A dynamic study of the thermal components in electrical injury mechanism for better understanding and management of electric trauma: an animal model.

The thermal effects of acute electric trauma to living cells show some variation patterns and kinetics for different body components (muscle, bone, blood-vein and skin). Thermal energy transfer is random with no preferred directions, but electrical energy transfer is vectorial in the direction of the current. In the present study, a total 50 white male Wistar Albino rats, body weight 250-300 g, have been used to study electrical injury mechanism with subsequent change in muscle perfusion at different post-traumatic stages. The muscle temperature was found to increase with a sudden jump from 35.3+/-1.2 to 75.2+/-7.6 degrees C. The bone temperature increased from 35.2+/-1.4 to 45.8+/-1.2 degrees C and decayed slowly within 600+/-90 s. The venous blood curves show a similar pattern to that of muscle with a sudden jump of temperature from 36.4+/-.9 to 40.5+/-3.1 degrees C. The core temperature showed a flat pattern with a slight increase from 36.1+/-0.8 to 37.3+/-0.6 degrees C and the peak temperature was found after 70+/-10 s. From the scintigraphic study, muscle perfusion was found to be a minimum 72 h after electric shock. The right hind limbs of all the rats (ground) exhibited more intense histopathological damages (electric burns) than the left fore limb (source).

An experimental study of skin flap associated with muscle: is muscle nourishment possible through the musculocutaneous perforators?

An experimental study was planned to examine whether the blood supply of muscle would be maintained by reverse flow from the cutaneous arteriolar microcirculatory system via the musculocutaneous perforators. A flap model containing both muscle and skin based on the inferior superficial epigastric vessels was designed with the blood supplied directly from the cutaneous arteriolar microcirculatory system. A total of 154 male Wistar Albino rats were divided into three groups. Group I included the standard vertical rectus abdominis musculocutaneous flap based on the superior deep epigastric vessels (N = 48). Group II included the acute cutaneous muscle flap (N = 53). Group III contained the delayed cutaneous muscle flap (N = 53). Skin flap survival area, muscle scintigraphy with technetium-99m-methoxy-isobutyl-isonitrile, microangiography, and histopathological examination of the flaps were conducted. The mean percentage of surviving skin paddle area was 96.4 +/- 5.2%, 84.9 +/- 21.6%, and 91.0 +/- 16.8% in groups I, II, and III respectively. There was no significant difference between groups. Microangiography revealed the blood flow from skin to muscle through the musculocutaneous perforators. The radioisotope uptake of the muscle flap was expressed as A percentage of the intact contralateral muscle. Mean uptake in group I was 90.1 +/- 4.9% immediately after flap elevation, 62.5 +/- 13.5% on day 2, and 88.3 +/- 12.0% on day 7. These values were 53.7 +/- 7.1%, 63.6 +/- 14.1%, and 89.2 +/- 18.1% in group II, and 64 +/- 7.8%, 75.5 +/- 9.8%, and 92.8 +/- 40.1% in group III. Radioisotope uptake in group I was significantly higher than groups II and III immediately after flap elevation (p < 0.05, analysis of variance), whereas there was no significant difference on days 2 and 7. Histopathological examination revealed surviving muscle tissue without marked atrophy. There was no marked difference between groups histopathologically. These results indicate that muscle tissue may survive by reverse flow through the musculocutaneous perforators when elevated with an axial skin flap.

Secondary venous ischemic injury associated with neutrophil infiltration and lipid peroxidation: amelioration of injury by cyclosporin A in a rat inguinal island flap.

Secondary venous ischemia caused by anastomotic failure is one of the major causes of failure after free tissue transfers and replantations. The effects of cyclosporin A (CsA) on secondary ischemic injury associated with neutrophil infiltration and lipid peroxidation were evaluated in a rat inferior epigastric island skin flap model. Primary ischemia was produced by arteriovenous occlusion for 2 hours. Twenty-four hours later, secondary venous ischemia was produced by 5 hours of venous occlusion. Nonischemic (n = 5), primary ischemic (n = 5), and secondary ischemic control groups (n = 10), and four treatment groups (n = 10) were created. Treatment groups received either 15 or 30 mg per kilogram per day oral CsA for 3 days before flap elevation, or 15 or 30 mg per kilogram intravenous CsA at 4 hours of secondary venous ischemia. Flap survival area, malondialdehyde (MDA) content, and myeloperoxidase (MPO) activity were assayed for each group. The mean flap survival area of the high-dose posttreatment group was significantly higher than the secondary ischemic control group (29% +/- 39% vs. 3% +/- 8%; p < 0.05, Student's t-test). The MDA and MPO levels of each treatment group were significantly lower than the secondary ischemic control group at hours 1 and 24 (p < 0.0001, Student's t-test). The lowest MDA and MPO levels were achieved in the high-dose posttreatment group. Results suggest that CsA may improve flap survival after secondary venous ischemia by attenuating neutrophil infiltration and by reducing lipid peroxidation.

Malignant tumors requiring maxillectomy.

Seventy cases with malignant tumors requiring maxillary resection in the past 10 years were reviewed, retrospectively. The primary site of tumor was adjacent skin in 53%, maxillary sinus or maxilla in 20%, palate and alveolar arch in 13%, lip and buccal mucosa in 13%, and mandible in 1% of the cases. The most common histopathological diagnoses was squamous cell carcinoma (54%), followed by basal cell carcinoma (20%). Most of the patients had advanced tumors, either neglected or recurred. Orbital exenteration was performed in 28 cases, mandibulectomy in six cases, combined craniofacial resection in seven cases, and radical neck dissection in 18 cases. Major skin loss was present in majority of the patients. Postsurgical defects were reconstructed with pedicled flaps in 37 cases and free flaps in 12 cases. Lining of the maxillary sinus defects was provided with split-thickness skin grafts. Patients with palatal defects were encouraged to use prosthetic obturators. Postoperative radiotherapy was performed in 32 patients and combined radiotherapy and chemotherapy in 12 patients. Communication could be established with only 52 patients. Sixty-three percent of them have survived without recurrence and distant metastasis. Resection of the tumor with free surgical margins and appropriate evaluation of the surgical defect for the most suitable reconstruction are the mainstays of treatment of the midfacial tumors.

A method to evaluate microcirculatory vascular patency of full thickness burn in an animal model.

BACKGROUND: In cases of thermal injuries it is always difficult to predict the extent of necrosis to the peripheral ischemic zone. Practically, full-thickness skin burn also affects the underlying muscle, panniculus carnosus, which adheres tightly to the skin. In this proposed model, the muscle which was always partly damaged also covers the ischemic zone of full-thickness burn injury. To evaluate the deeper levels of injury, the status of the micro circulation of thermally affected muscle was evaluated by counting the accumulated radioactive agent, 99mTc methoxyisobutylisonitril (MIBI) in the muscle cells. METHODS: 370 MBq/kg (10 mCi/kg) MIBI was administered intravenously to the animals having burn injuries by a comb device as described in previous literature. Then, 20 minutes after injection, whole burned areas were excised and placed under a gamma camera. Each thermally injured area showed four rectangular defects with lower tracer uptakes than the three adjacent interspaces. The tracer uptake of the burned sites and interspaces was analyzed from the acquired images on a computer, and the degree of injury could be assessed quantitatively. Additionally, specimen counts were obtained from selected burned stripes, interspaces and normal tissue for comparison. RESULTS: Burned sites were evident with lower tracer uptakes whereas interspaces with higher uptakes. Captured activity in interspaces indicated that capillary patency mostly maintained and it permitted the arrival of the radiopharmaceutical to the muscle cells. CONCLUSIONS: Muscle layer, where just below the burn area and tightly attached to the skin, could be assessed as a representative of the extension of the injury.

Modulating the functions of neutrophils and lipid peroxidation by FK506 in a rat model of thermal injury.

Neutrophils diffusely invade lung, liver, kidney, intestine, muscle and burned skin following burn injury. To ameliorate this invasion and minimize its effects, neutrophils can be modulated by giving neutrophil inhibitors and modulators. In this study, FK506 was used to decrease neutrophil infiltration and lipid peroxidation in remote organs (lung, liver, kidney and intestine) in a burned rat model. FK506 is a new major immunosuppressive agent that is known to modulate neutrophils during inflammation. Neutrophil infiltration was assessed indirectly by measuring myeloperoxidase (MPO) activity biochemically in remote organs following 30% full thickness burn injury. Malondialdehyde (MDA), the end product of lipid peroxidation, was measured biochemically in remote organs and plasma to determine if there is a relationship between neutrophil infiltration and lipid peroxidation after burn injury. FK506 was given intramuscularly at the dose of 0.5 and 1.0 mg/kg for three days before burn injury. Thermal trauma to the skin caused a statistically significant increase in MPO activity and MDA content in remote organs. FK506 was effective in reducing lipid peroxidation and neutrophil infiltration especially at 24 h postinjury in lung, liver and kidney. FK506 may have some benefit (prophylactic) in reducing systemic neutrophilic injury and related lipid peroxidation in burns.

The effect of antioxidant therapy on cell-mediated immunity following burn injury in an animal model.

Although antioxidant therapy has been introduced into early post burn protocols to prevent oxidative injury, it is still not known how they effect the cellular immunity which was already depressed due to thermal injury. To investigate the effect of antioxidant therapy on postburn immunosuppression following burn injury in a rat model, well known antioxidants: allopurinol (50 mg/kg/day), desferrioxamine (15 mg/kg/day), PEG-catalase (PEG-CAT) (1200 U/kg/day), N-acetylcysteine (NAS) (1 mg/kg/day) and vitamin-C (Vit-C) (0.5 mg/kg/day) were given for 7 days following thermal injury. The immunologic status of the rat was studied using two in vivo measures at seventh day following (30% TBSA) full-thickness burn injury. The contact hypersensitivity response (CHR) of rats, and their ability to induce a host versus graft reaction (HVGR) in the popliteal node were used to assess immune system as in vivo measures. The use of mentioned antioxidants resulted in significant improvement (between P < 0.05 and P < 0.001) of burn induced immunosuppression as reflected by CHR. The treatment with allopurinol and PEG-CAT (P < 0.01) significantly improved, while desferrioxamine, NAS and Vit-C improved, but not significantly, HVG reaction in burned rats. This study demonstrated that a large burn was profoundly immunosuppressive and early intervention of antioxidant therapy was able to significantly restore cell-mediated immunity as reflected by two in vivo assays.

Effects of cyclosporin A and ibuprofen on liver ischemia-reperfusion injury in the rat.

Liver ischemia followed by reperfusion is an important and common clinical event associated with the activation of an endogenous inflammatory response. The aim of this study was to determine the effects of cyclosporin A (CsA) and ibuprofen (IBU) on ischemia-reperfusion injury. Male Spraque-Dawley rats were subjected to 60 min of total liver ischemia followed by 120 min reperfusion. Liver tissue samples were obtained for measurements of malondialdehyde (MDA) levels as an index of tissue lipid peroxidation by thiobarbituric acid assay. Three groups of animals were pre-treated with CsA or IBU or both. Treatment with these agents was given at onset reperfusion after ischemia. The other groups were designated as ischemic controls, non-ischemic controls and reperfusion group without treatment. Ischemic control animals showed increased liver MDA levels and in the reperfusion group MDA levels were significantly higher than ischemic levels. CsA and IBU-treated animals had better survival and diminished liver MDA levels. The most significant decrease MDA levels was observed in the group treated with two agents which were given together. Serum enzyme levels were significantly higher in the reperfusion group than in the ischemic controls and the enzyme levels were significantly diminished after the treatments. This study suggests that CsA and IBU may be important agents in modulating lipid peroxidation in ischemia-reperfusion liver injury, and combined therapy with these agents may be more effective in treatment of ischemia-reperfusion injury.

Involvement of neutrophils in ischemia-reperfusion injury of inguinal island skin flaps in rats.

Increased production of oxygen free radicals and infiltration of neutrophils into tissue subjected to ischemia-reperfusion have emphasized that neutrophils play a direct role in the development of injury. The present study was designed to elucidate the effect of FK506, a new immunosuppressive drug, on 11 hours of complete ischemia and reperfusion of the inguinal island skin flaps in rats. Group 1 (n = 10) control animals underwent ischemia and reperfusion and no treatment. Group 2 (n = 10) animals received FK 506 0.3 mg/kg/day, and group 3 (n = 9) animals received 0.5 mg/kg/day intramuscularly for 3 days before the ischemia. The effect of the drug was evaluated by measuring flap survival and tissue malondialdehyde content and myeloperoxidase activity and also by histopathologic examination of the skin specimens taken at the 1st and 24th hour after reperfusion. The survival of flaps controlled for 7 days was found to be significantly improved in group 2 (65.0 +/- 10.93 percent) and group 3 (93 +/- 6.25 percent) when compared with the control group (14 +/- 10.12 percent) (p < 0.04 and p < 0.0001). The tissue contents of malondialdehyde and activities of myeloperoxidase were significantly lower in groups 2 and 3 than in the control group. Three days of pretreatment with FK506 significantly reduced neutrophil infiltration in groups treated with either of the doses. These results showed that neutrophils play an important role in island flap survival associated with ischemia-reperfusion injury. Increased neutrophil infiltration was found related with increased levels of malondialdehyde and myeloperoxidase. Flap necrosis and the increase in malondialdehyde, myeloperoxidase, and neutrophil infiltration were improved by FK506 pretreatment, a neutrophil modulating agent.

Augmentation of the columella-labial angle to prevent the "smiling deformity" in rhinoplasty.

Aesthetic diagnosis of the smiling deformity, which is functional rather than anatomical, is essential to provide the best treatment in rhinoplasty. The nasal tip tends to rotate inferiorly during smiling, and the central upper lip moves superiorly. A posteriorly sloping upper lip with a retrodisplaced columella-labial junction gives an unaesthetic appearance. Downward movement of the tip and a sharper nasolabial angle are usually aesthetically unpleasant. In 28 nasal surgeries, augmentation of the columella-labial angle with cartilage strip grafts has been performed. The augmentation of the angle and additionally cutting of the depressor septi muscle created a wider nasolabial complex, and this angle looks full and more pleasant. This procedure has mainly been used as an additional procedure to standard reduction rhinoplasty in order to improve smiling deformity. Strip cartilage grafts were inserted subcutaneously into the upper lip extending half way to the columella and secured with a transcutaneous suture under the columella-labial angle to prevent misslocation. Augmentation by the cartilage graft together with cutting the depressor septi muscle prevented elevation and shortening of the upper lip, and also drooping of the nasal tip. This procedure provided an aesthetically pleasant appearance both at rest and during smiling.

Involvement of neutrophils in ischemic injury. I. Biochemical and histopathological investigation of the effect of FK506 on dorsal skin flaps in rats.

The purpose of this study was to investigate the role of neutrophils in ischemic tissue injury and the possible inhibition by pretreatment with FK506, a neutrophilic modulating agent. A dorsal caudally based skin flap (3 x 9 cm) was used as an ischemic injury model in experimental groups. Prior to flap elevation, FK506 at doses of 0.3 mg per kilogram (group 2), 0.5 mg per kilogram (group 3), and 1.0 mg per kilogram (group 4) was given for 3 days intramuscularly. The relationship among neutrophil accumulation (histopathologically), myeloperoxidase (MPO) activity, malondialdehyde (MDA) content (biochemically) of the flap tissue, and flap survival were studied. Skin flaps showed reduced necrosis in the FK506-treated groups (p < 0.08, p < 0.0001, and p < 0.0001 respectively). The increase in accumulation of neutrophils, and MDA and MPO levels (which were induced by ischemia) observed 1 and 24 hours after flap elevation was diminished by FK506 pretreatment. The increased neutrophilic infiltration, and raised tissue MDA content and MPO activity revealed involvement of both free radical production and neutrophils in ischemia. This injury was decreased by FK506, probably by inhibition of neutrophilic chemotaxis, infiltration, and releasing factors.

Oxygen free radicals impair wound healing in ischemic rat skin.

Oxygen free radicals are produced and play an important role in ischemic injury. We therefore wished to investigate the role of free radicals on ischemic skin wound healing. For this purpose, H-shaped flaps, where the test ischemic wound is the horizontal line in the H, were created on the dorsum of the rat. To inhibit the probable hazards of free radicals, allopurinol and superoxide dismutase (SOD) were given to the animals. Most of the studied wound-healing parameters were impaired in the ischemic group. In the allopurinol-treated group, breaking strength was increased by 52% by day 7 and by 109% by day 14 (p < 0.0002 and p < 0.001), and in the SOD-treated group the increase was 69% both by days 7 and 14 of healing when compared with the ischemic control group (p < 0.003 and p < 0.002). Hydroxyproline content was increased 75% with allopurinol and 113% with SOD in the wound by day 7 (p < 0.03 and p < 0.001 respectively). SOD treatment caused a significant decrease in wound edema by day 7 of healing (p < 0.05). Histopathological evaluation revealed that in the SOD- and allopurinol-treated groups, the amount of collagen and its organization were more prominent when compared with the ischemic controls. These results show that oxygen free radicals play an important role in the failure of ischemic wound healing, and antioxidants partly improve the healing in ischemic skin wounds.

Early postburn fatty acid profile in burn patients.

To understand the alterations in lipid metabolism following burn injury, 29 patients with burns, 18 survivors for the first 15 days and 11 non-survivors until death, were studied for total fatty acid (FA) profiles. No specific dietary fat was given. The plasma total FA profile was determined by capillary gas chromatography. The main observations of this survey were that: arachidonic acid decreased by 55.7 per cent (P < 0.0002), and linoleic acid decreased by 31.6 per cent (P < 0.004), more immunosuppressive mediators were probably produced. The elevated levels of both palmitic (12.1 per cent increase, P < 0.02) and oleic acids (63.0 per cent increase, P < 0.0001) in the plasma of burned patients suggested increased lipolysis from depot triglycerides. Eicosatrienoic acid showed decreased levels (49.5 per cent decrease, P < 0.005) at 3-4 days. Docosahexaenoic acid reached its lowest level at postburn days 7-9 (32.1 per cent decrease, P < 0.04). The significant changes of FA profile in patients could be related to the increased activity of fat metabolism. The results of this study have revealed the basic FA changes and requirements. Overfeeding and unnecessary intake of the source of immunosuppressive mediators would be avoided.

Evaluation of lipid peroxidation and total antioxidant status in plasma of rats following thermal injury.

Thermal injury initiates systemic inflammatory reactions producing burn toxins, an inflammatory response, oxygen radicals and finally peroxidation. The relationship between the amount of products of oxidative metabolism and natural scavengers of free radicals determines the outcome of local and distant tissue damage, and further organ failure in burn injury. To determine the relationship between the level of total natural scavengers of the body, the place of superoxide dismutase in this capacity, and its relation with lipid peroxidation, malondialdehyde, superoxide dismutase levels and total antioxidant status were measured in plasma. Animals were subjected to 30 per cent full thickness body surface area burn, and their blood was collected at 24 h postburn. Plasma malondialdehyde levels were significantly elevated above the level of controls (P < 0.02). Burn injury caused a remarkable decrease in superoxide dismutase (45 per cent decrease, P < 0.0001) and total antioxidant status (14 per cent decrease, P < 0.01) when compared to control.

Effects of allopurinol, ibuprofen and cyclosporin A on local microcirculatory disturbance due to burn injuries.

This experiment was designed to study the reactions in the surrounding area of burn injury that may lead to further necrosis in 24 h. To prevent extension of burn size into the tissue adjacent to burn injury, it was attempted to reduce progressive microvascular damage by different drugs (ibuprofen, allopurinol or cyclosporin A (CyA)) in a rat model. The burn model consisted of a row of four 10 x 20 mm burn areas separated by three unburned 5 x 20 mm skin bridges (interspaces). To evaluate microcirculation and perfusion of panniculus carnosus muscle which is beneath the burned area of skin, the radioactive agent, technetium-99m methoxyisobutylisonitrile (99Tc01-MIBI) was used 24 h after the burn. Capillary permeability of injured tissue was assessed by the wet and dry weight technique. In all study groups, interspaces showed higher uptakes of 99Tc01-MIBI between 40 and 95 per cent, in comparison with burn sites in the first 24 h following burn. Among the treated rats better results were obtained by allopurinol and CyA treatment that commenced before burn than ibuprofen. Wet and dry ratios were found to be significantly lower in interspaces in rats pretreated with allopurinol and CyA. Results of this experiment showed that neutrophils and free radical-mediated injury may be involved in the pathogenesis of local response to thermal injury, and allopurinol and CyA have some effects to prevent progressive ischemia, capillary compromise and oedema.

The fate of alloplastic materials placed under a burn scar: an experimental study.

The behavior, under burn scars, of three different alloplastic materials, silicone, Medpor and Proplast, was compared in an animal model. A standard burn wound was created in rats, and 3 months later silicone, medpor and proplast alloplasts were placed under the burn scar. The rats were followed for another 3 months and ulceration and/or alloplast exposure rates were evaluated. At the end of this period specimens were examined histologically for the thickness of the fibrous capsule around the implant, thickness of the overlying tissue, tissue ingrowth and vascularization of the implants. Ulceration and exposure occurred in 2 of the 12 Medpor, 2 of the 12 Proplast and none of the 12 silicone implants. Fibrous capsule was significantly thicker around the silicone implants. Tissue ingrowth and vascularization were most prominent in Medpor implants while thickness of the overlying tissue was maximum in Proplast implants. These findings suggest that complications with silicone implants may be less than with other porous implants when used under burn scarred tissue.

Effects of N-acetylcysteine on lung glutathione levels in rats after burn injury.

This study was designed to determine the effect of N-acetyl-cysteine (NAC, a natural hydroxyl radical scavenger) treatment on levels of pulmonary malondialdehyde (MDA, the end product of lipid peroxidation) and glutathione (GSH, a natural antioxidant) in thermally injured rats. Severe skin scald injury (30 percent TBSA) caused a significant decrease in GSH levels, and a significant increase in MDA levels in lung tissue both at 1 h and 1 day postburn injury. Treatment of rats with NAC (15 mg/kg intraperitoneally, 15 min and 12 h following the burn) significantly improved GSH levels, and decreased ongoing lipid peroxidation at 1 day. This study showed that thermal injury resulted in increased pulmonary lipid peroxidation, and this remote organ injury was decreased by treatment with NAC. In addition NAC, a scavenger of hydroxyl radicals, improved GSH levels in the lungs. The higher level of GSH in the lungs of the burned rats treated with NAC could be due to either a decrease in the rate of degradation of GSH or to an increase in its synthesis. No data about these possibilities are provided.

Neutrophil-mediated injury in ischemic skin flaps: amelioration of ischemic injury by cyclosporine in the rat.

The role of neutrophils, their presence, and their degree of infiltration was examined in ischemic skin flaps. In a rat model, caudally based dorsal flaps were studied and neutrophils were manipulated by giving cyclosporine at two different doses (15 and 30 mg per kilogram), administrated either for 5 days as a pretreatment or 15 minutes before flap elevation. The presence of neutrophils and lymphocytes in both intravascular and extravascular space was assessed at 15, 30, and 60 minutes by skin biopsies, taken after elevation of the flap, by direct quantitative counting under the light microscope. The correlation between the counts and localization of the neutrophils, but not the lymphocytes, and the percentage of necrosis showed an early and definite role of neutrophils on skin flap survival during ischemic insult. Cyclosporine-treated flaps showed a 24% to 37% increase in viability when compared to control flaps. These data suggest that neutrophils, probably their interactions and/or products, play an important role in ischemic flap survival, and cyclosporine A is able to inhibit neutrophil accumulation and sequestration.

Reverse first dorsal metatarsal artery adipofascial flap.

An adipofascial flap distally based on the first dorsal metatarsal artery is described. This flap was used successfully in three cases with skin defects of the distal foot. The advantages of this flap are minimal donor site morbidity and its applicability for larger defects. The surgical technique is described, and indications, advantages, and disadvantages of the method are discussed and compared with the distally based first dorsal metatarsal artery fasciocutaneous flap. The reverse first dorsal metatarsal artery adipofascial flap offers a new solution for reconstruction of distal foot defects.

[Fournier gangrene]. / Fournier-Gangrän.

Fournier's gangrene is a relatively rare, mixed aerobic and anaerobic soft tissue infection in the perineoscrotal area. Although it is convenient to give it a separate name, it is really either necrotizing fasciitis or nonclostridial myonecrosis of the scrotal and perineal areas. The condition frequently develops from perineal diseases, including perianal abscess, and fistulas, inflamed haemorrhoids and indwelling urethral catheter. In patients with Fournier's gangrene morbidity is extreme and mortality high. This article is based on a retrospective study of 15 cases of Fournier's gangrene, 13 in male and 2 in female patients. A combination of surgery and antibiotics was used to treat 9 patients. The last 6 cases were treated with a combination of surgery, antibiotics and hyperbaric oxygen. In 13 cases, the diagnosis was made on the basis of the fulminating progression of the infection to a scrotal gangrene, identification of multiple underlying pathogenic organisms and toxaemia. In the 2 female patients, a similar infection developed in the labia majora and perineum and extended to the buttocks and the anterior abdominal wall.