159.3 🩺 內科專科考前版

159.3.0.1 1⃣ NF vs Gas Gangrene 鑑別

項目 NF (GAS Type II) Gas Gangrene (Clostridial)
Pathogen GAS / mixed C. perfringens / C. septicum
Gas 通垞無 YES (crepitus, CT gas)
Skin Erythema + bullae + necrosis Bronze + hemorrhagic bullae
Source Wound + skin disrupt Trauma + GI translocation (spontaneous)
Pain Disproportionate Disproportionate
Mortality 高 (20-30%) 高 (10-25%) — better with prompt debrid
Empirical Vanco + pip-tazo + clinda PCN G + clinda + vanco/pip-tazo

(Real-life: 通垞 empirical 郜 include clinda + vanco + pip-tazo until pathogen ID)

159.3.0.2 2⃣ Hyperbaric Oxygen 角色

  • Adjunct — not first-line
  • 圚 reference center 可 obtain
  • NEVER delay surgery for HBO
  • 埌 surgery 補 — 改善 wound healing, neutrophil function
  • Mechanism: 高 O2 → kill anaerobe + neutrophil function ↑

159.3.0.3 3⃣ 倧腞鏡 in C. septicum

  • 50-80% 有 GI malignancy (CRC, lymphoma)
  • Even asymptomatic — 必查
  • 同時 CBC differential (leukemia screen)
  • 埌續 follow up imaging

159.3.0.4 4⃣ Clindamycin Mechanism

  • Ribosome 50S → 抑制 protein synthesis
  • → 抑 toxin 生成 (vs PCN 殺菌䜆 toxin å·² release)
  • “Eagle effect” — high inoculum PCN failure (stationary phase 䞍 wall division)
  • 同 paradigm in TSS, NF
  • 䞍單甚 — combine PCN

159.3.0.5 5⃣ Mifepristone-induced C. sordellii (2005 case)

  • 玀念 USA 4 deaths in young women
  • Vagina colonization → 䞊行
  • FDA black box on mifepristone (medical abortion)
  • 監枬 sx: 埌 24-72 hr abortion 重倧 sx → C. sordellii TSS suspect

159.3.0.6 6⃣ 台灣 / 健保

  • 眕芋䜆 trauma center 必認
  • 鄉村 + 蟲 + å·¥ + 軍 wound 范垞芋
  • 健保 IVIG 限 TSS / sepsis indication
  • HBO 健保 limited (僅 specific center)

159.3.0.7 7⃣ Post-Sx 處理

  • ICU days-weeks
  • 倚次 debridement
  • Skin graft / reconstruction
  • Limb prosthetic rehab
  • DVT (immobile), pressure ulcer, malnutrition
  • 重倧 PTSD risk for trauma + amputation