World J. Surg. 15, 240-247, 1991

World Journal of Surgery 9 1991 by the Soci6te lnternationale de Chirurgie

Necrotizing Soft Tissue Lesions after a Volcanic Cataclysm Jos6 F. Patifio, M.D., F . A . C . S . (Hon.), Daniel Castro, M.D., Alvaro Valencia, M.D., and Pedro Morales, M.D. Department of Surgery, Centro M6dico de los Andes, Fundaci6n Santa Fe de Bogotfi; Department of Surgery, Hospital de La Samaritana; and Department of Pathology, Hospital San Juan de Dios and National Institute of Forensic Medicine, Bogotfi, Colombia A volcanic cataclysm of major proportions, the fourth largest in terms of total casualties in the history of mankind, wiped out the town of Armero, Colombia, in 1985 resulting in over 23,000 deaths and 4,500 wounded. Among the hundreds of survivors who were transferred to hospitals in the capital city of Bogotfi, there was as overwhelming number who developed necrotizing fasciitis. These patients constitute, perhaps, the single largest group of this type of lesions in the recorded literature. Thirty-eight patients with well established necrotizing fasciitis were identified at 4 selected hospitals in Bogot~i; 8 of them presented with zygomycetic infection (mucormycosis), a highly lethal entity. Many additional cases were treated at uther hospitals in Bogot~i and several cities in Colombia. The main clinical features of these 38 patients affected by necrotizing fasciitis are reviewed, with special emphasis on the patients with mucormycosis. Patients with necrotizing fasciitis had an overall mortality rate of 47.7%; patients with mucormycosis, 80%. A plea is made for an early diagnosis, utilizing tissue sampling and microbiological studies, so that prompt and radical treatment can be instituted. This is especially pertinent in situations of natural disasters resulting in massive numbers of casualties and seriously injured survivors.

of survivors were caused by anaerobic and aerobic bacteria in synergistic combinations; zygomycetic organisms were identified in 8 patients with more severe and rapidly progressing lesions. Other associated serious entities were frequently observed. With the purpose of defining the clinical characteristics, pathology, microbiology, and natural course of this unprecedented number of necrotizing and gangrenous lesions generated in a unique natural disaster situation, we studied, in collaboration with the National Institute of Health, a subgroup of 38 patients admitted to 4 selected hospitals in the city of Bogot& Their clinical characteristics are reviewed herein. Magnitude of the Colombian Cataclysm

During the evening of November 13, 1985, a Plinian eruption of the Nevado del Ruiz volcano in Colombia ejected 3.5 x 10 kg of mixed dasitic and endacitic tephra during a 20-minute interval, forming a smoking column that reached a height of 27 km. Sites as distant as the Caribbean islands registered the fall of volcanic ashes. Melting of the icecap generated huge lahars (volcanic mud), with flows larger than the Amazon river that wiped out the town of Armero (Fig. 1) with a loss of over 23,000 lives. Of the 4,500 injured survivors, 1,500 required hospitalization, hundreds of them with severe and progressive soft tissue injuries consisting of gangrenous cellulitis and necrotizing fasciitis. Such lesions exhibited an extremely aggressive behavior (Figs. 2, 3) and were associated with high major amputation and mortality rates. They usually were the result of skin lacerations and abrasions, some of them quite minor, but aggravated by prolonged immersion in the mud flow; in many cases, the on-site first aid provided by paramedics and volunteers was inadequate and contributed to the worsening of the problem. The necrotizing infections that developed in a large number

A symposium on the Medical Aspects of the Volcanic Catastrophe of Armero was held in Bogot~i in 1986 under the auspices of the National Academy of Medicine; the different reports by the persons and institutions involved in the study of the natural disaster and the care of the victims were published in a comprehensive monograph [1]. Many valuable lessons were derived from the effects of this cataclysm, the fourth largest in terms of total casualties in the history of mankind. A report by L.J. P6rez, M.D., Chief of Natural Disasters Operations of the Ministry of Health of Colombia, issued on November 27, 1985, revealed a total death toll of 22,942 (21,015 in the town of Armero and 1,927 in the town of Chinchin~i). Hundreds of the wounded died in the ensuing weeks. Survivors were trapped and remained submerged in the lahar for hours, and even days, before they could be rescued by helicopter to be air-lifted from the Armero area and transferred to hospitals in Bogota and other cities of Colombia. The patients admitted to the principal hospitals of Bogot~i exhibited a diversity of serious lesions associated with extremely high rates of complications, major amputations, and mortality. The main recorded diagnoses were:

Reprint requests: Jos6 F. Patifio, M.D., F.A.C.S. (Hon.), Chairman, Department of Surgery, Centro M6dico de los Andes, Calle 119 No. 9-33, Bogot~i, Colombia.

1. Necrotizing gangrenous infections of soft tissues: necrotizing fasciitis, clostridial gangrene, zygomycetic infections (mucormycosis, zygomycosis);

J.F. Patifio et ai.: Necrotizing Soft Tissue Lesions

Fig, 1. The lahar (volcanic mud) that covered the town of Armero,

241

Fig. 2. Necrotizing fasciitis of the arm. The patient eventually required amputation. Photograph courtesy of H. Aristizgbal, M,D., Medellfn.

Colombia. 2. Fractures and fascial compartmental compression and crush syndromes of extremities; 3. Acute abdominal syndromes; 4. Acute respiratory failure (ARDS); 5. Severe conjunctivitis; otitis; 6. Tetanus; 7. Delayed upper gastrointestinal bleeding. Clostridial gas gangrene was suspected in many patients with the most rapidly progressive, gas-forming, and toxic necrotizing infections. Health authorities ordered patients suspected to have clostridial gas gangrene to be transferred and confined in the E1 Guavio Polyclinic Hospital. Many of the most severe cases were treated at this institution, which was not optimally equipped for this complex task [1]. Major amputations were performed at the different hospitals harboring survivors with grave necrotizing lesions, several of them gas-producing but not representing true clostridial myonecrosis (gas gangrene). Much debate was generated about the indication for amputation in some of these patients. It was evident that at the provincial hospitals, and even at some city hospitals, a clear differential diagnosis between seriously infected wounds, necrotizing fasciitis, and clostridial gas gangrene had not been promptly established. Such a situation has

Fig. 3. Severe progressive necrotizing fasciitis of the abdominal wall. The patient died in spite of extensive debridements. Photograph courtesy of Dr. G. Supelano. often been referred to in reports from different parts of the world when physicians face necrotizing soft tissue infections in their ordinary clinical practice; the situation tends to be more

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Table 1. Type of lesions in volcano survivors.

Table 3. Characteristics of patients with necrotizing fasciitis.~ No. of cases

Fractures Lacerations Penetrating wounds Internal trauma Eye lesions Other Total

207 606 404 144 295 435 719

Table 2. Clinical outcome in volcano survivors. No. of cases Discharged Referred to other institutions Dead Still in the hospital Unknown, unrecorded Total

379 77 30 219 14 719

Male: 21 (55.3%), female: 17 (44.7%) Mean age: 31.2 yr (range: 8-74 yr) Time submerged before rescue: 12-72 hr Primary emergency care provided on-site (35 patients): Washing and dressing: 19 (54.3%) Suture of wound: 8 (22.9%) Debridement: 13 (37.1%) Fasciotomy: 3 (8.6%) Immobilization of fracture: 2 (5.7%) Parenteral fluids: 22 (62.9%) Tetanus toxoid administration: 7 (20%) Tetanus antitoxin: 7 (20%) Antibiotics: 18 (51.4%) Timing of admission (38 patients): Same week of disaster: 30 (79%) 1 week after: 6 (15.8%) 3-4 weeks after: 2 (5.2%) Associated trauma: 16 (42.1%) Thorax: 9 (23.7%) Abdomen: 4 (10.5%) Craniocephalic: 3 (7.9%) ~Total number reviewed: 38. Table 4. Severity of lesion versus mortality.

pronounced at the time of natural disasters that result in soft tissue trauma in many of the survivors. In the preceding article in this symposium, we referred to the importance of a prompt diagnosis and urgent aggressive surgical therapy in the management of necrotizing fasciitis. Tables 1 and 2 show the major pertinent features of 719 survivors admitted to hospitals under direct surveillance by the Ministry of Health, as recorded 2 weeks after the catastrophe [2]. Of the 606 lacerations and 404 penetrating wounds recorded, it is believed that close to one-half represented cases of polymicrobial necrotizing fasciitis. It is not known how many of the hundreds of patients, treated at a variety of provincial and state hospitals, had undetected mucormycosis as a primary or contributing etiology, and the number of cases of clostridial myonecrosis was not accurately established. The admission diagnosis failed to record the specific nature of the necrotizing infections in many instances. Diagnoses such as "infected laceration," "purulent wound," "infected gangrene," "gas gangrene," etc., were common, caused confusion, and, in some cases, resulted in delays in the initiation of proper treatment; when "gas gangrene" was diagnosed because of the presence of gas in the soft tissues (clinically or radiologically detected), it raised a multitude of anxiety and near-panicdriven measures that included recommendations for major amputations. About 2 weeks after the disaster, knowing that several patients with necrotizing lesions admitted to diverse hospitals in Bogot~i were deteriorating and dying in spite of what appeared to be adequate surgical therapy, we decided to review these patients with the aim of confirming the diagnoses and, especially, of investigating the possibility of undetected mucormycosis. Patifio and associates [3] had previously reported mucormycosis as a cause of fulminating necr0tizing lesions. Four hospitals in the city of Bogot~ that had received Armero survivors were chosen for the investigation: E1 Guavio Polyclinic Hospital, Sim6n Bolivar Regional Hospital, La Samaritana Hospital, and the Medical Center of the Andes of the Santa

Depth of lesion No. (%)

Mortality (%)

Skin/subcutaneous tissues 25/38 (65.8) Superficial fascia 10/38 (26.3) Muscle 8/38 (21.1)

56 60 75

Fe de Bogot~i Foundation. A total of 169 charts were reviewed and 38 were selected, corresponding to those patients who had persuasive clinical evidence of necrotizing fasciitis. Their main characteristics appear in Table 3. Most of the 38 patients who developed necrotizing fasciitis presented with more than one body region affected by the lesions, with clear preference for the lower portion of the body. The lower extremities appeared affected in 32 (84.2%) patients, the upper extremities in 16 (42.1%), the abdomen in 5 (13.2%), the chest in 4 (10.5%), the face in 5 (13.2%), and the cranium in 5 (13.2%). The severity of the lesions, judged by the depth of tissue necrosis, correlated well with the mortality rate as is seen in Table 4. The overall mortality rate was 47.4%, while 6 (75%) of the 8 patients who developed mucormycosis died. The importance of tissue biopsy was demonstrated when our group embarked on the specific search for mucormycosis. Until then, no patient had had this procedure done. Of the initial 6 patients who were selected for biopsy because of their progressive, very severe illness, 4 showed zygomycetic infection (Figs. 4-7). Major surgery, including diverse and repeated procedures in each patient, was performed in this study subgroup of 38 cases of necrotizing fasciitis. Surgical cleansing with major debridement was done in 32, radical debridement in 13, major amputations in 13, fasciotomy in 9, open reduction of fracture in 1, closed reduction in 3, and skin grafts in 11. The major amputations were undertaken in the face of severe necrosis and advancing gangrene despite ample debridement; 2

J.F. Patifio et al.: Necrotizing Soft Tissue Lesions

243

Fig. 4A. Severe gangrene of the face followinga minor laceration. B. Appearance after debridement. The patient died of progressive sepsis and multiple organ failure. Mucor infection was demonstrated on histological examination and special cultures.

patients had amputation at the level of the thigh--1 survived. At another hospital, 1 patient not included in this series of 38 patients, a young intern who had remained trapped in the ruins of the Armero Psychiatric Hospital for more than 48 hours, had bilateral disarticulation at the hips; she survived very critical ARDS and multiple organ failure and is currently back at work. The microbiology of the necrotizing lesions was studied in the different hospitals according to their diverse technological capacity. Table 5 lists the isolates obtained from the necrotizing wounds: a rich polymicrobial flora and the presence of Zygomycetes (R. arrizus). Cultures of the mud flow taken at the site of the disaster revealed a similar polymicrobial flora, and also the presence of zygomycetes and other ubiquitous fungi (Table 6). The anaerobic cultures were considered to be suboptimal in some instances due to delays or inadequate technology. Therefore, no further in-depth analysis of this specific aspect was carried out. Tissue sections and cultures for the identification of fungi were carefully done at the excellent laboratories of the Centro M6dico de los Andes and the National Institute of Health. Rhizopus arrhizus was initially identified in tissue sections taken in 4 patients with the most aggressive lesions, and an

immediate warning was issued by our group to the health authorities. Another patient, in critical condition, was promptly identified. The 5 patients with mucormycosis (identification of R. arrhizus) were the subject of a special study. Three other cases of mucor infection (also R. arrhizus) among the Armero survivors, but outside the present series, were subsequently identified at other hospitals in the city of Bogota (Table 7). The extremely serious nature of the zygomycotic lesions is depicted in the clinical photographs (Figs. 2, 31 4, 6). Radical debridement in the 4 patients with lesions of the face, chest, and abdomen did not control the violent progression of this entity and all patients died. One patient with a lesion in the upper thigh who underwent a high amputation also died. One of the 2 survivors had radical debridement of the lower extremity, and the other high amputation at the thigh; neither one received amphotericin B. Only 2 patients with the diagnosis of mucormycosis received amphotericin B, although late in their hospital course; both died. This series of 8 simultaneous cases of necrotizing fasciitis with zygomycetic infection, proved by histologic examination and culture, seems to be quite unique in the literature.

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Fig, 5A. Microscopic appearance of short, thick hyphae of R. arrhizus in affected tissues. B. Zygomycetes invading vessels, the typical lesion of mucormycosis. This lesion corresponds to the patient depicted in Fig. 4.

Discussion

In the preceding article of this symposium, we reviewed the clinical, epidemiologic, and histopathological characteristics of necrotizing infections of the skin and soft tissues. The volcanic cataclysm that wiped out the town of Armero in Colombia, causing over 23,000 deaths and thousands of wounded survivors, originated an unprecedented true epidemic of necrotizing fasciitis [4]. This occurred because the injured remained submerged in the volcanic mud (lahar) made up of a mixture of inorganic and organic materials, with a mixed natural flora of bacteria and fungal organisms, for a prolonged interval (12-72 hours) without treatment or support. The severity of the lesions was not identified by the paramedical personnel who provided

primary care, and even at some of the receiving hospitals delays in diagnosis or in the initiation of proper treatment was documented. The young age of the survivors is a commonly observed phenomenon in natural disasters: the fit tend to survive, while mortality tends to be high among the very young and the very old. Furthermore, the Colombian population exhibits a high proportion of younger persons, a demographic characteristic of developing countries. Injuries of the skin, abrasions, lacerations, and blunt trauma would be expected after an avalanche of such magnitude; the fact that survivors were trapped, immersed in the lahar made up of a mixture of highly irritating inorganic tephra with organic

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245

Fig. 7. Short, thick, branching hyphae of R. arrhizus. This lesion corresponds to the patient depicted in Fig. 6. Table 5. Isolates from necrotizing wounds. n

Fig. 6A. Progressive lesion which started over the inner aspect of the left thigh, initially debrided at a provincial hospital. High amputation was performed, with continued advancement of the gangrenous process. B. Appearance of the wound, showing mold, at the autopsy table. materials contained in the soil of a rich land dedicated to agriculture and cattle raising, explains the very high incidence of necrotizing fasciitis, a phenomenon that was not seen in this magnitude after the recent major earthquakes of Perti, Central America, and Mexico City. Delayed transfer to the hospitals in Bogot~i and other major cities contributed to the high morbidity and mortality that was recorded in the group of patients that developed necrotizing fasciitis. In many instances, the correct diagnosis had not been established at the time of presentation at these hospitals; certainly, there was late identification of the zygomycetic infections (mucormycosis). Especially important was the presence of mucormycosis as a fundamental or contributing etiology in some of the more severe lesions. This was not suspected at the outset. Once the red flag was raised by our group, tissue sections and cultures revealed the presence of the zygomycetes in 8 individuals; only 2 of them survived. In ordinary clinical practice, necrotizing fasciitis appears sporadically, usually in association with major operations on the gastrointestinal tract, especially colorectal procedures, but

Proteus vulgaris Escherichia coli Proteus mirabilis Enterobacter aerogenes CIostridium freundii Pseudomonas aeruginosa Klebsiella pneumoniae Clostridium intermedius Klebsiella oxytoca Hemophilus alvei Staphylococcus spp. Staphylococcus aureus Staphylococcus epidermidis Morganella morganii Enterobacter hafniae Proteus inconstans Providencia Clostridium diversus Rhizopus arrhizus

9 8 8 5 4 4 3 2 1 1 1 1 1 1 1 1 1 1 4

also with minor operations such as percutaneous gastrostomy [5], closure of gastrostomy [6], or with suprapubic catheters [7]. We have seen this entity occurring after routine appendectomies for nongangrenous appendicitis and after clean herniorrhaphies in uncompromised hosts. Other authors, in very recent studies have reported necrotizing fasciitis following complicated appendicitis [6, 8], simple herniorrhaphies [6], associated with varicella [9, 10], renal transplantation [11], after minor trauma [12-14], in compartmental syndromes [15], in mandibular fractures [16], and in compromised patients with neoplasia receiving chemotherapy [17], or with pancytopenia, where surgical treatment presents additional problems [18]. Antiinflammatory drugs may worsen the course of this entity [19]. The most recent reports coincide with the well established polymicrobial nature of necrotizing fasciitis [20], as reviewed in the preceding article in this symposium. Severe cases of streptococcal necrotizing fasciitis [21, 22], and even of gangrenous myositis [23], continue to appear. Streptococcal necrotizing fasciitis has been produced in an experimental model [24].

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Table 6. Isolates from the volcanic mud flow.

Table 7. Patients with zygomycetic infection.

Enterobacter aerogenes Enterobacter cloacae Klebsiella oxytoca Klebsiella pneumoniae Klebsiella ozaenae Pseudomonas mallaei Pseudomonas stuartii Pseudomonas maltophilia Escherichia coli Clostridium freundii Hemophilus alvei Enterobacter aglomerans Proteus vulgaris CIostridium perfringens CIostridium bifermentans Clostridium tetani Clostridium sporogenes Clostridium paraputrificum Bacillus melaninogenicus Bacillus fragilis Bacillus spp. Rhizopus arrhizus Mucor spp. Trichoderma spp. Penicillium spp. Fusarium spp. Aspergillus niger Paecylomyces spp. Candida spp.

Case no.

Age (yr)

Sex

Location

Survived

1 2 3 4

33 26 52 28

M M F F

No No No No

5 6 7 8

19 29 40 ?

M F F F

Face Chest Abdomen Lower extremities and abdomen Thigh Thigh Leg Leg

Eighty percent of our cases were polymicrobial infections. We were successful in diagnosing mucormycosis, with the identification of the ubiquitous R. arrhizus, recognized as the most predominant organism in cases of human mucor infection, in a total of 8 cases; this organism, along with other Mucor spp., was also isolated from the Armero lahar soil. Primary mucormycosis (synonyms: zymycosis, phycomycosis, hyphomycosis) may occur in debilitated and aged patients, in those with chronic and degenerative diseases, in diabetics, in patients with malignancies, in compromised hosts, and in severe burns [25]. Absidia, Mucor, and Rhizopus are the 3 genera of the family Mucoracea that most often cause the spectrum of this disease [26]. Saksenaea, of the family Saksenaecea, order Mucorales, is very rarely pathogenic [3]. Mucormycosis may appear in different clinical forms, affecting various organs or regions: cutaneous (necrotizing cellulitis), subcutaneous (necrotizing fasciitis), pulmonary, gastrointestinal, rhinocerebral, and disseminated. In the acute form, it may be an extremely aggressive and rapidly fatal entity, truly the most fulminating form of fungal infection that occurs in the human being [25]. Mucormycosis rarely occurs in trauma patients [26-28]; however, it may develop in compromised patients who sustain trauma [29]. We have previously reported a very unique case of fatal massive gangrenous infection by Saksenaea vasiformis in a previously healthy young woman [2]; a similar case of subcutaneous zygomycosis by the same organism has been recently reported in India [30]. Experience with the management of this single series of 38 patients (only a fraction of the much larger group among the survivors of the volcanic disaster) with necrotizing fasciitis,

Yes No Yes No

including 8 with mucormycosis, seems to be unprecedented and leaves us with valuable lessons: 1. Necrotizing fasciitis continues to be a most serious challenge to surgeons; 2. The entity is often diagnosed late and the delay may have lethal consequences; 3. Although most cases are due to a polymicrobial synergistic infection, zygomycetic infection (mucormycosis) may be the primary or a major contributing etiology in some of the more aggressive cases; its early recognition by biopsy and culture is imperative; 4. In the setting of natural disasters, with massive and contaminated wounds, the physicians in attendance should be well aware of the grave nature and very aggressive behavior of the necrotizing lesions of the soft tissues; 5. Early diagnosis and emergency surgical treatment consisting of radical debridement, and amputation in well selected cases, constitutes the mainstay of management and the only way to achieve survival. R~sum6

En 1985, une terrible 6ruption volcanique, la quatri~me en importance de perte de vie de toutes les catastrophes de l'histoire de l'humanit6, a ravag6 la ville de Armero en Colombie, provoquant plus de 23,000 morts et 4,500 bless6s. Parmi les centaines de survivants qui ont 6t6 transport6s dans les h6pitaux de Bogota, la capitale, il y a eu un hombre impressionnant d'individus qui ont d6velopp6 une cellulite n6crosante. Ces patients constituent probablement le plus grand groupe de ce type de 16sion jamais rapport6 dans la litt6rature. Trente huit patients, avec une cellulite n6crosante bien 6tablie, ont 6t6 trait6s darts les quatre h6pitaux les plus importants de Bogota; 8 d'entre eux avaient une infection zygomyc6tique (mucormycosis), affection le plus souvent mortelle. D'autres cas ont 6t6 trait6s dans d'autres h6pitaux de Bogota et de plusieurs villes de Colombie. Les principaux traits cliniques de ces 38 patients avec cellulite n6crosante sont 6tudi6s avec une mention sp6ciale pour les patients ayant une mucormycosis. Les patients ayant une cellulite n6crosante avaient un taux global de mortalit6 de 47.7%; les patients ayant une mucormycosis avaient un taux global de mortalit6 de 80%. Nous insistons sur un diagnostic pr6coce, bas6 sur des pr61~vements avec 6tude microbiologique, de mani~re a pouvoir instaurer un traitement imm6diat et efficace. Ceci est particuli~rement val-

J.F. Patifio et al.: Necrotizing Soft Tissue Lesions

able en cas de catastrophe naturelle provoquant un nombre important d'accidentrs et de survivants gravement blessrs. Resumen

U n cataclismo volc~inico de proporciones mayores, el cuarto, en cuanto al ntimero de v/ctimas, en la historia de la humanidad, arras6 con la ciudad de Armero, Colombia, causando mgs de 23,000 muertos y 4,500 heridos. Entre los cientos de sobrevivientes que fueron transferidos a hospitales en la ciudad de Bogot~i, un ntimero desproporcionadamente alto desarroll6 fascitis necrotizante. Estos pacientes constituyen quiz~s el grupo tinico m~is numeroso que se registra en la literatura. Treinta y ocho de ellos fueron identificados en 4 hospitales seleccionados de Bogot~i; 8 presentaban infecci6n por zigomicetos (mucormicosis), una entidad altamente letal. Muchos casos adicionales fueron tratados en otros hospitales de Bogotgt y de diversas ciudades de Colombia. Se revisan las caracterfsticas principates de estos 38 pacientes afectados por fascitis necrotizante, con especial 6nfasis en los que desarrollaron mucormicosis. Los pacientes con fascitis necrotizante tuvieron una tasa global de mortalidad de 47.7%; en aquellos con mucormicosis fue de 80%. Se preconiza la necesidad de un diagn6stico precoz, utilizando biopsia tisular y estudios microbi61ogicos, para emprender prontamente tratamiento radical. Esto es especialmente pertinente en situaciones de desastres naturales que resultan en gran ntamero de victimas y de sobrevivientes con lesiones graves de la piel y de los tejidos blandos.

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8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

19. 20.

Acknowledgments

The valuable assistance of Dr. Carlos Fernando Garcia, of the Department of Pathology, Centro M6dico de los Andes, Fundaci6n Santa Fe de Bogota, and of Dr. Miguel A. Guzmfin, of the National Institute of Health, Bogot~i, Colombia, in the study and identification of the zygomycetic infections is gratefully acknowledged.

21. 22.

23. References

1. Fermindez, G., G6mez Martfnez, P., Malag6n, V., Mtinera, I., Patifio, J.F., editors: Aspectos M6dicos de la Catfistrofe Volc~inica del Nevado del Ruiz, Academia Nacional de Medicina y RESURGIR, Bogota, Escorpio Editores, 1989 2. Patifio, J.F., Holgufn, F., Escall6n, J. Garcia, C.F., Guti6rrez, M.T., Fern~indez, G.: Necrotizing soft tissue infections in the volcanic cataclysm of Colombia. Poster presentation. 18th Int. Cong. Intern. Med., Bogot~i, July 29-August 2, 1986 3. Patifio, J.F., Mora, R., Guzm~in, M.A., Rodriguez-Franco, E.: Mucormycosis: A fatal case by Saksenaea vasiformis. World J. Surg. 8:419, 1984 4. Patifio, J.F.: Infecciones necrotizantes de tejidos blandos. La experiencia con los heridos en el cataclismo volc~inicode Armero, Colombia. In Infeccidn Quirtirgica, J.F. Patifio, editor, Bogot~i, Fundaci6n Santa Fe de Bogot~i y Editorial Presencia, 1989, pp. 91-108 5. Haas, D.W., Dharmaraja, P., Morrison, J.G., Potts, III, J.R.: Necrotizing fasciitis following percutaneous endoscopic gastrostomy (letter). Gastrointest. Endosc. 34:487, 1988 6. Farrell, L.D., Karl, S.R., Davis, P.K., Bellinger, M.F., Ballantine, T.V.: Postoperative necrotizing fasciitis in children. Pediatrics 82:874, 1988 7. Bearman, D.M., Livengood, III, C.H., Addison, W.A.: Necrotiz-

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30.

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