LETTERS

CIRCUMCISION DISASTERS

To the Editor. -

              The article by Cleary and Kohl (Pediatrics 64:301, 1979)
describes an unusual and disastrous complication of infant circumcision.
We recently cared for a neonate who developed a similar infection of the
perineum, genitalia, and abdominal wall following routine circumcision.1
On admission, three days after circumcision, he was lethargic, hypotensive,
thrombocytopenic, and had multiple skin emboli.  His genitalia had a bluish
discoloration and there was a subtle induration of the skin of the lower
abdominal wall.  He was treated with parenteral fluids, albumin, cryo-
precipitate, and platelet concentrates.  Immediate parenteral therapy with
nafcillin, penicillin G, cholomycetin, and kanamycin was instituted.  Early
extensive surgical excision and debridement of the genitalia and abdominal
wall to the level of the flanks was performed.  Micrococcus species was
grown from the blood. Clostridium perfringens, coagulase-positive
Staphylococcus aureus, Staphylococcus epidermis, diptheroids, nonhemolytic
Streptococcus, and alpha-hemolytic Streptococcus were grown from various
areas of debrided tissue.  Ten days later primary closure of the abdominal
wounds and skin grafting of the penile shaft were performed.  His
subsequent course has been smooth and his wounds have healed.

              These destructive life-threatening soft tissue infections are
familiar to the surgeon.  Cleary and Kohl's significant article brings an
awareness of this entity to those physicians who initially encounter the
early complication of circumcision in infants.  I feel that several points
require emphasis: (1) These infections are often more extensive than their
superficial appearance indicates.  (2) Whether designated necrotizing
fasciitis, Melaney's ulcer, or mixed synergistic gangrene, they are usually
caused by a combination of aerobic, anaerobic, and facultative anaerobic
bacteria.2,3  (3) Initial antibiotic therapy should be effective against
a broad range of aerobic and anaerobic organisms and appropriately includes
penicillin, a penicillinase resistant penicillin, an aminoglycoside, and
clindamycin, or chloramphenicol.4  A most important and urgent aspect of
therapy is early surgical debridement of excision of all involved fascia
and subcutaneous tissue.

                              Jeffrey R. Woodside, MD
                              Division of Urology
                              The University of New Mexico
                              School of Medicine
                              2211 Lomas Blvd NE
                              Albuquerque, NM 87131

References

   1.  Woodside JR, Necrotizing fasciitis following neonatal circumcision.
       Am J Dis Child in press 1980.

   2.  Tehrani MA, Ledingham IM: Necrotizing fasciitis.
       Postgrad Med J 53:237, 1977. [Medline]

   3.  Wilson HD, Haltalin KC: Acute necrotizing fascitis in
       childhood. Am J Dis Child 125:592, 1973.

   4.  Guiliano A, Lewis F Jr, Hadley K, et al.  Bacteriology of
       necrotizing fascitis. Am J Surg 134: 52, 1977. [Medline]



To the Editor. -

              With regard to the article by Cleary and Kohl (Pediatrics
64:301, 1979), is there a literature on such infection following
circumcision by a licensed mohel, ritual circumcisor.  In 45 years of
pediatric practice in a largely Jewish area, I have never seen any
occurrence.  The only infection I have seen is minor oozing, easily
controlled.

              Perhaps the seventh day is the best time for the procedure,
and use of the Gomco clamp is the simplest and least traumatic.

                              Abraham Kanoff, MD
                              1715 Nottingham Road
                              Charlotte, NC 27607

In Reply.-

              We appreciate the interest in our report.  We generally agree
with Dr. Woodside, although we are uncertain of the exact role surgery
should play.  Clearly in there is an abscess, necrotic gangrenous tissue,
or subcutaneous crepitance surgery is crucial.  For the infant who has
cellulitis without these features a less aggressive approach seems
reasonable.

              In reference to he comments of Dr. Kanoff, the largest series
evaluating the complications of ritual circumcision performed on day 8 by
skilled mohelim comes from Jerusalem.  In this series of approximately
8,000 procedures it is only noted that "infection of the wound is . . . a
fairly common complication" but "becoming rare due to improvement in the
traditional technique."1  As far as the relative merits of the Gomco
clamp, there are data suggesting that the frequency of infection with a
Gomco is lower than with the Plastibell (0.14% vs 0.72%) but that other
complications are more common with the Gomco.2  Perhaps the end of the
first week represents a "best time for the procedure" for those requiring
ritual circumcision but for those not requiring this ceremony we doubt that
there is a best time.

                           Thomas G. Cleary, MD
                           Steve Kohl, MD
                           Program in Infectious Diseases
                           and Clinical Microbiology
                           The University of Texas
                           Health Science Center at Houston Medical School
                           Houston, TX  77025

References

   1.  Schulman J, Ben-Hur N, Neuman Z: Surgical complications of
       circumcision. Am J Dis Child 107:
       149; 1964.

   2.  Gee WF, Ansell JS: Neonatal circumcision: A ten year
       overview with comparison of the Gomco clamp and the
       Plastibell device. Pediatrics 58:824, 1976.