Fournier’s gangrene: an unusual presentation of sepsis

Abstract

A 77-year-old woman was brought to the Emergency Department from a nursing home because of vaginal discharge. The past medical history included neurogenic bladder, stroke, hypertension, and congestive heart failure. The nursing home reported a 4to 5-day history of a foul-smelling, brownish-red vaginal discharge and foul-smelling urine. A gynecologist was consulted 4 days earlier and a pelvic examination was conducted, revealing vaginal wall atrophy, no lesions, and a normal bimanual examination. It was thought that the discharge was due to soiling of the vagina with feces and urine, and the gynecologist requested that the Foley catheter be changed frequently. Two days before admission the patient started to complain of achy legs and back pain. The morning of admission a nurse’s aide saw a ‘gray-brown discolored area on the right labia extending back to the gluteal fold.’ Over the next several hours the patient complained of increased pain in the genital area, and she became confused. Vital signs on admission included blood pressure of 100/38 mm Hg, respirations of 20 breaths/min, rectal temperature 38.0°C (100.1°F), and pulse of 100 beats/ min. The patient’s only verbal communication was to complain of pelvic pain. Examination revealed a pale, toxic-appearing woman who opened her eyes only to verbal or tactile stimuli. Physical examination of the perineum revealed a 5-cm diameter ulcer with necrotic edges adjacent to the right labium and two 1.5 cm areas on the proximal medial right thigh (Figure 1). The tissue was warm, swollen, and tender to palpation. Crepitus was not appreciated on examination. A foul-smelling, thin gray discharge exuded from these ulcers. No vaginal discharge or fistulas were noted. A clinical diagnosis of Fournier’s gangrene was made and broad-spectrum antibiotics were started. Surgery was consulted, and she was immediately taken to the operating room for wide debridement.