen was soft, with tenderness only on deep palpation and slight muscle guarding in the lower right quadrant without rebound tenderness. There were no palpable abdominal masses. T_he liver and spleen were not felt. Bimanual pelvic examination revealed normal adult external genitals and a two-finger introitus with good support. There was no discharge from the Bartholin, urethral, or Skene glands ducts. The cervix was long, conical, eroded, and without pain on motion. The uterus was smaller than normal, acutely antefiexed, and movable. The left adnexa were normal, and in the right adnexal region close to the pelvic wall a cystic tender mass about 4 em. in diameter was felt. With these findings the possibilities of ectopic gestation, right cystic ovary, or torsion of a right ovarian cyst were considered. During the next two days the temperature ranged from 99• to 102• F. The pain persisted. The red blood count, hemoglobin, and urinalysis were normal. The white blood count rose from 11,000 to 13,000. Chest x-rays and electrocardiogram were normal. On the third hospital day pelvic examination revealed the right adnexal mass to have doubled in size, and an exploratory laparotomy under spinal anesthesia was performed. A hemorrhagic right ovarian cyst, 8 em. in diameter, was found. This cyst was enucleated and the ovaTy preserved. All pelvic organs, as well as the liver, gall bladder, *Presented at a· meeting of the Bronx Obstetrical-Gynecological Society, Nov. 23, 1953.
425
426
ALTMAN AND BRANm'
\m.
1.
Obst. & Gynec. fehruarY. FJ.S.~
stomach, and intestines, appeared nonnaJ. The immediate poHtoperative eondition wa' good. 'fhe pathological report of the e)(cisetl cyst read; ''l•'mgment nf ovanan t.iBsu•~ containing corpus luteum and follicle ryHt. No evidence of malig·nancy.'' On the first postoperative day the temperature rose to HH o F. Yomiting and sevtHe diarrhea developed. Therapy at this time included intravenouH fluids, glucose, eleetrolyteR, and Terramycin. The abdomen was soft. The red blood count, hemoglobin, and urinalyBi~ 'verc normal, but the \Yhlte blood count had risen to 17,500, with a shift tu thG left. Jf cr condition remained the same on the following day, but on tlw third postoperativeYas no abdominal pain or distention. The operative wound appeared to be healing and was free of infedion. Chest examination, x-rays of the chest and abdomen, urinalysis, an
coccus aureus hemolyticus, coagulase positive of a highly virulent stain.
Volume 69
Number 2
FATAL COMPLICATION OF GYNECOLOGICAL SURGERY
427
The pathological diagnosis was: (1) pseudomembranous enterocolitis caused by a Staphylococcus aureus hemolyticus; ( 2) terminal bronchopneumonia; ( 3) chronic cervicitis and endocervicitis. In summary, we have reported upon a patient admitted with abdominal pain, fever, and diarrhea, and a palpable ovarian mass, who underwent surgery because of the increasing size of the mass. She had been taking Terramycin intermittently for six months and re· ceived this and other antibiotics both pre- and postoperatively. Her postoperative course was characterized by fever, severe vomiting, and diarrhea, with collapse and death. The autopsy findings led to the diagnosis of acute pseuclomembranous enteroeolitis caused by hemolytic Staphylococcus aureus.
Terplan and associates 1 of Buffalo reported 6 postoperative deaths in patients who underwent operative procedures and who received one of the following antibiotics: Terramycin in 2; penicillin and streptomycin in 3; and penicillin, Terramycin, and Aureomycin in one case. The causative agent responsible for the acute drsquamative and membranous enterocolitis terminating in a shocklike state and death was demonstrated in the exudate within the lumen, and in the floating membranes covering the surface of the acutely inflamed intestinal tract. In all cases, masses of gram-positive cocci, identified as hemolytic Staphylococcus aureus were found in the intestinal tract. Not only were they not affected by antibiotics which normally are lethal to this staphylococcus, hut, indeed, later experiments proved that the bacteria flourished in a mrdinm to which the antibiotic was added. In all, the clinical course and pathological pictures were similar: nausea and vomiting followed by severe progrcssiYe watery diarrhea, occurring from the first to the fourth postoperative day, with death between the third and eighth postoperative days. The most striking feature which led to the belnted recoYery of hemolytic staphylocoecus in pure culture in one of the cases was the presrnce of exuberant masses of the organism in the shed watery exudate. There had been no septicemia. These findings support the clinical and bacteriological observationR of Jackson and Finland 2 in patients treated for pneumonia with Terramycin. In four such cases of severe "superinfection," pathogenic Rtaphylococci were recovered from their stools. Similar complications were observed by \V omack:l in the course of Terramycin therapy of urinary tract infections. No postmortem bacteriological or following Terramycin therapy with fatal termination was reported. However, staphylococcic dysentery and pneumonia were presumably the cause of death in one case as that organism was repeatedly cultured from the sputum and stool. Additional information regarding staphylococcic enteritis as a complication of antibiotic therapy was reported by Dearing and Heilmann 4 from the Mayo Clinic. Severe diarrhea and shock developed in these cases following Terramycin therapy and in one case after Aureomycin. At postmortem examination pseudomembranous jejunitis, enteritis, or enterocolitis was found in all 4 cases. Included in this series are data on an 8-year-old child who was treated for simple pharyngitis with Terramycin. The major postmortem finding in this case, too, was pseudomembranous colitis.
428
ALTMAN AND BRANDT
t\m.
J.
Ob.;t. & (;ynec FehruJ.rv, 19'~
Severe pseudomembranous colitis following Aureomycin and Chloromy(~etin, corroborated by postmortem findings, was r·eported by Heiner." Bernhart6 from Switzerland reports 2 cases very similar to those of ,Jackson and Finland in which surgery was performed and 1'etramycin administered on the third and fifth days in both cases. Severe enterocolitis was found at postmortem. Gram-positive cocci were cultured post mortem from the feces. The French have reported similar cases of antibiotic therapy followed by diarrhea, collapse, and death when pseudomembranous enterocolitis on a staphylococcic basis was found at postmortem. In the ease here reported from Fordham Hospital, sensitivity studies on the intestinal organisms were performed. 1'he bacteria were resistant to penicillin, Terramycin, and Aureomycin, but sensitive to Erythromycin. This substantiates the work of Dearing and Heilmann who report that the organisms recovered not only were resistant to the therapeutic drug but actually flourished when it was added to the culture medium. Erythromydn was the only drug which inhibited the growth of the cultured organism. Since Erythromycin is one of the newer antibiotics and has not been widely used, it is probable that, with increased administration, the syndrome of staphycoccic pseudomembranous enterocolitis will result from its usage as well.
References 1. Terplan, Kornel, Paine, J. R., Sheffer, J., Egan, R., and Lansky, H.:
Gastroenterology
24: 476, 1953. 2. Jackson, G. G., and Finland, M.: Arch. Int. Med. 88: 44u, 1951. 3. Womack, C. R., Jackson, G. G., Gocke, T. M., Kass, E. H., Haight, T. H., and Finland, M.: Arch. Int. Med. 89: 240, 1952. 4. Dearing, W. H., and Heilmann, F. R.: Proc. Staff Meet., Mayo Olin. 28: 121, 1953. 5. Reiner, L., Schlesinger, M. J., and Miller, G. M.: Arch. Path. 54: 39, 195R. 6. Bernhart, G.: Schweiz. med. Wchnschr. 82: 1335, 1952. 10 SOUTH GATE ROAD GREAT NECK, N. Y.
G.
ALTMAN, M.D., AND MURRAY
l{EW YORK, :t'~.
L.
BRANDT, M.D., F.A.C.S.,
Y.
(From the Obstetrical-Gynecological Service of Fordham Hospital, Bronx, New York)
HE purpose of this paper is to present the recent syndrome of acute staphylococcal pseudomembranous enterocolitis following antibiotic therapy, and to add a case of our own which occurred incidentally to gynecological surgery. About twenty cases of this syndrome have been reported in the literature, not all of them following surgery.
T
A 21-year-old white woman, gravida 0, married nine months, was admitted to the Gynecological Service of Fordham Hospital with the chief complaint of lower abdominal pain. On the day prior to admission the patient suddenly developed severe pain in the right lower quadrant, followed by diarrhea and flatulence for which a physician gave her penicillin and Terramycin. Despite this therapy the pain persisted and became progressively more severe. The diarrhea continued, and vomiting developed on the day of admission. Appendectomy had been performed nine years before. Nevertheless, she complained of recurrent episodes of right lower quadrant pain. A history of recurrent purulent vaginal discharge and therapy for chronic cervicitis was elicited. Terramycin, 2 Gm. daily, without medical supervision had been taken sporadically for a six-month period. The physical examination revealed a well-developed, well-nourished woman in no acute distress. The temperature was 102lh F.; the blood pressure was 132/76. Eye, ear, nose and throat examination was completely normal. No nuchal rigidity or lymphadenop· athy was found. A regular sinus rhythm was present, and there were no murmurs. The lungs were clear. The abdomen was soft, with tenderness only on deep palpation and slight muscle guarding in the lower right quadrant without rebound tenderness. There were no palpable abdominal masses. T_he liver and spleen were not felt. Bimanual pelvic examination revealed normal adult external genitals and a two-finger introitus with good support. There was no discharge from the Bartholin, urethral, or Skene glands ducts. The cervix was long, conical, eroded, and without pain on motion. The uterus was smaller than normal, acutely antefiexed, and movable. The left adnexa were normal, and in the right adnexal region close to the pelvic wall a cystic tender mass about 4 em. in diameter was felt. With these findings the possibilities of ectopic gestation, right cystic ovary, or torsion of a right ovarian cyst were considered. During the next two days the temperature ranged from 99• to 102• F. The pain persisted. The red blood count, hemoglobin, and urinalysis were normal. The white blood count rose from 11,000 to 13,000. Chest x-rays and electrocardiogram were normal. On the third hospital day pelvic examination revealed the right adnexal mass to have doubled in size, and an exploratory laparotomy under spinal anesthesia was performed. A hemorrhagic right ovarian cyst, 8 em. in diameter, was found. This cyst was enucleated and the ovaTy preserved. All pelvic organs, as well as the liver, gall bladder, *Presented at a· meeting of the Bronx Obstetrical-Gynecological Society, Nov. 23, 1953.
425
426
ALTMAN AND BRANm'
\m.
1.
Obst. & Gynec. fehruarY. FJ.S.~
stomach, and intestines, appeared nonnaJ. The immediate poHtoperative eondition wa' good. 'fhe pathological report of the e)(cisetl cyst read; ''l•'mgment nf ovanan t.iBsu•~ containing corpus luteum and follicle ryHt. No evidence of malig·nancy.'' On the first postoperative day the temperature rose to HH o F. Yomiting and sevtHe diarrhea developed. Therapy at this time included intravenouH fluids, glucose, eleetrolyteR, and Terramycin. The abdomen was soft. The red blood count, hemoglobin, and urinalyBi~ 'verc normal, but the \Yhlte blood count had risen to 17,500, with a shift tu thG left. Jf cr condition remained the same on the following day, but on tlw third postoperative
coccus aureus hemolyticus, coagulase positive of a highly virulent stain.
Volume 69
Number 2
FATAL COMPLICATION OF GYNECOLOGICAL SURGERY
427
The pathological diagnosis was: (1) pseudomembranous enterocolitis caused by a Staphylococcus aureus hemolyticus; ( 2) terminal bronchopneumonia; ( 3) chronic cervicitis and endocervicitis. In summary, we have reported upon a patient admitted with abdominal pain, fever, and diarrhea, and a palpable ovarian mass, who underwent surgery because of the increasing size of the mass. She had been taking Terramycin intermittently for six months and re· ceived this and other antibiotics both pre- and postoperatively. Her postoperative course was characterized by fever, severe vomiting, and diarrhea, with collapse and death. The autopsy findings led to the diagnosis of acute pseuclomembranous enteroeolitis caused by hemolytic Staphylococcus aureus.
Terplan and associates 1 of Buffalo reported 6 postoperative deaths in patients who underwent operative procedures and who received one of the following antibiotics: Terramycin in 2; penicillin and streptomycin in 3; and penicillin, Terramycin, and Aureomycin in one case. The causative agent responsible for the acute drsquamative and membranous enterocolitis terminating in a shocklike state and death was demonstrated in the exudate within the lumen, and in the floating membranes covering the surface of the acutely inflamed intestinal tract. In all cases, masses of gram-positive cocci, identified as hemolytic Staphylococcus aureus were found in the intestinal tract. Not only were they not affected by antibiotics which normally are lethal to this staphylococcus, hut, indeed, later experiments proved that the bacteria flourished in a mrdinm to which the antibiotic was added. In all, the clinical course and pathological pictures were similar: nausea and vomiting followed by severe progrcssiYe watery diarrhea, occurring from the first to the fourth postoperative day, with death between the third and eighth postoperative days. The most striking feature which led to the belnted recoYery of hemolytic staphylocoecus in pure culture in one of the cases was the presrnce of exuberant masses of the organism in the shed watery exudate. There had been no septicemia. These findings support the clinical and bacteriological observationR of Jackson and Finland 2 in patients treated for pneumonia with Terramycin. In four such cases of severe "superinfection," pathogenic Rtaphylococci were recovered from their stools. Similar complications were observed by \V omack:l in the course of Terramycin therapy of urinary tract infections. No postmortem bacteriological or following Terramycin therapy with fatal termination was reported. However, staphylococcic dysentery and pneumonia were presumably the cause of death in one case as that organism was repeatedly cultured from the sputum and stool. Additional information regarding staphylococcic enteritis as a complication of antibiotic therapy was reported by Dearing and Heilmann 4 from the Mayo Clinic. Severe diarrhea and shock developed in these cases following Terramycin therapy and in one case after Aureomycin. At postmortem examination pseudomembranous jejunitis, enteritis, or enterocolitis was found in all 4 cases. Included in this series are data on an 8-year-old child who was treated for simple pharyngitis with Terramycin. The major postmortem finding in this case, too, was pseudomembranous colitis.
428
ALTMAN AND BRANDT
t\m.
J.
Ob.;t. & (;ynec FehruJ.rv, 19'~
Severe pseudomembranous colitis following Aureomycin and Chloromy(~etin, corroborated by postmortem findings, was r·eported by Heiner." Bernhart6 from Switzerland reports 2 cases very similar to those of ,Jackson and Finland in which surgery was performed and 1'etramycin administered on the third and fifth days in both cases. Severe enterocolitis was found at postmortem. Gram-positive cocci were cultured post mortem from the feces. The French have reported similar cases of antibiotic therapy followed by diarrhea, collapse, and death when pseudomembranous enterocolitis on a staphylococcic basis was found at postmortem. In the ease here reported from Fordham Hospital, sensitivity studies on the intestinal organisms were performed. 1'he bacteria were resistant to penicillin, Terramycin, and Aureomycin, but sensitive to Erythromycin. This substantiates the work of Dearing and Heilmann who report that the organisms recovered not only were resistant to the therapeutic drug but actually flourished when it was added to the culture medium. Erythromydn was the only drug which inhibited the growth of the cultured organism. Since Erythromycin is one of the newer antibiotics and has not been widely used, it is probable that, with increased administration, the syndrome of staphycoccic pseudomembranous enterocolitis will result from its usage as well.
References 1. Terplan, Kornel, Paine, J. R., Sheffer, J., Egan, R., and Lansky, H.:
Gastroenterology
24: 476, 1953. 2. Jackson, G. G., and Finland, M.: Arch. Int. Med. 88: 44u, 1951. 3. Womack, C. R., Jackson, G. G., Gocke, T. M., Kass, E. H., Haight, T. H., and Finland, M.: Arch. Int. Med. 89: 240, 1952. 4. Dearing, W. H., and Heilmann, F. R.: Proc. Staff Meet., Mayo Olin. 28: 121, 1953. 5. Reiner, L., Schlesinger, M. J., and Miller, G. M.: Arch. Path. 54: 39, 195R. 6. Bernhart, G.: Schweiz. med. Wchnschr. 82: 1335, 1952. 10 SOUTH GATE ROAD GREAT NECK, N. Y.