Fournier's gangrene (necrotising fasciitis) complicated by renal and respiratory insufficiency: a case report.

A case report of a 68-year-old male obese diabetic patient with an abscess of left femoral region, and diffuse inflammation of abdominal wall and genital region developing sepsis, respiratory and renal failure. At admission in the regional hospital a diagnosis of polymicrobial necrotising fasciitis with suspected sepsis was declared. The patient was transferred to the special intensive care unit (SICU) of Burns and reconstructive surgery at the Kosice-Saca. The patient was treated surgically, with hyperbaric oxygen and pharmacologically to control his diabetes. The main aetiological agent of the condition was identified as Stenotrophomonas maltophilia. In addition to respiratory and metabolic acidosis and gastric bleeding occurred. Due to acute renal failure (day 38) the patient was transferred to clinic of anaesthesiology and the intensive care medicine at the University Hospital in Kosice. The patient was treated by continuous veno-venous haemodialysis, mechanical ventilation and nasogastric nutritional support. On day 48 the conscious sub-febrile patient with healed wounds was transferred back to the regional hospital with ventilation support and continuous renal replacement therapy. His diabetes was uncontrolled, and only kidney parameters remained pathological. The survival of this patient with an extremely poor prognosis was achieved through prompt transfer to a specialised centre, early identification of the aetiological agent and immediate appropriate antibiotic treatment as a result of good cooperation between surgeons and laboratory specialists.

Pulmonary administration of activated recombinant factor VII.

Diffuse alveolar haemorrhage (DAH) is a serious pulmonary complication seen in patients with autoimmune disorders and patients treated with chemotherapy or after hematopoietic stem cell transplantation. The clinical management of DAH is complex and the condition has a high mortality rate. During inflammation, tissue factor is expressed in the lung alveoli and therefore pulmonary administration of human recombinant activated factor VIIa (rFVIIa) could be a rational treatment option (4.1). A case report of the patient with an acute, bronchoscopically confirmed DAH from intensive care unit university hospital is described. The patient was treated by the intrapulmonary administration of 50 microg/kg rFVIIa in 50 ml of 0.9% sodium chloride; 25 ml into each of the main bronchi. An excellent response, defined as complete and sustained haemostasis after a single dose of rFVIIa was achieved. The oxygenation capacity, as reflected by the paO2/FiO2 (arterial oxygen pressure/inspiratory fractional oxygen content) ratio, decreased immediately after the bronchoscopy and the local rFVIIa instillation, but the following course of the patient's illness was favourable. Symptomatic therapy--intrapulmonary administration of one dose of rFVIIa was found to have an excellent haemostatic effect in the patient with DAH. The intrapulmonary administration of rFVIIa seemed to have a high benefit-to-risk ratio. These findings warrant further exploration (Ref. 12).

Successful therapy with intravenous immunoglobulin in the management of polymyositis.

Polymyositis is an inflammation of muscle tissue of unknown etiology. It is characterized by symmetric, mainly proximal muscle weakness, muscle fiber damage proved on biopsy, increased enzymes and myoglobin, and has corresponding electromyography findings. Other systems such as joints, lungs, heart, and gastrointestinal system are involved. Lung involvement is rather common. The most frequent symptom represents shortness of breath caused by muscle weakness. We report a case of a 66 year old woman with primary idiopathic polymyositis. The clinical state of the patient was complicated by progressive muscle weakness, dysphagia, and respiratory failure. Due to the ineffectiveness of the treatment with corticsteroids and cyclophosphamide, treatment with high doses of immunoglobulins was started. A total of 100 g of i.v. immunoglobulin therapy was administered beginning on the 13th day after hospital admission. The state of the patient progressively improved and after 7 weeks of treatment in a significantly improved state the patient was transferred to a Rehabilitation Unit. We therefore conclude that IVIg therapy may be an effective therapeutic approach for the treatment of acute complications of polymyositis, especially in cases in whom other therapeutic strategies are ineffective or harmful (Ref. 10). Full Text (Free, PDF) www.bmj.sk.