Favorable outcome of Fournier gangrene in two patients with diabetes mellitus on continuous peritoneal dialysis.

Fournier gangrene (FG), a form of necrotizing fasciitis of the perineum and genitals, with high morbidity and mortality in the general population, carries the additional risk of involvement of the peritoneal catheter tunnel and peritoneal cavity in patients on chronic peritoneal dialysis (PD). We describe two men with diabetes who developed FG in the course of PD. Computed tomography showed no extension of FG to the abdominal wall, and spent peritoneal dialysate was clear in both patients. Broad-spectrum antibiotic therapy with anaerobic coverage and early aggressive debridement followed by negative-pressure wound therapy and repeated debridement led to improvements in clinical status in both cases. Surgical closure and healing of the wound was achieved in one patient; the wound of the second patient is healing, but remains open. Both patients experienced prolonged hospitalization, with a serious decline in nutrition status. In patients on PD, FG can be treated successfully. However, additional measures are required to evaluate for potential involvement of the PD apparatus and the peritoneal cavity in the infectious process; and prolonged hospitalization, worsening nutrition, and multiple surgical interventions can result.

Imaging of peritoneal catheter tunnel infection using positron-emission tomography.

Imaging by ultrasonography or scintigraphy may assist in the diagnosis and management of tunnel infections of the peritoneal dialysis (PD) catheter. Here, we report a case of tunnel infection in which imaging with positron-emission tomography (PET) correctly predicted failure of conservative management. A 61-year-old man with diabetic nephropathy commenced PD in January 2008. He developed erythema and drainage at the exit site, with negative cultures in February 2008, and frank exit-site infection (ESI) with purulent drainage growing methicillin-sensitive Staphylococcus aureus [MSSA (treated with 3 weeks of oral dicloxacillin)] in August 2008. Subsequently, MSSA-growing purulent drainage from the exit site persisted. Systemic antibiotics were not administered, but there was gradual improvement with gentamicin ointment alone. In November 2008, the patient developed partial extrusion of the outer cuff of the PD catheter. In January 2009, a new ESI developed. Despite a week of treatment with cefazolin and gentamicin, the patient still developed his first episode of peritonitis with coagulase-negative Staphylococcus. He then received intraperitoneal vancomycin with good response. Although the ESI appeared to have responded to the treatment, PET imaging showed increased fludeoxyglucose (FDG) activity in the whole abdominal wall portion of the PD catheter. The patient resisted removal of the catheter and had no further signs of infection until June 2009. At that time he presented with exuberant inflammatory tissue ("proud flesh") at the exit site. Repeated PET imaging again showed increased FDG activity along the abdominal wall portion of the catheter. The PD catheter was removed and found to be infected. The patient was placed on temporary hemodialysis. This case demonstrates that PET imaging, in addition to other imaging techniques, may be useful for diagnosing and managing PD catheter infections.

Surgical procedures before and after starting chronic hemodialysis in a predominantly male population with high prevalence of diabetes.

PURPOSE: The purposes of this study were to analyze changes in the frequency of different categories of surgical procedures after initiation of chronic hemodialysis (HD) and to identify the types of procedures associated with in-hospital postoperative mortality. METHODS: This was a retrospective analysis of surgical procedures performed in an incident HD population of 392 patients followed in the dialysis unit of one hospital over 15 years. Among these patients, 384 were men and 258 had diabetes mellitus. At the start of HD, age of the patients was 66.3 ± 11.2 years and Charlson index 5.35 ± 2.41. Rates of procedures per patient year (n/[pt-yr]), reported as mean (95% Confidence Interval [CI]), were compared by nonparametric methods. RESULTS: In the whole HD population, the overall rate of procedures increased in the HD period (pre-HD 0.125 [95% CI 0.101-0.149] n/[pt-yr]; HD 0.928 [95% CI 0.795-1.061] n/[pt-yr]; p<0.001). The increase, noted in patients with and without diabetes, reflected increases in the rates for both vascular access and non-vascular access procedures from the pre-HD to the HD period. Amputations and surgery for hip fractures accounted for the increase in the rates of procedures related to non-vascular access. Procedures associated with mortality in the HD period included amputations, hip repair and abdominal surgery for septic conditions. CONCLUSIONS: Rates of surgical procedures for vascular access, amputations, and hip fractures ?increased after the start of HD. Amputations and hip fractures, both potentially preventable, are associated with mortality in HD patients.