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Judith C. Hagedorn &. Stock Images, Royalty-Free Pictures, Illustrations & Videos - iStock 46, no. You wont get this infection from anyone else, and they wont get it from you. Rather, the superficial and deep layers of fibrous tissue, as well as the skin, are typically destroyed. Its estimated that 97 people a year develop this condition. Necrotizing fasciitis destroys your soft tissues, including your: Fourniers gangrene affects the soft tissues of your scrotum, penis and perineum. As gangrene sets in, the decomposing tissue starts giving off a strong, rotten smell. Some studies report the mortality rates to be much higher. Sometimes it's necessary to skip the diagnosis process and go straight to debridement (the removal of damaged tissues from your body). DOI: Kim SY, et al. Necrotizing pancreatitis occurs when parts of the pancreas die from lack of blood and oxygen. At the end of one postoperative year, the mortality rate was higher in . Surgery is the number one treatment for Fourniers gangrene. bacteria [green] - fournier gangrene stock pictures, royalty-free photos & images. Fournier gangrene after debridement of necrotic tissue Often the testicles, urethra (tube that allows urine to exit the body), and the chamber inside the penis that fills with blood to produce an erection are not usually affected. Fascia is a type of connective tissue. 647654, 1999. Meleney's gangrene. Its usually caused by organisms that are in the gastrointestinal tract. [2] Most cases present mildly, but can progress in hours. The first symptoms of Fourniers gangrene you might notice include: Additionally, if you have diabetes and notice your glucose is elevated despite taking your insulin as instructed, please contact your healthcare provider. 3, pp. A few examples include an: Children sometimes get a bacterial infection from circumcision. DISCUSSION. Fournier's gangrene often begins when bacteria enter the genitalia, perineum, or colorectal area through a wound and cause an infection that deprives the infected tissue of oxygen, thus leading to necrosis. This is a rare type of gangrene. The typical causes of death are spread of the infection into the bloodstream, which is known as sepsis, kidney failure, or multiple organ failure. 212217, 2001. Last medically reviewed on January 21, 2018, Necrotizing fasciitis, also known as flesh-eating disease, is a rare but serious bacterial infection. In severe cases, the bacterial infection stretches to the thighs, stomach and chest, destroying those areas' muscles, nerves and arteries. Symptoms of an advanced infection include: In men, the infection can destroy their scrotum. Introduction. (2017). The infection commonly starts in the area between your genitals and rectum, known as the perineum, and spreads outward underneath your skin. It usually affects men, but women also can get it. Blood tests also help in the diagnosis. Next, youll have reconstructive surgery. The following risk factors are associated with Fournier's gangrene in women: Other associated conditions and/or events that involve both men and women include: Perineal abscess (when pus collects in the area between the scrotum and the anus in men or between the vulva and anus in women), Immune system deficiencies (e.g. Fournier's gangrene, also known as necrotizing fasciitis of the perineum and genitalia, is a flesh eating infection that typically affects men's scrotum, penis and perineum. Ultrasound can help a doctor identify underlying gases or fluids in the body. The perineum is the area between the scrotum and anus for a man; or the area between the anus and vulva for a woman. This infection leads to complications including. Fournier gangrene - About the Disease - Genetic and Rare Diseases Information Center National Center for Advancing Translational Sciences Browse by Disease About GARD Contact Us We recently launched the new GARD website and are still developing specific pages. Finally, you might go through hyperbaric oxygen therapy. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. Copyright 2012 Jason D. Heiner et al. Fourniers gangrene is a type of necrotizing fasciitis (flesh-eating disease) that affects your scrotum, penis or perineum. This involves cleaning the affected skin and removing areas of dead tissue. Results: In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). He reported that past episodes of masturbation often resulted in recurrent penile erythema and abrasions which had worsened over the previous three days since his last masturbation episode. Nature Reviews Urology 14 , 205-214 ( 2017) Cite this article. Do you have nausea, or have you been vomiting? To lower your risk of infection, wash open wounds with soap and water and keep them dry and clean until they heal. The inciting factor for isolated Fournier's gangrene of penis may be periurethral abscess following trauma due to . The number of people who develop Fourniers gangrene is unknown, but overall its rare. J. Sterile technique needs to be followed when dealing with a person who has these wounds. 40 Citations. This is a rare type of aggressive, infectious wet gangrene characterized by the presence of more than one infectious microbe. According to the PMI, sarcopenia was detected in 67 (36.2%) patients and 70 (37.8%), according to the HUAC. It may be that the high male to female ratio in the diagnosis is the result of the lack of recognition of this entity among women by physicians. 59, no. The symptoms of Fourniers gangrene often begin with a general feeling of being unwell. Can poor sleep impact your weight loss goals? 12131224, 2002. Ideally, your healthcare provider can remove enough tissue to keep the bacterial infection from spreading. Fournier gangrene is a life-threatening urosurgical emergency characterized by a polymicrobial infection of the perineal, genital, or perianal region that may rapidly progress to sepsis, septic shock, fulminant multi-organ dysfunction, and death. If a bacterial infection causes gangrene, you may have signs and symptoms that include: Changes in skin color (from red to brown, and ultimately to purple or greenish black). Mallikarjuna, M. N., Vijayakumar, A., Patil, V. S., & Shivswamy, B. S. (2012, December 3). Download Citation | Effect of Sarcopenia on Mortality and Morbidity in Patients With Fournier's Gangrene | Background Preoperative sarcopenia is an essential factor that negatively affects . Fournier gangrene severity index (FGSI) scores > 9 predicts severity and mortality ( J Urol 1995;154:89, J Postgrad Med 2008;54:102 ) FGSI: nine variables are assigned scores of 0 - 4, which are added together. Fournier Gangrene Causes. Last medically reviewed on June 21, 2017, Blood poisoning is a serious infection. Healthline Media does not provide medical advice, diagnosis, or treatment. According to the PMI, sarcopenia was detected in 67 (36.2%) patients and 70 (37.8%), according to the HUAC. While it's more common in men, women and children also can get it. Xeropotamos NS, Nousias VE, Kappas AM. He underwent three separate surgical debridements of the scrotum and penis as well as penoscrotal split-thickness skin grafting. When the pudendal arterial tree is dead, that's when the bacteria spread further. Can I catch it from a sexual partner? Fourniers gangrene is typically caused by one of three to four different kinds of bacteria. Aggressive intravenous (IV) fluid resuscitation with normal saline was begun and, with a provisional clinical diagnosis of Fourniers gangrene, IV clindamycin, and ampicillin/sulbactam, was administered, and surgery was consulted. The Glickman Urological & Kidney Institute offers innovative treatments in urology and kidney medicine, including minimally invasive, scarless options for urologic procedures and medical management of kidney disease. A 48-year male smoker presented with pain and blackish discoloration of the distal part of penis for the last 4 days which developed following rupture of a papulo-ve Isolated Involvement of Penis in Fournier's Gangrene: A Rare Possibility J Coll Physicians Surg Pak. The patient was taken to the operating room where cystoscopy and anoscopy were found to be normal with no sign of gangrenous extension or source of infection from the bladder or rectum. Fournier gangrene, a relatively rare form of necrotizing fasciitis, is a rapidly progressive disease that affects the deep and superficial tissues of the perineal, anal, scrotal, and genital regions. Surgery to remove the dead and dying tissue and to confirm the diagnosis. The nidus of infection is typically urogenital or anorectal, but cutaneous sources of infection have been reported, with poor personal hygiene acting as an apparent contributing element of infection occurrence [15]. Fourniers gangrene involves an infection in the scrotum (which includes the testicles), penis, or perineum. 2 However, since the . It's a medical emergency that can be fatal without immediate treatment. Usually, it involves the male scrotum and may extend to the penis and abdominal wall. Fourniers gangrene is rare. []Given its eponymous name by Jean-Alfred Fournier in 1883 to describe a case of gangrene in the genitals and perineum of a previously healthy young male,[] it is a devastating infection that can prove fatal if treatment is . Learn more about these serious fractures, how theyre treated, and what to expect. Fournier's gangrene is a form of necrotising fasciitis that affects the perineum. He was given intravenous antibiotics and immunoglobulin and promptly underwent three surgical debridements of the scrotum and penis with split-thickness skin grafting. Fournier's gangrene is a rare, acute infection in the scrotum that would affect middle-aged, diabetic men. Fourniers gangrene is a rapidly progressing, tissue-destroying infection on the genitals and nearby areas. Nerves. 1953 Accesses. Fourniers gangrene can occur when a person has a skin wound that allows bacteria, viruses, or fungi to get deeper into the body. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised. E. Morpurgo and S. Galandiuk, Fournier's gangrene, Surgical Clinics of North America, vol. is unclear. DermNet provides Google Translate, a free machine translation service. If diabetes, alcohol abuse, or other illnesses are contributing factors, those will also need to be treated. Feeling hot or sweaty. M. J. Cawley, M. Briggs, L. R. Haith Jr. et al., Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review, Pharmacotherapy, vol. 2004-2023 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. Fournier's gangrene is a rare and often fulminant necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection. Images 9, pp. [11] Males 50 to 79 years old had the highest rate at 3.3 per 100,000. Although extremely rare, it is important that Fournier's gangrene, if suspected, is treated immediately to avoid excessive debridement, multiple organ failure, amputation, or death (particularly if the infection reaches the blood). The most common aerobic organisms include: The most common anaerobic organisms include: Bacteria can enter the genital and rectal areas of your body in several ways. He denied any recent travel, notable lapses in personal hygiene, or any other preceding genitourinary injury or symptoms. An estimated 25 to 50 percent have an alcohol use disorder. Imaging studies may be ordered to rule out other potential causes. Looking at the symptoms and statistics of Fourniers gangrene would frighten anyone. Its important to get treated right away to prevent serious outcomes. [2], Most cases of Fournier gangrene are infected with both aerobic and anaerobic bacteria such as Clostridium perfringens. Examples of symptoms and conditions include: There are some skin symptoms as well, including: Some symptoms are in your urinary tract. Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the external genitalia or perineum. A contemporary update on Fournier's gangrene. Examples of these skin injuries include anorectal abscesses, surgical incisions, diverticulitis, rectal cancer, or genital piercings. Fournier's gangrene after genital piercing [Abstract]. We do not endorse non-Cleveland Clinic products or services. Cleveland Clinic is a non-profit academic medical center. From there, they can go through the fascia to other areas of your body, such as your thighs, stomach and chest. Up to 70 percent of people who develop the condition have diabetes and up to 50 percent have chronic alcoholism. [1] Males are affected about 40 times more often than females. Prompt surgery to completely remove tissue and aggressive antibiotics can reduce the chance of death. Harvey is also suffering from Type 2 diabetes and recently tested positive for . Fournier's gangrene is a rare type of necrotizing fasciitis specific to the superficial fascia and subcutaneous tissues of the external genitalia, perineum, perirectal, and ischiorectal regions. The views expressed herein are solely those of the authors and do not represent the official views of the Department of Defense or Army Medical Department. Other studies determined that the number is as high as 50%. These may also be paired with hyperbaric oxygen therapy. G. W. Grumet, Pathologic masturbation with drastic consequences: case report, Journal of Clinical Psychiatry, vol. All rights reserved. This involves exposing the body to 100 percent oxygen, in comparison to normal air that has about 21 percent oxygen. Examples include: The following conditions are associated with the late stages of Fourniers gangrene: Sudden pain in the genitals and perineum is usually the first symptom of Fourniers gangrene. Weight fluctuations such as obesity or malnourishment may also put patients at risk of developing this. Policy. This type of gangrene involves the genital organs. Seriously, one of the worst things you could do to yourself is look up pictures of Fournier's Gangrene. Fournier's gangrene is a type of necrotizing fasciitis (flesh-eating disease). Hospital admissions for Fourniers gangrene are rare, representing less than 0.02 percent of all hospital admissions in the United States. [2] X-rays and ultrasounds may show the presence of gas below the surface of the skin. M. Capelli-Schellpfeffer and G. S. Gerber, The use of hyperbaric oxygen in urology, Journal of Urology, vol. What you need to know about nail fungal infection. But remember Fourniers gangrene is a very rare type of necrotizing fasciitis. Your scrotum has plenty of small crevices that trap bacteria, which makes it easy to. The faster you get care, the better. 12, pp. I. Singh, M. K. Joshi, and M. S. Jaura, Strangulation of penis by a ball bearing device, Journal of Sexual Medicine, vol. . Fournier's gangrene is a rapidly progressing, tissue-destroying infection on the genitals and nearby areas. Chills. This is known as debridement. . Fourniers gangrene is an emergency. A. Fournier, Jean-Alfred Fournier 1832-1914. A 67-year-old male patient with diabetes mellitus and nephritic syndrome under cortisone treatment was admitted to our hospital with fever and severe perianal pain. Its a medical emergency that can be fatal without immediate treatment. Metrics. About one per 62,500 males are affected per year. Learn more here. The incidence of the disease is higher in males with Sorensen et al., reporting an overall incidence rate of 1.6 cases per 100,000 males/year [ 3 ]. The overall frequency reported is 1:7500, most cases occur between 30-60 years of age and male-to female ration in large series is about 10:1.It is interesting that ICD . In 1764, Baurienne originally described an idiopathic, rapidly progressive soft-tissue necrotizing process that led to gangrene of the male genitalia. [5] Another study reported that about one third of patients were alcoholic, diabetic, and malnourished, while another ten percent had been immunosuppressed through chemotherapy, steroids, or malignancy. J Soc Colon Rectal Surgeon, Thwaini A., Khan A., & Mammen K. (2008). That leaves their testes exposed. The subcutaneous tissue is the deepest layer of your skin. Know the symptoms and what to do if you experience them. Nevertheless, an estimated 20 to 40 percent of people with Fourniers gangrene die due to complications, according to an article published in the journal Urologia Internationalis. ", National Organization for Rare Diseases: "Fournier Gangrene. Dont ignore the early signs. Fournier's gangrene: diagnostic approach and therapeutic challenge. If you have any concerns with your skin or its treatment, see a dermatologist for advice. 2 It was described by Baurienne in 1764 and formally named by Fournier in 1883. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. 5, pp. 162, no. An infection in the genital area or urinary tract causes this type of gangrene. Decreased quality of life, which can contribute to clinical. [2] Formation of a colostomy may be required to divert bowel motions away from the area. According to an article in Postgraduate Medical Journal, a person with Fourniers gangrene typically requires 3.5 procedures in an attempt to reduce the diseases spread. Check the skin of your genitals and perineum regularly for any redness, tenderness or swelling. Other conditions that can initially appear similar to Fourniers gangrene include epididymitis and orchitis. This infection moves forward very quickly, and you can get worse very suddenly. Your immune response is slow or it fails (immunosuppression). Subcutaneous air is often one of the specific clinical signs, but is not seen in >50% of presenting clinical cases. Necrotizing fasciitis is the necrosis of soft tissue, which can lead to eventual widespread systemic toxicity and high mortality rate. Fournier is the name of the French physician who first identified this disease. 173, no. Pain that is moderate to severe and starts around the abdomen. These organisms tend to make the blood clot, thus depriving tissue of necessary oxygen. Fournier's gangrene is a life-threatening disease, but there are ways you can reduce your risk. 11931198, 2010. It is an emergency.. As a general rule, the older a person is and the more complicating health conditions they have, the more likely they are to experience severe side effects from Fourniers gangrene. Youll likely need multiple surgeries to remove all of the dead tissue and stop the infection. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. If you also have sepsis, youll receive additional medications to decrease your risk of blood clots. Is exercise more effective than medication for depression and anxiety? Is the ketogenic diet right for autoimmune conditions? This infection is fatal in a third or more of people who contract it. If you have Fournier's gangrene, the skin of your perineum, penis or scrotum will change color. 1, pp. Sem Med 1883, Diseases of the Colon and Rectum, vol. Fournier's gangrene (FG) is a rare, synergistic, fulminant form of necrotizing fasciitis involving the genital, perineal, and perianal regions [ 2 ], with gangrene of the overlying skin. Fascial anatomy plays an important role in the pathophysiology of Fournier's gangrene. The pudenal artery that takes blood to your sex organs, to the skin of your perineum and to your scrotal skin. It is believed that the male to female proportion may be anywhere from 5:1 to 10:1. . METHODS/RESULTS: A young, male alcoholic developed Fournier's gangrene after an episode . 30, no. When bacteria enter your perineum, scrotum or penis, they infect your subcutaneous tissue and muscle fascia. Your healthcare provider will evaluate your symptoms and examine your skin. Reconstructive surgery helps your perineum, scrotum or penis look like it did before the Fourniers gangrene. Reported mortality rates range from 3% to 45%, affected by factors such as underlying comorbidities, the source of infection, and the presence of severe illness or sepsis upon initial evaluation and treatment [15]. Necrotizing fasciitis is a serious condition that kills soft tissues, often quickly, including muscles, nerves, and blood vessels. How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction, http://www.tandfonline.com/doi/abs/10.1080/00365540410017086, https://rarediseases.org/rare-diseases/fournier-gangrene/, http://www.nejm.org/doi/full/10.1056/NEJMicm1609306#t=article, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518952/, https://www.karger.com/Article/FullText/445695, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585703/, Cardiovascular health: Insomnia linked to greater risk of heart attack. 2018 Feb;28(2):164-165. doi: 10.29271/jcpsp.2018.02.164. Gangrene happens when body tissue is dead or is dying (known as necrosis) because of a lack of blood flow or a bacterial infection. Fourniers gangrene is most commonly seen in men in their 60s or 70s. The CT findings confirmed the diagnosis and showed the extent of the lesion. Penoscrotal reconstruction using groin and bilateral superomedial thigh flaps: a case of penile vaselinoma causing Fournier's gangrene. [11], A 2009 epidemiological study found the incidence of Fournier gangrene to be 1.6 cases per 100,000 males, in the United States. More frequently, occasional reports exist of male patients with other medical and surgical genital complications due to masturbation, autoerotic, and other sexual activities. Noting that there are limited resources, an app that is community driven and provides information on all types of healthcare providers, not exclusively surgeons or endocrinologists , was developed. It can also spread outside the genital area into your abdominal wall or buttocks. These include: Seeking quick treatment can reduce the chances of symptoms becoming even more severe. There might be three or more operations. Fournier's gangrene (FG) is a rare and potentially life-threatening surgical condition. Fournier gangrene after debridement of necrotic tissue 6, pp. The majority of FG is caused by polymicrobial organisms involving mixed aerobes and anaerobes but rarely reveals Actinomyces species. A ruptured Achilles tendon is not uncommon for athletes and can cause a great deal of pain. 984988, 1988. It's usually a complication of surgery. The infection then progresses rapidly, and your skin develops a reddish-purple color or blue-gray patches. CT evaluation of patients with Fournier's gangrene is advocated and the extent of the lesion observed on CT correlated with the surgical findings in the case described herein. Fourniers gangrene is a rare, life-threatening bacterial infection of your scrotum, penis or perineum (the area between your genitals and rectum). There are some steps you can take to lower your chances of getting Fourniers gangrene: Mayo Clinic: "Diseases and Conditions Gangrene. Bacteria (anaerobic bacteria or aerobic bacteria) sometimes cause Fournier's gangrene. Here, we present the case of an immunocompromised 59-year-old male with surgical history of a pancreatic pseudocyst stented endoscopically. They will take a medical history and perform a physical examination. Medical imaging may include: Your doctor will administer multiple antibiotics to treat the underlying bacterial infection. ABSTRACT: Fournier gangrene (FG), a polymicrobial necrotizing infection of the perineal, perianal, or genital area, can affect any age group and either gender, but is most common in older males. But Fournier's gangrene is very rare. Fournier Gangrene is thought to be a case of mixed infection. Fournier's gangrene is a rare and often fulminant necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection. 1,2 The appearance of this disease process was first described . Fournier gangrene after debridement of necrotic tissue The disease initially described by Alfred Fournier in 1883 was a polymicrobial life threatening infection of unknown origin occurring in otherwise healthy young men ( 1 ). The bacteria require an entrance into the skin, usually by local trauma to the genital region. Introduction. There are steps you can take to prevent it, and there are treatments available. The lower incidence in females may reflect better drainage of the perineal region. Intravenous immunoglobulin (IVIG) was added to his treatment regimen and blood cultures identified strains of Staphylococcus aureus and Streptococcus pyogenes. In the late 1800s, the Parisian dermatologist and venereologist Professor Jean-Alfred Fournier used the term fulminant gangrene of the penis and scrotum to describe a sudden onset of rapidly progressing idiopathic scrotal gangrene in young men [6]. Background Fournier's gangrene (FG) is a fulminant form of infective, polymicrobial, necrotizing fasciitis of the perineal, genital, and perianal regions. The disease is one of the few urological emergencies and requires prompt surgical debridement as well as antibiotic therapy. Urinary extravasation is where your urine fills cavities in your body other than your bladder. A ruptured spleen can be a life threatening condition and requires immediate attention. According to an article in the journal ISRN Surgery, an estimated 20 to 70 percent of those with Fourniers gangrene have diabetes. 6, pp. Fournier's gangrene is an extremely rare but life-threatening bacterial infection of the tissue under the skin that surrounds muscles, nerves, fat, and blood vessels of the perineum. Fournier's gangrene: Current practices. After the surgery, your healthcare provider will likely prescribe broad-spectrum antibiotics. 718728, 2000. FG is a severe polymicrobial, infective necrotising fasciitis predominantly affecting the male perineal, perianal, genital and anterior abdominal wall regions. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Blood work to test for the possible presence of infection will be done, as well as to check for the bloods clotting abilities. Microscopic view of green bacteria (germs). Part of your healthcare providers process to diagnose Fourniers gangrene is to ask you questions. Fourniers gangrene is a rare and often fulminant necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection [15]. Youre at a higher risk if you have any of the following conditions, including: Youre also at a higher risk of Fourniers gangrene if: Fourniers gangrene is an emergency. If theres time, theyll likely order some imaging tests, including: Often, there is no time for tests. [2] It begins as a subcutaneous infection. P. Thomas, A. Boussuges, M. Gainnier et al., Fat embolism after intrapenile injection of sweet almond oil, Revue des Maladies Respiratoires, vol. Sorensen, M. D., & Krieger, J. N. (2016). Simple reconstructive procedures following wound debridement yield satisfactory outcomes in majority of the cases..mw-parser-output .ambox{border:1px solid #a2a9b1;border-left:10px solid #36c;background-color:#fbfbfb;box-sizing:border-box}.mw-parser-output .ambox+link+.ambox,.mw-parser-output .ambox+link+style+.ambox,.mw-parser-output .ambox+link+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+style+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+link+.ambox{margin-top:-1px}html body.mediawiki .mw-parser-output .ambox.mbox-small-left{margin:4px 1em 4px 0;overflow:hidden;width:238px;border-collapse:collapse;font-size:88%;line-height:1.25em}.mw-parser-output .ambox-speedy{border-left:10px solid #b32424;background-color:#fee7e6}.mw-parser-output .ambox-delete{border-left:10px solid #b32424}.mw-parser-output .ambox-content{border-left:10px solid #f28500}.mw-parser-output .ambox-style{border-left:10px solid #fc3}.mw-parser-output .ambox-move{border-left:10px solid #9932cc}.mw-parser-output .ambox-protection{border-left:10px solid #a2a9b1}.mw-parser-output .ambox .mbox-text{border:none;padding:0.25em 0.5em;width:100%}.mw-parser-output .ambox .mbox-image{border:none;padding:2px 0 2px 0.5em;text-align:center}.mw-parser-output .ambox .mbox-imageright{border:none;padding:2px 0.5em 2px 0;text-align:center}.mw-parser-output .ambox .mbox-empty-cell{border:none;padding:0;width:1px}.mw-parser-output .ambox .mbox-image-div{width:52px}html.client-js body.skin-minerva .mw-parser-output .mbox-text-span{margin-left:23px!important}@media(min-width:720px){.mw-parser-output .ambox{margin:0 10%}}, While recent case series (n=980) studies have found a mortality rate of 2040%, a large (n=1641) 2009 study reported a mortality rate of 7.5%.