A case of Meleney’s abdominal gangrene in Madras Medical College

INTRODUCTION

Meleney’s gangrene is a rapidly destructive infection involving the skin and the subcutaneous tissue and in severe cases the deep fascia. First described by Dr. Meleney and Dr. Brewer in 1926 its microbial effectors were further classified by Meleney in 1931.¹ The mortality as a result of Meleney’s gangrene is almost 34%. Meleney’s ulcer or postoperative synergistic bacterial gangrene is a rare form of abdominal wall gangrene but has well documented clinical entity. It develops following intra abdominal surgery in the immediate vicinity of the surgical wound. It is caused by the synergistic interaction between microaerophilic nonhemolytic Streptococcus and hemolytic aerobic staphylococcus aureus.² Meleney’s ulcer or post-operative synergistic bacterial gangrene is a rare form of necrotizing infection of the abdominal wall which develops following intra-abdominal surgery. If not promptly identified and treated, it can lead to extensive gangrene leading to fatal complications.³ We report a case of Meleney’s gangrene with superadded aspergillosis which rapidly progressed to gangrene of a large area of the anterior abdominal wall leading to mortality of the patient.

CASE REPORT

A 57 years old male presented with a swelling over the left lower abdomen and groin for 2 days. The patient was a known case of type 2 diabetes on regular treatment with oral hypoglycemic agents. There was no history of trauma or previous surgeries. On examination, the patient was febrile, dehydrated and tachycardic. Local examination revealed a tender discoloration over the left iliac fossa and groin of size 8×6 cm and an ulcer of size 1×0.5 cm over it with undermined edges (Panel A) and foul smelling seropurulent discharge. Other regions of the abdomen were soft and non-tender. External genitalia, scrotum, and perianal region were found to be normal. A clinical diagnosis of necrotizing fasciitis was made. Initial investigations showed a random blood sugar of 356 mg/dl, blood urea of 61 mg/dl, serum creatinine of 2.1 mg/dl and a total count of 19000/µl. A wound culture and sensitivity revealed the polymicrobial infection. An abdominal ultrasound showed subcutaneous air pockets and ruled out intraperitoneal involvement. The patient was offered emergency debridement under Intravenous sedation (Panel B). All necrotic tissue was removed and the patient was treated in the post-operative ward with intravenous antibiotics and adequate glycemic control Patient’s total count and renal parameters normalized over the next few days. Daily debridement and a sterile dressing were done and wound status continued to improve. The patient was discharged after 17 days with a healthy wound and normal blood work. Patient came for follow up after 30 days which revealed a healthy wound and a normoglycemic status.

DISCUSSION

Necrotizing fasciitis is spreading inflammation of the skin, deep fascia and soft tissues with extensive destruction, toxemia commonly due to mixed infections caused by anaerobes, coliforms, and gram-negative organisms.⁴ Diabetes, drug addiction, alcoholism, obesity, malnutrition, tumors, immunodeficiency, and other chronic medical conditions are important predisposing factors.⁵ Hippocrates first described necrotizing fasciitis as early 5th century BC. Fournier later in 1883, described Necrotizing Fasciitis in the genital and perineal regions, and Meleney reported the first involvement of abdominal wall in 1926. Wilson proposed the term necrotizing fasciitis in 1952.⁶ Meleney’s gangrene is known to be progressive synergistic gangrene, representing a polymicrobial infection in which microaerophilic streptococci flourish with Staphylococcus aureus. Meleney demonstrated this synergy by noting the formation of the typical gangrenous lesion when both of the organisms were injected into the skin of dogs. Neither organism was capable of forming such a lesion when injected alone.⁷ Meleney's ulcer usually begins as a small, superficial ulcer following trauma or surgery. It may also arise from infected lymph nodes. Meleney's ulcer primarily represents an infection of the subcutaneous tissue leading to small-vessel thrombosis followed by subcutaneous necrosis.⁸ The condition is a surgical emergency. Early diagnosis is absolutely crucial for improved prognosis, and this is usually on the basis of clinical means. Aggressive surgical debridement is the first line of management of necrotizing fasciitis; followed by specific antibiotic therapy.⁹ Excision of all necrotic fascia and non-viable skin and subcutaneous tissue is mandatory. This has to be repeated as often as is necessary due to the rapid spread of the necrosis. The involved tissue usually extends beyond the obviously visible margins; thereby requiring debridement well into the healthy area. Frequent postoperative dressing changes and wound inspections are recommended.¹⁰

CONCLUSION

Unfortunately, many signs of meleney’s gangrene are initially overlooked which leads to unnecessary higher mortality. In the post-surgical patient, signs of sepsis wound dehiscence and discharge at the operative site may suggest Meleney’s gangrene. The essence of treatment lies in aggressive debridement and good antibiotic cover. Healthcare providers at the periphery should be made aware of this condition for its prompt recognition and diagnosis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Meleney FL, Shambaugh P, Millen RS. Systemic bacitracin in the treatment of progressive bacterial synergistic gangrene. Ann Surg. 1950;131(2):129–44.
2. 2. Wallace S. Progressive postoperative gangrene of the skin. BJS. 1935;22(88):642-56.
3. 3. Meleney FL. Bacterial synergism in disease processes: with a confirmation of the synergistic bacterial etiology of a certain type of progressive gangrene of the abdominal wall. Ann Surg. 1931;94(6):961–81.
4. 4. David AB, Robinson KP, Hedd R. Meleney's progressive synergistic bacterial gangrene due to subcutaneous end-ileostomy perforation, with delayed plastic reconstruction. RSM J. 1982;75:749-50.
5. 5. Meleney FL, Brewer GE. Progressive gangrenous infection of the skin and subcutaneous tissues, following an operation for acute perforative appendicitis: a study in symbiosis. Ann Surg. 1926;84(3):438-50.
6. 6. Roberts DB, Hester LL. Progressive synergistic bacterial gangrene arising from abscesses of the vulva and Bartholin's gland duct. Am J Obstet Gynecol. 1972;114(3):285–91.
7. 7. Flanigan RC, Kursh ED, McDougal WS, Persky L. Synergistic gangrene of the scrotum and penis secondary to colorectal disease. J Urol. 1978;119(3):369–71.
8. 8. Grainger RW, MacKenzie DA, McLachlan AD. Progressive bacterial synergistic gangrene: chronic undermining ulcer of Meleney. Can J Surg. 1967;10(4):439-44.
9. 9. Luckett WH. Large Phagedenic Ulcer of the Abdomen. Ann Surg. 1909;50(3):605–8.
10. 10. Rea WJ, Wyrick WJ Jr. Necrotizing fasciitis. Ann Surg. 1970;172(6):957–64.