Fournier's Gangrene in an Older Patient

Fournier's Gangrene: Population Based Epidemiology and Outcomes

To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index. From 1989 to 2018, 118 male patients diagnosed with Fournier's gangrene with complete medical records were retrospectively reviewed. Patients' demographics, laboratory parameters at initial diagnosis, Fournier's Gangrene Severity Index and Simplified Fournier's Gangrene Severity Index, and the time interval from emergency room arrival to surgical intervention were collected. The Fournier's gangrene patients were categorized into low-risk (Simplified Fournier's Gangrene Severity Index ≤2) and high-risk groups (Simplified Fournier's Gangrene Severity Index >2). Differences between the variables within the two groups were analyzed. The optimal surgical timing was analyzed with the receiver operating characteristic curve in high-risk Fournier's gangrene patients. The overall mortality of 118 Fournier's gangrene patients was 14.4%. After risk stratification with the Simplified Fournier's Gangrene Severity Index scoring system, the mortality of low-risk and high-risk Fournier's gangrene patients was 1.3% and 41.0%, respectively. In the high-risk group, the time interval from emergency room arrival to surgical intervention was the only variable with a significant difference between survivors and non-survivors (P=0.039). The optimal surgical timing was determined at 14.35h, which allowed the highest sensitivity (0.688) and specificity (0.762) to affect mortality. The mortality was significantly lower in high-risk Fournier's gangrene patients with early surgical intervention compared with late intervention (23.8% vs 68.8%, P=0.007). The Simplified Fournier's Gangrene Severity Index is a quick and reliable screening tool for first-line physicians to identify high-risk patients with Fournier's gangrene (Simplified Fournier's Gangrene Severity Index >2) who have poor survival outcomes. We recommended early surgical intervention within 14.35h to maximize the survival of high-risk Fournier's gangrene patients.

Validation of the Fournier's Gangrene Severity Index in a Large Contemporary Series

Diagnosis

Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study.

We investigated the value of the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) as markers of mortality in patients with Fournier's gangrene. Records from 62 patients treated for Fournier's gangrene between 2003 and 2014 were reviewed retrospectively. Data were collected regarding medical history, symptoms, physical examination findings, admission laboratory tests, and the extent of body surface area involved (%). Fournier's Gangrene Severity Index score, NLR, and PLR were calculated. The data were assessed separately for surviving and deceased patients. Of the 62 patients, 36 survived (58%, group 1) and 26 died (42%, group 2). Parameters that were statistically different between the two groups (p < 0.05) were the NLR, PLR, Fournier's Gangrene Severity Index score, and admission laboratory parameters, including body temperature, heart rate, bicarbonate, albumin, and serum calcium. The average body surface area affected in group 2 was statistically different from that of group 1 (6.0% versus 2.3%, p = 0.001). A high Fournier's Gangrene Severity Index score (>9), high NLR (>8), and high PLR (>140) were associated more frequently with group 2 patients. Multivariable regression analysis showed that high NLR (adjusted odds ratio [OR], 4.66; 95% confidence interval [CI], 1.25-17.3; p = 0.022) and high PLR (adjusted OR, 11.6; 95% CI, 2.7-49.5; p = 0.001) were independent prognostic factors for poor prognosis from Fournier's gangrene. However, the Fournier's Gangrene Severity Index score did not shown any statistically significant effect on mortality (p = 0.086). The Fournier's Gangrene Severity Index scoring system was not associated with determining poor prognosis, however, high NLR and high PLR were associated with predictors of mortality in patients with Fournier's gangrene.

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BackgroundSGLT2 inhibitors have gained popularity in treatment of Type 2 Diabetes, and recently in lowering the risk of major adverse cardiovascular events (MACE). Genitourinary infections are well known side effects of SGLT2 inhibitors. Fournier's gangrene is a necrotizing fasciitis of the perineum which can be rarely associated with SGLT2 inhibitors. Between 2013 to 2018, the FDA received 12 case reports of Fournier's gangrene in patients taking SGLT2 inhibitors. Glucosuria from the medication creates a milieu which increases the chances of developing Fournier's gangrene. The annual incidence of Fournier's gangrene in the general population is 1.6/100,000 males in the US. Here, we present a case of Fournier's gangrene within few months of starting Dapagliflozin.Clinical caseA 62-year-old male with history of poorly controlled Type 2 DM was brought to the ED after being found down at his residence covered in feces. He reportedly had nausea, vomiting and diarrhea for 3 days prior to his presentation. His diabetes home regimen consisted of metformin 1000 mg BID, oral semaglutide 14 mg daily, glimepiride 8 mg daily, pioglitazone 45 mg daily and dapagliflozin 10 mg daily. Of note, dapagliflozin was started 3.5 months prior to presentation. Workup revealed WBC count 14.2 k/ul with left shift, sodium 132 mmol/L, HCO3 15 mmol/L, anion gap 26 mmol/L, glucose 432 mg/dL, Cr 3.27 mg/dL (Baseline 1.18 mg/dL), Lactic acid 2.7 mmol/L, AST 131 u/l, CK 905 u/l and A1c 9.2%. CT abdomen and pelvis with contrast showed necrotizing infection of the scrotum and perineum, consistent with Fournier's gangrene. Gas was seen tracking into the mesorectal fascia layer in the extraperitoneal spaces of the pelvis. He was given IV antibiotics and IV fluids per sepsis protocol. Urology and General Surgery consultations were obtained with the patient taken emergently to the operating room and underwent exploration of groin with debridement of genitals, right gluteal and perianal debridement, and bilateral orchiectomy. The patient had an extensive hospital stay with gradual improvement in clinical status. He later underwent extensive reconstructive plastic surgery. All oral diabetes medications were discontinued, and he was ultimately discharged on an insulin regimen consisting of insulin glargine 20 units BID, insulin lispro 5 units before meals and insulin lispro correction scale.ConclusionSGLT2 inhibitors remain valuable drugs in treating Type 2 Diabetes. Fournier's gangrene is a rare but serious possible adverse effect of SGLT2 inhibitors that requires a high index of suspicion to recognize. Time to onset of Fournier's gangrene after initiation of SGLT2 inhibitor therapy can be variable. Patients on SGLT2 inhibitors should be alerted to seek medical attention if they develop fever associated with pain, redness, or swelling in the genital or perineal area.Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Early diagnosis remains the cornerstone of management of Fournier's gangrene. As a result of variable progression of disease, identifying early predictors of necrosis becomes a diagnostic challenge. We present a scoring system based on objective admission criteria, which can help distinguish Fournier's gangrene from nonnecrotizing scrotal infections. Ninety-six patients were identified, 38 diagnosed with Fournier's gangrene and 58 diagnosed with scrotal cellulitis or abscess. Statistical analyses comparing admission vital signs, laboratory values, and imaging studies were performed and Classification and Regression Tree analysis was used to construct a scoring system. Admission heart rate greater than 110 beats/minute, serum sodium less than 135 mmol/L, blood urea nitrogen greater than 15 mg/dL, and white blood cell count greater than 15 × 10(3)/μL were significant predictors of Fournier's gangrene. Using a threshold score of two or greater, our model differentiates patients with Fournier's gangrene from those with nonnecrotizing infections with a sensitivity of 84.2 per cent. Only 34.2 per cent of patients with Fournier's gangrene had hard signs of necrotizing infection on admission, which were not observed in patients with nonnecrotizing infections. Objective admission criteria assist in distinguishing Fournier's gangrene from scrotal cellulitis or abscess. In situations in which results of the physical examination are ambiguous, this scoring system can heighten the index of suspicion for Fournier's gangrene and prompt rapid surgical intervention.

To validate the predictive value of Fournier's Gangrene Severity Index in patients with Fournier gangrene and to facilitate patient mortality risk-stratification by simplifying the Fournier's Gangrene Severity Index. From January 1989 to December 2011, 85 male patients with clinically-documented Fournier's gangrene undergoing intensive treatment and with complete medical records were recruited. The demographic information and nine parameters of Fournier's Gangrene Severity Index were compared between survivors and non-survivors. The parameters that showed a significant difference between the two groups were selected to generate a simplified scoring index. Of the 85 patients recruited, 16 patients died of the disease with mortality rate of 18.8%. The Fournier's Gangrene Severity Index score at initial diagnosis was significantly higher in non-survivors than in survivors. Of the nine parameters of Fournier's Gangrene Severity Index, the scores of serum creatinine level, hematocrit level and serum potassium level were significantly different between the two groups. However, the mean body temperatures, heart rate, respiration rate, white blood cell count, serum sodium and bicarbonate levels were non-significantly different. Of the 12 patients with chronic kidney disease or end-stage renal disease, 10 died of severe sepsis. A simplified scoring index including parameters of creatinine, hematocrit and potassium was generated, which provided sensitivity and specificity of 87% and 77% in predicting patient mortality, respectively. The predictive values of this simplified Fournier's Gangrene Severity Index were shown to be non-inferior to Fournier's Gangrene Severity Index in our patients. The simplified Fournier's Gangrene Severity Index is easy to use at initial diagnosis, and offers a way to compare outcomes in different clinical populations.

Outcome Prediction in Patients with Fournier's Gangrene

Figure: Contrast-enhanced CT of the abdomen and pelvis showing air extending into the right scrotum (shown in black).FigureFigureA 50-year-old man with hypertension presented to the emergency department with an exacerbation of his lower back and perianal pain that he had had for two weeks, with a new onset of active fecal draining and difficulty urinating for four hours. He said he had no headache, nausea, vomiting, weakness, fatigue, fever, and chills, and all other reviews of systems were negative. His temperature was 98.5°F, blood pressure was 108/57 mm Hg, pulse rate was 113 bpm, respiratory rate was 20 bpm, and oxygen saturation was 97% on room air. His abdomen was soft, mildly distended, and not tender to palpation with normal bowel sounds. His rectum was edematous with indurated perianal tissue. Digital rectal exam was deferred due to draining stool. Contrast-enhanced CT of the abdomen and pelvis was obtained, which revealed the presence of air within the bilateral ischiorectal fossa with air extending anteriorly into the right scrotum. (Photo.) Fluid was also present along the bilateral levator ani. A diagnosis of Fournier's gangrene was made. The patient was promptly started on fluid resuscitation and triple antibiotics—piperacillin-tazobactam 3.375 g, metronidazole 500 mg, and vancomycin 1 g. Morphine 4 mg IV push was given for pain, and the patient was hospitalized for surgical debridement. He became stable and was discharged without any complications after six weeks of inpatient care. A Fatal Infection Fournier's gangrene is a polymicrobial infection, mainly anaerobic, that arises in the perianal, genital, or abdominal area, followed by the spread of infection in a matter of hours along the epidermis, dermis, subcutaneous tissues, fascia, and muscles, causing necrotizing fasciitis. (Urol Int 2018;101[1]:91; http://bit.ly/2DyAVbL.) Trauma, impaired immunity as seen in diabetics, the HIV virus, and chemotherapy are possible causes of Fournier's gangrene. (J Emerg Med 2013;44[2]:e247.) This case is unique because none of the above predisposing factors contributed to the development of Fournier's gangrene. Besides tenderness over the perianal area and new onset of mild fecal drainage, the clinical presentation showed no major evidence of systemic infection, necrotizing tissue, or subcutaneous crepitation. A case series analysis of inpatients with Fournier's gangrene who had a surgical debridement revealed a 20-40 percent mortality rate, with some as high as 88 percent. (Urol Int 2016;97[3]:249; http://bit.ly/2DAyrK0.) The diagnosis would have been missed had a contrast-enhanced CT scan of the abdomen and pelvis not been performed, which would have led to sepsis and a fatal outcome in hours. Determining Prognosis The clinical presentation of Fournier's gangrene varies from anorectal or genital pain with little evidence of cutaneous necrosis to a rapidly spreading necrosis and systemic sepsis without any suspicious source of infection. Methods commonly used to diagnose Fournier's gangrene are radiography, ultrasound, computed tomography, and magnetic resonance imaging. A semi-quantitative way of estimating the risk of developing a necrotic infection (the laboratory risk indicator for necrotizing fasciitis, or LRINEC) is based on the assessment of six laboratory considerations, including the number of leukocytes, value of hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein. A score of 6 was recorded in this patient. A LRINEC score of 5 suggests a favorable outcome, compared with a score of 10 pointing to a lethal outcome. (Scand J Trauma Resusc Emerg Med 2017;25[1]:28; http://bit.ly/2DCHlGE.) Patients must receive prompt fluid resuscitation, triple antibiotic therapy, and pain control. Cultures should also be obtained to define the causative organism and determination of sensitivity to antibacterial drugs. (Urol Int 2018;101[1]:91; http://bit.ly/2DyAVbL.) Septic shock is the most common cause of death. Prognostic factors of unfavorable outcomes for Fournier's gangrene include tissue damage beyond the perineum, severe sepsis, pulse over 90 bpm, leukocytes more than 20 × 109/L, and urea level equal to 7 mmoL/L. (Changgeng Yi Xue Za Zhi 1999;22[1]:31.) Management of Fournier's gangrene should be aggressive. Detection of gas in deeper soft tissues is considered an absolute indication for surgical intervention. (Surg Today 2007;37[7]:558.)

Fournier's gangrene is a fast progressing, life-threatening necrotizing infection, which is commonly seen in the dermis and subcutaneous layers of the anogenital region. The infection is usually caused by organisms that spread along the subcutaneous and fascial planes across the perineum, scrotum and often beyond these tissues. The usual treatment is a prompt surgical debridement and, in many cases, a diverting colostomy 1, 2. Here, we present a Fournier's gangrene case, where a combined treatment with the Flexi-Seal Faecal Management System 1 and a negative pressure wound therapy (NPWT) were used to achieve optimal results. Presented case was a 43-year old, female patient, with a body mass index of 38. She was first seen in the emergency unit with a large wound in the gluteal region and high fever. She had been diabetic for at least 5 years. There was also a history of abdominal hernia operation. An extensive necrosis was noted between right gluteal region and labium major. The necrosis was continuing to the femoral canal. The subcutaneous tissues and the deep fascia were also involved. The proximity to anal canal was about 3 cm (Figure 1A). A giant ventral hernia was noted, although we were not sure if it was related to the present problem. The clinical diagnosis of the wound was sepsis associated with Fournier's gangrene. An immediate surgical debridement was planned and performed. As medical treatment, ceftriaxone and metronidazole were used. At the end of the debridement, a Flexi-Seal Faecal Management System was applied. This is a rectal tube allowing diversion of faecal matter from the rectum, aiming to decrease infectious load, and thus avoiding re-infection (Figure 1B). A series of debridements was performed when necessary. At the end of the fourth debridement, no necrosis was seen. Then, to increase granulation tissue formation, NPWT was applied 2 (Figure 1C). This was continued for 28 days, with a dressing change every second day. The pressure was 60 mmHg, and continued with 5 min on and off intervals. At the end of the 28th day, the wound was ready to close with sufficient granulation formation (Figure 1D). In the literature, there are few reported cases regarding the use of Flexi-Seal Faecal Management System in Fournier's gangrene. Our approach differs from previous cases 3, 4, with the combination of Flexi-Seal and NPWT, as presented here. This helped us to achieve faster wound healing. The bacteria that cause the destructive infection in Fournier's gangrene syndrome are colonic in origin. Hence, faecal diversion using a colostomy has been a choice in the treatment of Fournier's gangrene with successful results. Flexi-Seal is an alternative to colostomy with less complications 5. NPWT is a leading wound management method, indicated by successful usage in almost every part of the human body. Recently, there are reports about its successful use in the wound management of Fournier's gangrene, in addition to conventional debridement. Once the necrosis is eliminated, NPWT helps to induce granulation tissue formation with the mechanisms of increased perfusion, fibroblast migration, remove of infected materials and excess exudates. The suggested pressure limits change between 50 and 125 mmHg. In critical areas such as in our case, the safe pressure would be better if maintained at the lower border. Hence, any complication such as perforation due to the high pressure is avoided 6. The combined treatment with Flexi-Seal Faecal Management System and NBWT in the management of Fournier's gangrene in this case seems promising. The advantages can be listed as: avoiding colostomy, rapid wound healing, shorter hospital stay, early return to work, and most importantly, contribution to survival. Omer Faruk Ozkan, MD1, Ediz Altýnlý, MD2, Neset Koksal, MD3, Serkan Senger, MD4 & Atilla Celik, MD5 1Department of General Surgery, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakale, Turkey 2Department of General Surgery, Faculty of Medicine, Bilim University, Istanbul, Turkey 3Department of General Surgery, Faculty of Medicine, Kafkas University, Kars, Turkey 4Department of General Surgery, Kartal State Hospital, Istanbul, Turkey 5Department of General Surgery, Bagcýlar Training and Research Hospital, Istanbul, Turkey [email protected]

The delta neutrophil index represents the fraction of circulating immature granulocytes and is a marker of infection and sepsis. Our study aimed to evaluate the usefulness of the delta neutrophil index in predicting mortality in patients with Fournier's gangrene. We enrolled patients with Fournier's gangrene who were admitted to the Wonju Severance Christian Hospital (Wonju, Korea) between September 2010 and December 2021. We retrospectively analyzed the patients' characteristics, factors related to management, scoring systems such as the Fournier's Gangrene Severity Index, and laboratory data measured at initial presentation. There were 58 (68.2%) survivors and 27 (31.8%) non-survivors. The initial levels of serum lactate, hemoglobin, delta neutrophil index, albumin, international normalized ratio, creatinine, Fournier's Gangrene Severity Index, Uludag Fournier's Gangrene Severity Index, and prognostic nutritional index differed between survivors and non-survivors. Age, international normalized ratio, and delta neutrophil index were independent predictors of mortality in Fournier's gangrene. In receiver operating characteristic curve analysis, delta neutrophil index on the day of admission was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval [0.679-0.929]). The optimal cutoff for delta neutrophil index in predicting mortality was 11.25% (sensitivity, 74.1%; specificity, 91.4%). The initial delta neutrophil index was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval 0.679-0.929). The delta neutrophil index can be useful for predicting mortality in patients with Fournier's gangrene. A delta neutrophil index >11.25% at initial presentation is a reliable predictor of Fournier's gangrene.

Fournier's Gangrene: Management and Mortality Predictors in a Population Based Study