Penile strangulation or entrapment is an unusual entity that requires urgent treatment due to its potential complications. Several cases have been reported in the medical literature, some of them describing serious injuries such as necrosis, gangrene, and amputation of the penis. However, as far as we know, no fatal cases have been described before. We present the death of an adult male secondary to the complications due to penile strangulation with a plastic bottle neck. The time of incarceration was unknown, but according to a witness it could be about 10 to 14 days. The findings of autopsy were penile strangulation, necrosis of the penis, acute pyelonephritis, and bronchopneumonia. The subject's refusal to ask for medical help was the cause of this atypical evolution.

BACKGROUND: Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acral gangrene. It is a distinct complication of chronic renal failure that must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the main underlying conditions. The benefit of parathyroidectomy is controversial. OBJECTIVE: This article is based on a literature search to determine prognostic factors and, in particular, the benefit of parathyroidectomy. METHODS: The literature on uremic small-artery disease (so-called calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and transplant) and outcome were analyzed. The relation between diabetes and acral gangrene was also examined. Further epidemiologic data on the reviewed group of patients were established. RESULTS: Thirty-eight of 58 patients who underwent parathyroidectomy survived compared with 13 of 37 patients who did not undergo parathyroidectomy (p = 0.007, n = 95). Forty of 53 patients with distal localization of necrosis survived compared with 11 of 42 patients with proximal pattern (p < 0.00001; n = 95). Dialysis and kidney transplantation followed by immunosuppression showed no relation to disease outcome. No association was found between diabetes and acral gangrene (p = 0.50). CONCLUSION: Uremic small-artery disease is a distinct complication of chronic renal failure. Its recognition and early diagnosis should allow more effective treatment. In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parathyroidectomy vs conservative treatment of secondary hyperparathyroidism) can establish the value of parathyroidectomy in uremic small-artery disease.

Sixty-three patients with pyoderma gangrenosum were seen and studied at the Mayo Clinic from 1971 to 1980. Biopsies from the erythematous border or necrotic edge of the pyoderma gangrenosum lesions usually demonstrated a characteristic pathogenic morphologic evolution. The early lesions revealed mild to moderate perivascular lymphocytic infiltrate associated with endothelial swelling. The fully developed lesions demonstrated necrosis in addition to a dense lymphocytic infiltration surrounding as well as involving the blood vessels. Extravasation of erythrocytes and thrombosis sometimes were seen. Ulceration, infarction, and abscess formation were found in the later stages of evolution. Direct immunofluorescence results were positive in the blood vessels of 36 of 65 (55%) specimens. IgM, C3, and fibrin were found in the papillary and reticular dermal vessels. IgG and IgA were only occasionally present. Pyoderma gangrenosum appears to be a reactive process that is manifested as a vasculitis. Biopsy material from the advancing active erythematous border has early characteristic dermatopathologic findings of lymphocytic vasculitis. Cutaneous vascular immune deposits suggest an immune pathogenesis of either an immune complex disease or lymphocytotoxic reaction.

Six patients are presented, all of whom had systemic lupus erythematosus or a "lupus-like" disease and who developed major thromboses with gangrene of the extremities. Four of the 6 patients had circulating antiphospholipid antibodies at some point during the course of their illness. These serological markers, which have been associated with a tendency to thrombosis, may have contributed to the development of gangrene in these patients. Histological examination of affected arteries in 4 patients did not show any evidence of vasculitis. One patient in whom antiphospholipid antibodies were negative showed healing vasculitis on histology.

Necrotizing fasciitis is a rare infection frequently preceded by trauma and usually caused by beta-hemolytic Streptococcus. The disease is characterized by cutaneous necrosis, suppurative fasciitis, and vascular thrombosis. Associated systemic problems are common, with chronic alcoholism and diabetes being the most prominent. Involvement of head and neck structures is exceedingly rare, with only seven cases reported in the literature. We report an additional case that terminated fatally. Management requires high doses of aqueous penicillin G potassium given intravenously, early surgical drainage, and debridement of necrotic tissue. Mortality may be as high as 30%, and it is negatively influenced by delay in diagnosis and treatment.

Purpura fulminans presents as a catastrophic illness with gangrene of the distal extremities and necrosis of skin. The clinical picture consists of septicemia, shock, and disseminated intravascular coagulation. The Shwartzman and Arthus reactions are thought to be responsible for the pathogenesis of purpura fulminans. The exact mechanisms of these reactions are not completely understood. Immediate resuscitation is the treatment for shock and sepsis. Heparin is recommended to reverse the disseminated intravascular coagulation component of this disease. Surviving patients require treatment of skin necrosis and digital and extremity gangrene. The former are managed in a fashion similar to the management of burns. Amputation should be delayed until maximal collateral circulation has developed. A series of 10 patients is presented and 58 cases from the literature are analyzed.

BACKGROUND: Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside. METHODS: Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process. RESULTS: These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis. CONCLUSION: Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.

Human immunodeficiency virus (HIV) infection can present with musculoskeletal syndromes including systemic vasculitis. We describe vasculitis resembling polyarteritis nodosa (PAN) in 2 HIV-infected individuals and review reported cases to emphasize clinical features. Our patients presented with digital gangrene and had vasculitis confirmed by angiography. In reports in the literature, patients have presented with digital ischemia and gangrene, peripheral neuropathy and constitutional symptoms. The diagnosis has been confirmed by angiography and by nerve and muscle biopsy. Treatment with systemic corticosteroids has afforded short term benefits to patients; however the effectiveness of alternative therapy and longterm prognosis remain unclear.