SAEM Clinical Images Series: An Adult with a Lower Extremity Rash

vasculitis

A 37-year-old male with a past medical history of type 2 diabetes presents to the Emergency Department (ED) with a rash. Initial symptoms began one week prior with small spots on the right leg with associated itching and burning. He initially presented to an outside facility where he was diagnosed with an allergic reaction versus scabies and was given a short course of oral steroids and topical permethrin that provided some relief. The rash progressed to bilateral lower extremities prompting re-presentation to the ED. He also reports associated dark urine and nausea.

GI: Abdomen soft, non-tender, non-distended.

MSK: No joint swelling, tenderness, erythema or warmth.

Skin: Numerous scattered bright red palpable purpuric papules and plaques, most concentrated on bilateral lower extremities extending to lower abdomen at the level of the umbilicus.

White blood cell (WBC) count: 14.5 k

Creatinine: 1.1 mg/dL on day of presentation, peaked at 2.2 mg/dL approximately 10 days later.

C-reactive protein (CRP): 32.7 mg/L

Erythrocyte sedimentation rate (ESR): 34 mm/hr

Urinalysis: 3+ protein, 2+ blood, 11-20 RBC, 26-50 WBC, rare bacteria

This is a case of IgA vasculitis, formerly called Henoch-Schonlein purpura or HSP. This diagnosis is suspected when a patient has purpuric skin lesions predominantly on the lower limbs as well as at least one of the following: abdominal pain, joint involvement, renal involvement (proteinuria/hematuria), and biopsy demonstrating IgA deposition. This vasculitis is more commonly seen in children and has a male predominance.

Similar to children with IgA vasculitis, adults presenting with this palpable purpuric rash can have associated joint involvement and GI involvement, though intussusception is less common in the adult population. Renal manifestations are more common in adults with this diagnosis and range from proteinuria and hematuria to renal failure. Our patient initially presented with hematuria/proteinuria and less than two weeks later had a doubled his creatinine. A renal biopsy later confirmed IgA nephropathy.

Take-Home Points

  • Consider IgA vasculitis in patients with lower extremity purpuric skin lesions with associated abdominal pain/GI bleed, arthralgia, renal involvement, and/or biopsy confirming IgA deposition.
  • In adults with IgA vasculitis, renal involvement is more common and often more severe.

  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Yaseen K, Herlitz LC, Villa-Forte A. IgA Vasculitis in Adults: a Rare yet Challenging Disease. Curr Rheumatol Rep. 2021 Jul 1;23(7):50. doi: 10.1007/s11926-021-01013-x. PMID: 34196893.

By |2023-01-20T15:48:31-08:00Jan 30, 2023|Dermatology, Renal, SAEM Clinical Images|

SAEM Clinical Images Series: Spicy Gum Leads to Spicy Gums

gums

A 32-year-old male with a past medical history of asthma presents with a two-day history of cracked lips and progressively worsening oral pain, associated with white discharge, foul smell, and a metallic taste. The patient presented to urgent care and was sent to the Emergency Department (ED) for a sepsis workup. The worsening sores caused him to eat and drink less, including the gum he normally chews. He endorses oral sex with one female partner one week ago. No recent dental work. He recently completed a prednisone course for the same issue. Denies fevers, tooth pain, tongue pain, dysphagia, odynophagia, chest pain, difficulty breathing, abdominal pain, genitourinary discharge or lesions, sick contacts, trismus, facial swelling, or voice changes.

Vitals: T 102°F; HR 125; BP 114/81; RR 19; SPO2 94%

General: No distress. Alert and oriented.

Skin: Warm and dry, no rash.

Ears: Hearing grossly intact.

Nose: Bilateral nares patent, no bleeding.

Neck: Soft, symmetric, no adenopathy, non-tender.

Extraoral: Ulcerations on upper and lower lips.

Intraoral: 1 small ulcer on tip of the tongue on the right. Inflamed, erythematous and bleeding gingiva and interdental papilla. Uvula midline. Maximal interincisal opening ~ 40 mm. Teeth intact.

Heart: Regular rate and rhythm, no murmur.

Lungs: Clear to auscultation, air entry to bases.

Abdomen: Soft, non-tender, no guarding.

GU: Patient denied symptoms and declined exam.

White blood cell (WBC) count: 11.4

pH: 7.386

Lactic Acid: 1.7

Urinalysis (UA): Negative Blood. Culture sent.

STI workup including HSV titers and HIV testing obtained and pending.

The differential is broad, including ANUG (acute necrotizing ulcerative gingivitis) also known as “trench-mouth” and, more commonly, primary herpes gingivostomatitis and candidal infection. Consideration of periodontitis and dental abscess/pulpitis is necessary. The spectrum of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis is important to include, as well as autoimmune disorders which commonly have mucosal involvement such as systemic lupus erythematosus (SLE), Behcet’s, and Crohn’s disease. Scurvy, although uncommon, can also present with gingival erythema and pain.

Consider the presence of a known autoimmune disorder, chronic systemic disease, or an immunocompromised state. History should include new sexual partners, dietary changes, and changes in dental hygiene. We were concerned given this patient’s vital signs on presentation, and alongside a sepsis workup, called dental to the bedside. They immediately asked the patient about the recent use of chewing gum and its flavor, and the patient described a recent preference for cinnamon gum, which he had been using for about 1-2 weeks. The dental consultant came to the diagnosis immediately. A literature search reveals a phenomenon called “cinnamon-contact stomatitis” which is believed to be caused by a delayed T-cell-mediated hypersensitivity reaction. It is characterized by white patches on the mucosa with erythema and erosions on the buccal mucosa and lateral tongue. Treatment consists of discontinuation of the offending agent, and corticosteroids in patients with severe symptoms. Lesions can take up to two weeks to heal, and appropriate follow-up with dental is needed to monitor for resolution.

Take-Home Points

  • The differential for ulcerated, painful gums is broad, and one must consider any history of systemic disease or an immunocompromised state.
  • Consider cinnamon-contact stomatitis in patients that present with extensive oral ulcerations in the absence of other risk factors.

  • Georgakopoulou EA. Cinnamon contact stomatitis. J Dermatol Case Rep. 2010 Nov 19;4(2):28-9. doi: 10.3315/jdcr.2010.1047. PMID: 21886744; PMCID: PMC3157809.
  • Vivas AP, Migliari DA. Cinnamon-induced Oral Mucosal Contact Reaction. Open Dent J. 2015 Jul 31;9:257-9. doi: 10.2174/1874210601509010257. PMID: 26312097; PMCID: PMC4541332.

SAEM Clinical Images Series: An Ominous Umbilical Lesion

umbilical

A 54-year-old male with a past medical history of atrial flutter and alcohol use disorder presents with an umbilical wound that has been bothering him for approximately six months. There is no history of trauma, prior infection, or umbilical surgery. There is intermittent mild pain and irritation that occurs randomly. No drainage or bleeding. He admits to picking at the wound regularly. He denies fever, chills, nausea, generalized abdominal pain, diarrhea, constipation, dysuria, and hematuria. The patient drinks four or more alcoholic beverages daily and has a long-standing history of tobacco use.

 

Vitals: BP 105/73; HR 70; RR 16; SpO2 97% on room air; Temp 36.1°C

Constitutional: Appears stated age, resting comfortably, well-appearing.

Abdominal: Soft, flat, non-tender.

Skin: Umbilical wound characterized by a peripheral eschar and a central area of hyperpigmented and crusted tissue overlying an area of whiteish moist tissue that was uncovered by gentle cleansing. No surrounding erythema and no areas of fluctuance. No active drainage or malodor.

None available.

Sister Mary Joseph (SMJ) nodule is a rare cutaneous metastasis of gastrointestinal or genitourinary primary malignancies to the umbilicus [1,3]. They are typically firm, painful, indurated, and irregularly shaped, with sizes typically less than 2 cm [1]. They can be ulcerated or necrotic with variable presence of discharge ranging from purulent to serous or serosanguinous [1]. Sister Mary Joseph nodules typically arise late in disease and portend a poor prognosis [1]. Most primary malignancies are adenocarcinomas (75%), and pancreatic cancers represent approximately 9% of umbilical metastases [1]. Mean survival of patients with SMJ nodules is less than 12 months, and less than three in those with pancreatic primaries [1]. Prognosis is slightly less bleak if the SMJ nodule is the only metastatic site [1]. Sister May Joseph Dempsey was a nun and surgical assistant to Dr. William Mayo, the surgeon who developed the approach to umbilical hernia repair and the first to identify the connection between abdominopelvic cancers and umbilical nodules [2,3].

Abdominal CT imaging.

Our patient was discharged on the initial visit with wound care instructions. He returned to the Emergency Department two months later and was admitted for atrial flutter with rapid ventricular response and acute on chronic congestive heart failure. During that visit, the patient had a CT chest/abdomen/pelvis that demonstrated likely a pancreatic tail adenocarcinoma with metastasis to the peritoneal and abdominal walls. The patient declined any further intervention.

Take-Home Points

  • Sister Mary Joseph nodules are umbilical metastases from abdominopelvic primary malignancies.
  • Recognition of their features on clinical exam can lead to a more rapid diagnosis.
  • Prognosis is grim with an average survival of less than one year.

  1. Vekariya P, Daneti DB, Senthamizh Selvan K, Verma SK, Hamide A, Mohan P. Sister Mary Joseph Nodule as an Initial Presentation of Pancreatic Adenocarcinoma. ACG Case Rep J. 2020 Aug 25;7(8):e00453. doi: 10.14309/crj.0000000000000453. PMID: 32903972; PMCID: PMC7447472.
  2. Palazzi DL, Brandt ML. Care of the umbilicus and management of umbilical disorders. UpToDate. Updated August 27, 2021. Accessed January 2, 2022. https://www.uptodate.com/contents/care-of-the-umbilicus-and-management-of-umbilical-disorders?search=sister%20mary%20joseph%20nodule&source=search_result&selectedTitle=2~6&usage_type=default&display_rank=2#H25.
  3. Tso S, Brockley J, Recica H, Ilchyshyn A. Sister Mary Joseph’s nodule: an unusual but important physical finding characteristic of widespread internal malignancy. Br J Gen Pract. 2013 Oct;63(615):551-2. doi: 10.3399/bjgp13X673900. PMID: 24152477; PMCID: PMC3782795.

SAEM Clinical Images Series: Dermatology Deserving a Deeper Dive

A 22-year-old female without significant past medical history presented to the Emergency Department (ED) for a progressive rash for the past six months. She had initially complained of dry and peeling skin on bilateral hands and feet and had multiple ED and dermatology encounters where topical steroids, acyclovir, and methotrexate were prescribed with no improvement. The rash continued to progress with worsening pain and inability to flex fingers secondary to lesions and scabbing at the joints. The patient also developed painful sores in her mouth primarily involving the tongue. More concerningly, she had lost 60 pounds since the onset of the rash and mouth lesions which she attributed to the inability to eat due to significant pain. Otherwise, she denied systemic symptoms, exposures, new medications, or previous illnesses.

Vitals: Within normal limits

HEENT: Swelling, erythema, and mild desquamation of the tongue mucosa with adherent white discharge present. Lesions are limited to the surface of the tongue with no buccal involvement.

Cardiovascular/Respiratory: Heart sounds within normal limits. Bilateral breath sounds without wheezes, rales, or rhonchi.

Abdomen: Soft, non-tender and non-distended.

Skin: The patient was noted to have desquamated, scabbing and oozing lesions on bilateral palms and fingers, soles of the feet, and web spaces between toes. The patient had no observable vesicles/bullae, or target lesions. Negative Nikolsky sign.

Complete Blood Count (CBC): Mild anemia, stable from baseline.

Basic Metabolic Panel (BMP): Within normal limits.

CT Abdomen/Pelvis with contrast (relevant findings only): Large solid right retroperitoneal mass lobulated in contour with heavy coarse calcifications measuring 21.2 x 8.5 x 10.4 cm, traversing the right hemidiaphragm and extending to the right lower mediastinum. The diaphragm itself is asymmetrically thickened as compared with the contralateral left side with a small volume of adjacent retroperitoneal fluid and there is extension into the right neural foramina.

The diagnosis of paraneoplastic pemphigus (PNP) was made after skin biopsy along with the constellation of findings including desquamating cutaneous lesions, painful mucosal erosions, and large retroperitoneal mass concerning for malignancy. Skin biopsy findings in this case include a distinct suprabasilar cleft, apoptotic keratinocytes, eosinophilic spongiosis, and superficial perivascular lymphocytic infiltrate with scattered eosinophils. Focally, there was full-thickness necrosis of the epidermis and dermis.

Patients with concern for PNP without known malignancy require a full neoplastic workup. In this case, a biopsy of the retroperitoneal mass and subsequently full resection was notable for Castleman’s disease, a rare lymphoproliferative disorder. PNP is an often fatal paraneoplastic mucocutaneous blistering disease that is most commonly caused by various lymphoproliferative disorders including non-Hodgkin’s lymphoma, chronic lymphocytic leukemia (CLL), and Castleman’s disease. It is an extremely rare condition with an unknown incidence rate. The mucosal erosions present are a requirement for the diagnosis. It typically presents as an erosive stomatitis involving the tongue and is characteristically chronic, progressive, and painful. These lesions are the initial disease manifestation in almost one-half of patients with PNP and often lead to malnutrition secondary to pain with attempts at oral intake. The cutaneous lesions in the disease are widely variable in morphology and can present with tense or flaccid bullae, as well as inflammatory papules or plaques.

Take-Home Points

  • In patients with a progressive rash involving the oral mucosa that have failed multiple outpatient regimens and have findings concerning for possible systemic involvement, dermatology consultation, tissue biopsy, and body imaging are often needed to confirm a diagnosis of complicated disease processes such as paraneoplastic pemphigus (PNP).
  • Significant unintentional weight loss may be due to a variety of reasons stemming from one unifying etiology. In this case, our patient had both mouth pain limiting oral intake as well as a lymphoproliferative disorder.
  • Anhalt GJ, Kim SC, Stanley JR, Korman NJ, Jabs DA, Kory M, Izumi H, Ratrie H 3rd, Mutasim D, Ariss-Abdo L, et al. Paraneoplastic pemphigus. An autoimmune mucocutaneous disease associated with neoplasia. N Engl J Med. 1990 Dec 20;323(25):1729-35. doi: 10.1056/NEJM199012203232503. PMID: 2247105.
  • Kaplan I, Hodak E, Ackerman L, Mimouni D, Anhalt GJ, Calderon S. Neoplasms associated with paraneoplastic pemphigus: a review with emphasis on non-hematologic malignancy and oral mucosal manifestations. Oral Oncol. 2004 Jul;40(6):553-62. doi: 10.1016/j.oraloncology.2003.09.020. PMID: 15063382.
By |2023-01-02T04:44:30-08:00Jan 2, 2023|Dermatology, Heme-Oncology, SAEM Clinical Images|

SAEM Clinical Images Series: Facial Swelling

facial swelling

A 5-year-old male with a history of recent frontal sinusitis associated with preseptal cellulitis requiring surgery presented with facial swelling. Swelling developed in the 24 hours prior to presentation without facial pain, nausea, or emesis. Denied facial trauma as well as any neurologic deficits, loss of consciousness, headaches, or fever/chills. At the time of his prior surgery, he presented with swelling localized to the left eye along with worsening pain, nausea, and emesis. After surgery, he was discharged in stable condition on antibiotics for 10 days. He has been in his usual state of health since that time.

Vitals: BP 93/59 (Sitting); HR 84; Temp 37.3 °C (99.1 °F) (Oral); Resp 12; Wt 20.6 kg (45 lb 6.6 oz)

General: Active, alert, normal development, and in no acute distress

HEENT: Swelling over the forehead and nasal bridge. Tenderness to palpation over the forehead. No erythema or overlying skin changes.

Nose: Normal appearance. No congestion or rhinorrhea.

Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.

White blood cell (WBC) count: 8.9 x 10^3/uL

Hemoglobin: 11.5 g/dL

Platelets: 365 x 10^3/uL

ANC: 4.490 x 10^3/uL

ESR: 15 mm

CRP: <0.5 mg

In the initial management of this patient, CT imaging of the head with contrast should be used to characterize the lesion and evaluate for intracranial involvement. In our patient, the CT scan showed frontal bone osteomyelitis with possible extension into the subdural space. He was admitted on broad-spectrum antibiotics and surgical washout was performed the following day.

Pott’s Puffy Tumor is a rare but serious complication of sinusitis with potential intracranial involvement. Complications include orbital cellulitis, intracranial abscess, meningitis, and cavernous sinus thrombosis.

Take-Home Points

  • Pott’s Puffy Tumor is a rare potential complication of sinusitis. Early diagnosis and treatment are essential to reduce morbidity.
  • CT of the head with contrast is the initial imaging that should be obtained in the emergency department.

  • Blumfield E1, Misra M. Pott’s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol. 2011 Jun;18(3):203-10. PMID: 21380513.
  • Palabiyik FB1, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016 May;27(3):e313-6. PMID: 27100642.

By |2022-12-08T22:22:41-08:00Dec 19, 2022|HEENT, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: Finger Pain

finger pain

A 57-year-old male presents after accidentally firing his son’s expired epinephrine autoinjector containing 0.3 mg of epinephrine into his left thumb two hours prior to arrival. He endorses mild pain and numbness at the tip of his thumb. The patient had spoken to poison control who had instructed him to present to the Emergency Department if his symptoms did not improve after two hours. He denied any palpitations or other systemic symptoms.

Vitals: HR 81; BP 128/81; RR 18; SpO2 99%

Extremities: Pallor noted at the distal tip of his left thumb extending 2 to 3 cm proximally with a central 2 mm area of bruising. Capillary refill could not be elicited in the left thumb pad. Sensation was intact to light touch and motor strength was intact in the left thumb.

No lab work was performed.

Treatment modalities are primarily based on case reports and range from conservative measures to local infiltration of vasodilatory medications. [1] Conservative treatments include digital massage, warm water soaks, and local application of nitroglycerin paste. Varying degrees of success have been associated with these conservative treatments. In our case, conservative measures failed and we proceed with local infiltration of phentolamine mesylate. The dosage and volume administered vary widely in reports; however, commonly reported doses were 2 to 3.5 mg of phentolamine reconstituted with 1 to 2 ml of 2% lidocaine or normal saline. This is then injected locally at multiple locations in the affected region or as a digital block. In our case, reperfusion occurred within minutes after local infiltration with approximately 1.5 mg of phentolamine reconstituted with lidocaine. No systemic side effects were noted.

There have been no documented reports of ischemic necrosis associated with accidental digital epinephrine injection. Additionally, spontaneous resolution in the majority of cases at less than two hours has been widely reported, though in some cases symptoms may persist for hours to days. [1,2] Though phentolamine may provide rapid symptomatic relief of pallor, pain, and/or paresthesia for the patient, limited data exist on long-term clinical outcomes and the overall effect on prognosis. [3]

The recommendation to never use lidocaine with epinephrine for digital nerve blocks or local digital infiltration is propagated in medical education. However, a large retrospective review of 127 accidental digital epinephrine injection cases noted a majority had spontaneous resolution. [2] Further, large studies from surgical literature have reported that local infiltration of lidocaine with epinephrine is safe and resulted in prolonged anesthesia and reduced bleeding.

Take-Home Points

  • Spontaneous resolution of accidental digital epinephrine injection often occurs within two hours and no cases of ischemic necrosis have been reported.
  • Symptomatic relief may be achieved with local phentolamine mesylate infiltration if conservative measures have failed. Commonly reported total effective doses range from 2 to 3.5 mg in volumes of 1 to 2 ml of 2% lidocaine or normal saline.

  • McNeil C, Copeland J. Accidental digital epinephrine injection: to treat or not to treat? Can Fam Physician. 2014 Aug;60(8):726-8. PMID: 25122817; PMCID: PMC4131962.
  • Muck AE, Bebarta VS, Borys DJ, Morgan DL. Six years of epinephrine digital injections: absence of significant local or systemic effects. Ann Emerg Med. 2010 Sep;56(3):270-4. doi: 10.1016/j.annemergmed.2010.02.019. Epub 2010 Mar 26. PMID: 20346537.

By |2022-12-08T21:58:38-08:00Dec 12, 2022|SAEM Clinical Images|

SAEM Clinical Images Series: A Rash You Don’t Want to Miss

rash

A 54-year-old female with a past medical history of diabetes presented to the Emergency Department (ED) for evaluation of unresponsiveness. The patient was found unresponsive by her spouse, who notes she had missed several doses of insulin over the past few days. EMS notes the glucometer read ‘HIGH’ on fingerstick. The patient remains unresponsive on presentation and is unable to contribute further history.

Vital Signs: BP 148/105; HR 120; RR 24; Pulse Oximetry 98% on room air; Temperature 97.7°F

Constitutional: Patient is morbidly obese, unresponsive, and toxic-appearing.

Cardiovascular: Regular rhythm with tachycardia. No murmur.

Pulmonary: Pulmonary effort is normal. Lungs clear to auscultation bilaterally.

Abdomen: Abdomen is soft and non-distended. Unable to assess for tenderness given unresponsiveness.

Skin: Cool, pale, mottled. Large gangrenous, draining, foul-smelling wound on proximal left thigh. There is necrotic, malodorous, black skin noted over the left lower abdomen and left upper thigh.

Neurological: Unresponsive. GCS 3.

White blood cell (WBC) count: 20.5

Comprehensive metabolic panel (CMP): K 5.8; Cr 2.06; BUN 86; Glucose >600

Venous blood gas (VBG): pH<7; lactate 3.4; bicarbonate 7

These photographs show advanced Fournier’s Gangrene, a form of necrotizing fasciitis located in the genitals, perineum, or perianal region. Rapid involvement of our surgical colleagues is crucial, as these patients will not recover without the debridement of affected tissues. Aggressive fluid resuscitation and broad-spectrum antibiotics can be initiated after a surgical consult is made.

This patient presented with impressive visual evidence of advanced disease including severe ecchymosis, but our clinical suspicion must be high as Fournier’s is rapidly progressing and carries a high mortality rate (may be upwards of 30%). Earlier symptoms are genital or perineal pain which may be associated with itching, lethargy, or fever. The biggest exam finding to keep in mind is ‘pain out of proportion to the exam’ as up to 40% of these patients may present without localized symptoms. Advanced disease, as seen in this patient, can present with crepitus and severe ecchymosis of tissue involved. This patient was also found to be in DKA, as evidenced by her laboratory findings. This case should serve as a reminder that it is vital to perform a proper skin examination in patients presenting with hyperglycemia. Ultimately in this case, the patient was intubated for airway protection and started on vasopressors for cardiovascular support in the setting of septic shock. She went into VTach arrest and was successfully defibrillated before further decompensating and becoming asystolic.

Take-Home Points

  • The first task after suspected diagnosis of Fournier’s Gangrene is a page to your surgery service for evaluation and emergent debridement in the OR (depending on your institution this may be general surgery, urology, or both). After your patient is on the path to definitive management, you can begin aggressive fluid administration and broad-spectrum antibiotics (gram-positive, gram-negative, and anaerobic coverage needed).
  • Fournier’s Gangrene is a clinical diagnosis. Imaging may assist in atypical or borderline cases, but should never result in delay of surgical evaluation and treatment. Crepitus and ecchymotic tissue are very late findings; have high clinical suspicion inpatients with signs of swelling, erythema, and pain.

  • Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001. Epub 2013 Apr 8. PMID: 23578806.
  • Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med. 2011 Sep;39(9):2156-62. doi: 10.1097/CCM.0b013e31821cb246. Erratum in: Crit Care Med. 2011 Nov;39(11):2592. Dosage error in article text. PMID: 21532474.
  • Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review. Surg Infect (Larchmt). 2016 Oct;17(5):503-9. doi: 10.1089/sur.2016.049. Epub 2016 Aug 2. PMID: 27483003.
  • Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
  • Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. doi: 10.1016/j.jamcollsurg.2008.10.032. Epub 2008 Dec 12. PMID: 19228540.
  • Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. p.592- 593.

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