Circumcision Disasters (letters)

Letters 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 hasbeen 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

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, anduse 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

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