Unusual necrotic disease (fwd)

[MCGEED at HAL.HAHNEMANN.EDU]

David J. McGee
MCGEED at hal.hahnemann.edu

Graduate Student
McPHU (Medical College of Pennsylvania and Hahnemann University)
Center City Campus
15th and Vine Streets
Dept. Microbiology and Immunology M.S. 410
New College Building RM 10302
Philadelphia, PA 19102

Phone: 215-762-8275
Fax: 215-762-1004 







Please forward comments/suggestions about the unknown necrotic disease to 
<huangxd at bepc2.ihep.ac.cn>  Please post to the immunology and 
microbiology newsgroups also, and NOT to me.  Thanks a lot!



---------- Forwarded message ----------
Date: Fri, 17 Feb 1995 08:13:10 +0800 
From:huangxd at bepc2.ihep.ac.cn
To: MCGEED at hal.hahnemann.edu
Subject: Re: FWD: Help required concerning unusual necrotic disease 



	An Abstract of Medical Record

    Yang Xiaoxia, female, a 13-year old student from Linnan Town, Linyi
county, Shandong Province. On 15th, Nov. 1994, she was hospitalized for
progressive necrosis and infection on the right forearm for three months,
with necrosis and infection on the left long finger for two  and  half
months.
    She found by accident a milletsized black spot on  the  thumbtip
of the right hand on Aug. 1994. It became swelling and causing pain, finally
suppuration under thumbnail after it was pricked out. So  extraction  of
nail,  dressing  change  and  antiseptic  treatment  with  intramuscular
injection of penicillin and Gentamicin  were  given  for  two  weeks in a
local clinic, but right thumb gradually turned into dark.  At  the  same
time, unexplainable bleeding and fester appeared under the  left  middle
fingernail, and necrosis in the phalangette began to develop. The patient
was sent to the outpatient department of a hospital for the  treatment, 
dressing change and antisepsis were given for more than 10 days with little
effects. The patient was admitted to another hospital then, debridement
and Xian Feng Bi Su(cephasporin B?) were given, but body temperature reached  
39.5 degree centigrade with the swelling of right forearm and palm, incision
and drainage were performed on right palm with little pus (bacterial
culture was administered but the results  unknown) .   With high  body
temperature for eleven days, the patient was  referred  to  Qianfeshan
provincial hospital, debridement and dressing change were administered,
treated with antibiotics for 50 days  according  to  the  results  of
bacterial culture and drug  sensitivity, red  and  swelling  on  right
forearm disappeared, but necrosis was presented on most of the skin  of
thumb, index finger and dorsum of right hand, 3 x 8cm skin necrosis seen
on radial surface of forearm,the hospital planed to perform  amputation
for the patient but the parents did not  agree,   so  the  patient  was
transfered to the Beijing Military General Hospital.

    General condition of the patient on admission:
    
    Massive soft tissue necrosis was seen on  the  right  thumb, medial
joint of index finger and  dorsal  part  of  forearm  with  foul  odor,
liquefaction surrounding the area of necrosis, failure of straighten of
fingers, at the same time, necrosis on  distal  joint  of  left  middle
finger with exposure of deep fascia on dorsal part of medial joint. The
better pulsation in both arms of brachial artery could be felt, failure
of enlarged lymph node  in  palpation, X- ray  indicated  that  evident
osteoporosis in benes of right forearm  and  phalanx  of  left  middle
finger, no destruction of bone could be seen.

    Treatments on Adimssion:

    Bacterial culture for surface of wound was given, indicating  growth
of foul odor pseudomonas and staphylococcus epidermidis,  so  cephazolin
1.0g b.i.d. was administered. Amputation for right  forearm,   and  left
middle finger combined with debridement were performed after  supporting
treatments and active antisepsis, soft tissue necrosis of right  forearm
exended  to  interosseous  membrane  was  seen  during  operation,    so
amputation was performed behind normal tissue of forearm at a  distance
of 7-8cm below elbow joint, normal blood circulation could  be  judged
according to the tissue color on planum of ampantation.The distal joint
of left middle finger was cut off and surface of wound  covered  with
oil immersion gauze, in addition, antisespsis, supplement of  nutrition
(whole blood, HSA) were given. Three days later, no  red  and  swelling
was seen on stump of right forearm, surface of wound on  medial  joint
of left middle finger showed fresh with little exudate;  but  since  the
fifth day, fissuration of suture  site  on  right  forearm  stump  of
amputation was seen,  flowing out of yellow and green  necrotic  tissue.
immersion of surface of  wound  with  hydrogen  dioxide  solution  and
bromogeramine, wet dressing of surface of wound with polymyxin B  were
given successively, and at the same time,  large  quantity  of  various
antibiotics was administered based on results of drug sensitivity test,
but unforfunately failed to control local tissue necrosis after all. 
Now necrosis has spreaded to  right  elbow   joint   and   left  middle
metacarpophalangeal of finger, with breaking  off of medial joint , and
involving nearby two fingers, in addition to red and swelling  of  left
palm. But the patient has no serious systemic symptoms. 

    Epidemiology: 

    the death of domestic animals was found in the area where the patient 
lived, corpses of dead animals are never buried and are even sold as food.   
There  is  farm cattlse in the home of the patient. 

The findings of laboratory tests:

blood picture
----------------------------------------------------------------------- 
Classification     16-11-1994  19-11-1994  26-11-1994  29-11-1994  6-12-1994   
----------------------------------------------------------------------- 
Leukocytes(xBil./L)    15.7        13.2        13.3       12.8        7.6
Neutrophils            82          82          65         80         66
Lymphocytes            11          12          32         16         24
Monocytes               6           2           0          2          4
Eosinophils             1           4           3          2          6
----------------------------------------------------------------------- 

Blood Sendimenlation:
		       1th hour        2th hour
16-11-1994               70mm            112mm
21-1-1995                41mm             77mm
7-2-1995                 62mm             80mm

Bood Glucose. the value of fasting blood glucose is in normal range

CIC (180u):
C3      0.9 g/L (0.7-1.3 g/L )
IgG    16.6 g/L (6-16 g/L)
IgA     1.8 g/L (0.4-3.38 g/L)
IgM     3.7 g/L (0.4-2.6 g/L)

Bacterial Culture:
17-11-1994   Staphylococcus Epidermidis
22-11-1994   Pseudomonas Feotidus
25-11-1994   Pseudomonas Feotidus
12-12-1994   Klebrielia
16-12-1994   Pseudomonas Alcaligenes
	     Staphylococcus Epidermidis (many)
	     Pseudomonas Feotidus (few)
06-1-1995    Staphylococcus Aureus
10-01-1995   Smear: G-Bacillus (many)
		    G-Diplococcus (few)
12-01-1995   Staphylococcus Aureus (60%)
	     Pseudomonas Aeruginosa (40%)
26-01-1995   G-Bacillus (-)
	     Staphylococcus Aureus
07-02-1995   Staphylococcus Aureus
	     Pseudomonas Aeruginosa
07-02-1995   Smear: G+ Phylococcus
		    G+ Bacillus
		    G- Bacillus
Blood culture: Anaerobic bacteria (-)
OT: (-)
Myelogram (-)

6-2-1995:    (Done by PLA General Hospital)

Antinuclear antibody: SSA(-) SSB(-)
Rheumatoid factor :(-)
C-Reaction protine: 3.3 above
Albumins 46 a1(alpha1) above  a2 above above
Anti-muscular antibody: (-)
Immunoprotein electrophorelogram: Igm above
lgA 274mg/dl (69-382)
lgG 1250mg/dl (723-1685)
lgM 333mg/dl (63-277)
Subgroup of/T-lymphocyles:
	 CD355% CD4/CD8=1.5
	 CD437.8%(644/mm3)
	 CD825.2%(429/mm3)
Complement: C3121mg/dl C434.7mg/dl
Hemocyte oxidation activity by the method of chemical luminescence:
	18.6mv (mormal: 4.9mv)

Staphylococcus aureus and short-small bacillus were isolated  from  dead
guinea-pig which had been inoculated with sample from  necrosis  tissue
(further identification has being done), done by The fifth Institute  of
Military Academy of Medicine

Pathologic  Diagnosis:   
	    Acute  suppurative and necrotic inflammation.

Antibiotic administration:
16-11-94:  Cefazotin 1.0, bid i.v. 13days
25-11-94:  
29-11-94:  Cefoperazone 2.0, bid i.v. 3 days
1-12-94:   Cefoperazone 1.0  bid i.v. 15 days
17-1294:   Cefotaxime   1.0  12h i.v.  7 days
30-12-94:  Aminobenzylpemicillin 2.0 bid i.v. 9 days
10-1-95:   Penicillin G 320u 6h i.v. 7 days
10-1-95:   Metronidazole 0.2 tid 14 days
18-1-95
23-1-95:   ofloxacin 100mg bid 14 days

Primitive diagnosis:
    Progressive infection and necrosis of arms with the unknown cause.



E-mail:Huangxd at bepc2.ihep.ac.cn

On behalf of the hospital and the expert group, I thank all those who have
continued to send in informative suggestions concerning the diagnosis and
treatment of Yang Xiaoxia's condition. So far I have received more than 200 
e-mail messages. To save the time and to reduced redundency of information,
I hope after the posting of the brief records, comments come only from 
experts in related fields. 
The girl's general condition is still stable but local infection and
tissue necrosis persists. Doctors begin to try some remedies of Chinese
Traditional Medcine.
Thanks for your cooperation.