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Early Diagnosis Saves Life in Flesh-Eating Disease

Dear Dr. B: My son has developed serious infection in his leg. How do I know if this is flesh-eating disease?

The most famous case of flesh-eating disease (FED) in Canada is Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

FED is a very serious kind of infection which spreads rapidly in the body. It is deep seated under the skin and progressively destroys fat, fascia and muscles. The condition is also known as necrotizing fasciitis.

FED was first described by Hippocrates around 500 B.C. The condition is not that common. In Canada, it is estimated that 90 to 200 cases of FED occur each year. In the US, approximately 1000 cases are seen in a year. Since the condition is not common, a physician would probably see one or two cases in his career.

The death rate in FED has not changed in the last 30 years and remains around 25 to 35 per cent. Death rate is directly related to early diagnosis and surgical intervention.

The most common sites of infection are perineal and groin areas and post surgical wounds. Infection around the umbilicus in a new born can be life-threatening. Among children the FED can be a serious complication of varicella infection. Infection can occur in the trunk and the limbs. Patient who are diabetic, intravenous drug abusers, immuno-compromised or have peripheral vascular disease are also prone to FED.

How to diagnose FED?

The diagnosis is clinical. It is not always easy to make a diagnosis. But the condition should be kept in mind in any kind of skin infection.

Initially, it is hard to differentiate from ordinary infection of the skin. But gradually patients get very sick. The pain is more severe than the clinical findings. There are only minor changes in the skin in early phases.

The factors that help distinguish FED from ordinary skin infection include a generalized rash, toxic appearance, fever and low platelet count. Plain x-ray can reveal gas under the skin or soft-tissue swelling but cannot show deeper gas under the fascia. CAT scan is more sensitive because it can show inflammatory changes like fascial swelling, thickening, abscesses and gas formation. MRI can add more information but ultrasound has poor sensitivity and specificity in this condition.

“The main diagnostic tool, however, is surgical exploration”, says an editorial in the British Medical Journal (BMJ). The characteristic finding at surgery is of grey, edematous fat, which strips off the underlying fascia with a sweep of the finger. Deeper changes are invariably more widespread than the skin changes. If FED is suspected then surgical exploration should be undertaken and can be life saving.

Intravenous antibiotic therapy has an important role in reducing generalized infection and spread of bacteria in the body. The BMJ editorial says that no evidence exists that antibiotics halt the infection in FED and their use may tempt the surgeon to perform less mutilating and less effective surgery. Nevertheless, broad spectrum antibiotic cover is routine and should specifically target anaerobes and streptococci.

Hyperbaric oxygen is strongly advocated by some. But there are no controlled studies to prove its usefulness. Using it would seem reasonable if it was readily available but not if the need for inter-hospital transfer delayed definitive surgery, says the editorial.

In summary, the diagnosis of FED is mainly clinical. Surgery is the mainstay of management. Patient should be taken to the operating room as soon as flesh-eating disease is suspected. Massive removal of dead and dying tissue is undertaken. Sometimes amputation becomes necessary. Patient may require surgery more than once.

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Science Behind the Use of Probiotics

There is increasing trend towards the use of probiotics and prebiotics by patients suffering from certain kinds of illnesses and by the public in general.

The word probiotics is a compound of a Latin and a Greek word. It means “favorable to life.” Probiotics, as defined by the Food and Agricultural Organization of the United Nations (FAO), are live microorganisms administered in adequate amounts which confer a beneficial health effect on the host.

The largest group of probiotic bacteria in the intestine is lactic acid bacteria, of which Lactobacillus acidophilus, found in yogurt, is the best known. Yeast is also a probiotic substance. Probiotics are also available as dietary supplements. These bacteria do not promote or cause disease. They are friendly germs.

Prebiotics refer mainly to certain foods, and occasionally to certain food products, that support the growth of probiotics. Included among prebiotics are foods such as regular artichokes, oats, leeks, onions, honey and whole grain breads or cereals.

The concept of using probiotics is not new. It goes back to the late nineteenth century. People tried to improve their health by supplementing their natural intestinal bacteria by additional bacteria taken by mouth. The Lactobacilli group of bacteria, found in yogurt, was the first identified probiotic. In the 1920s and 1930s, many doctors recommended acidophilus milk for the treatment of constipation and diarrhea. This treatment was effective for many patients.

In the 1950s, medical researchers began to study L. acidophilus as a possible answer to some of the digestive side effects of taking antibiotics. We know that antibiotics upset the natural balance of the intestinal organisms by killing the good bacteria along with the bad ones. The researchers thought that taking oral preparations of L. acidophilus might offset the side effects of the antibiotics.

According to Harvard Women’s Health Watch, probiotic therapy has been best studied for the treatment of diarrhea. It may also help people with Crohn’s disease, irritable bowel syndrome, and other gastrointestinal problems. Probiotics that help restore the balance of bacteria in the vagina may be useful in treating such common female urinary and genital problems as bacterial vaginosis, yeast infection, and urinary tract infection. More study is needed to know which probiotic strains work best for which conditions.

Harvard Women’s Health Watch suggests that people considering probiotics keep the following points in mind:
-The recommended doses range from 1 billion to 10 billion colony-forming units (CFU)—the amount contained in a capsule or two—several days per week.
-A daily supplement for one to two weeks may improve conditions such as infectious or antibiotic-related diarrhea.

The microorganisms in probiotic supplements need to be alive when you take them (or when they’re freeze-dried for capsules). They may die on exposure to heat, moisture or air. Some require refrigeration. See Harvard Health Publication (www.health.harvard.edu) and (www.usprobiotics.org).

In summary, probiotics are bacteria that help maintain the natural balance of bacteria in the intestine. The normal human digestive tract contains about 400 types of probiotic bacteria that reduce the growth of harmful bacteria and promote a healthy digestive system. Probiotics is not a panacea for all gastro-intestinal problems. Lot more research is required to establish the role of probiotics in health and illness.

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Fainting Attacks Amongst Children and Young Adults

A passed out child. (Top Photo Group/Thinkstock)
A passed out child. (Top Photo Group/Thinkstock)

A young man visits his doctor with a history of recurrent fainting attacks. Parents are worried. They want to know what could be the cause.

A transient, self-limited loss of consciousness, usually leading to falling is termed as syncope. Syncope is a common clinical problem accounting for five per cent of hospital admissions and up to three to five per cent of emergency department visits.

Syncope is a major challenge for the practicing physicians. It is very important to know the cause and clinical characteristics of syncope in children. Although most often benign, it can be a symptom of serious underlying conditions. It is estimated that 15-40 per cent of children and young adults have had at least one episode of syncope. Approximately one to two per cent of children presenting with syncope have a serious underlying disorder.

A paper published by the Department of Pediatrics, Peking University, retrospectively analyzed the causes of syncope and diagnostic workup of 154 consecutive children.

They found autonomic-mediated reflex syncope (also known as vaso-vagal or neuro-cardiogenic syncope) was the most common cause in 65.6 per cent of children, whereas cardiac disorders were found in 10 cases (6.5 per cent) comprising the second cause of syncope in children.

Other causes included psychological, neurological and metabolic disorders. Although many causes were studied, 25 cases (16.2 per cent) were found to have no definite cause for their syncope.

Vaso-vagal syncope is a temporary loss of consciousness associated with a drop in arterial blood pressure, quickly followed by a slowed heart rate. It usually occurs while standing. It may happen while a person is lying down. Emotional stress, stressful condition and pain may trigger an episode.

The fainting may occur suddenly or is associated with warning symptoms such as fatigue, weakness, nausea, sweating, pallor, visual disturbances, abdominal discomfort, headache, pins-and-needles, lightheadedness or vertigo. A person may feel hot or cold. He or she may have slurred speech and keeps yawning. During the faint “seizure-like” activity may occur.

Diagnosing vaso-vagal syncope is usually not difficult. It has a typical history and always completely normal physical examinations and ECGs. It is commonly seen in pubertal girls, but can happen in males. Usually, there is a clear precipitating cause of syncope.

Cardiac syncope can have be associated with life-threatening diseases. Therefore finding a cause for cardiac syncope is very essential.

A thorough medical history, ECG and echocardiography (ultrasound of the heart) can reveal life-threatening cardiac causes of syncope. Twenty-four-hour monitoring of the heart rhythm (Holter monitor) also helps in the diagnosis. Cardiac syncope often occurs suddenly or during exercise. Children with cardiac syncope often have history of cardiac diseases and they were often younger.

The authors of the Peking paper say that neurological causes of syncope should be considered if syncope is associated with seizure activity, syncope spells seen in any position, there is disorientation or neurologic abnormal signs. Diagnostic tests like EEG, CAT scan and MRI should be able to give us an answer.

A metabolic cause was entertained when the child had a history of metabolic diseases, prolonged anger or violent vomiting and diarrhea. Children with psychiatric disorders were adolescent girls with prolonged syncope spells and had more frequent syncopal episodes.

In summary, syncope in children may result from a wide variety of causes. In most cases, appropriate investigations will give us the diagnosis. History taking, physical examination and electrocardiography are the core of the syncope workup. Most causes of syncope are benign.

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Sexual Activity and Mysterious Headaches

Do you get mysterious headaches with sexual activity? May be not. But for one reader of my columns this has become a significant problem.

It is estimated that patients who have headache with sexual activity account for approximately one per cent of all headache patients. It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities.

This condition has been given many names: benign coital headache (most of the time no serious underlying cause is found), masturbatory headache, orgasmic cephalagia (as it occurs usually at or near orgasm).

Apparently, headache related to sexual activity has been recognized since the time of Hippocrates. But the first systematic descriptions of this condition appeared in medical literature in 1974. Since then primary headache associated with sexual activity has become a well defined entity.

Coital headache is usually a recurrent, benign headache and is more common in men than in women. It can occur just before, during, or immediately after orgasm. The headaches are usually dull and throbbing and last from minutes to hours. Occasionally, some patients experience a sudden, explosive headache that occurs during orgasm.

Three types of sexual headaches are recognized.

The first, the dull type, is described as a dull ache in the head and neck that intensifies as sexual excitement increases, peaking at orgasm. This type of headache is little less common than type two.

Type two, also known as vascular or explosive coital headache, is a sudden, severe, explosive headache that occurs just before or at orgasm and persists for a few minutes to 48 hours. This is the most common type of coital headache. Patients find orgasmic headache frightening, distressing and disabling.

Type three is a postural headache, resembling that of low cerebro- spinal fluid pressure that develops after coitus. This type of headache is rare.

When patients first present with coital or orgasmic headache, it is mandatory to exclude serious underlying condition like ruptured aneurysm and bleeding in the brain. When a patient presents with a new type two coital headache of sudden onset, a CT scan should be performed, and even if this is negative, a lumbar puncture should be obtained, says one research paper.

Aneurysm without rupture can present as coital headache. To pick this condition it is necessary to do an angiography and MRI of the cerebral blood vessels. Other cause for coital headache is central nervous system vasculitis.

During the acute phase of pain, usual analgesics (ibuprofen, diclofenac, acetaminophen, ASA) can be tried but are considered of limited value to relieve the pain. In 25 per cent of the patients the pain may last more than two hours and up to 24 hours. Other medications which have been tried with some success are triptans, propranolol and indomethacin.

Fortunately, the prognosis is good and in the majority of patients where no underlying pathology is identified. With time the headaches disappear without any specific treatment.

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