JUST ANOTHER PINPRICK MADE ME SICK

Abstract

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Fournier’s gangrene is a urological emergency characterized by rapidly progressive fulminant necrotizing infection of the genital, perineal and/or perianal regions.Most case series and observational studies indicate a mortality of 30 to 50 percent without prompt management.It is rare to have gas formation along fascial planes with non-clostridial organisms, however an increasing number of case reports have described a rise in non-clostridial organisms causing gangrene especially in diabetic patients. Emergent surgical debridement followed by aggressive local care and timely initiation of broad spectrum antibiotics remains the backbone of management. CASE PRESENTATION: A 37-year-old man presented with 5-days of worsening left testicular pain, swelling and erythema associated with subjective fevers, chills. He was pricked by a safety-pin in the scrotal area before engaging in sexual activity. He endorses binge drinking over the weekends, but denies tobacco consumption, illicit drug use, any sick contacts or travel outside the country recently. His left scrotum doubled in size with significant surrounding erythema, edema, crepitus and induration, over the course of 24 hours, driving the patient to seek medical attention. Ultrasound of the scrotum revealed extensive soft tissue swelling and gas formation extending to the retroperitoneum via perineum. Imaging revealed extensive gas formation in the perineum, ascending and descending along fascial planes. Subcutaneous emphysema of abdominal wall with mediastinal gas was also noted. Investigation showed WBC count of 22,000 with 12% bands and HIV testing was negative.IV Vancomycin and Ertapenem were administered on presentation followed by emergent debridement of bilateral scrotum, perineum and left inguinal region. Due to the extent of necrosis and gas formation, clindamycin was added for anti-toxin effect. Wound/tissue cultures grew methicillin sensitive staphylococcus aureus, group B streptococcus, group G streptococcus and anaerobic bacteroides. Antibiotics were de-escalated in 48 hours to IV Cefazolin and metronidazole.He has completed his antibiotic course and is currently recovering well. DISCUSSION: Fournier’s gangrene can also be caused due to a synergistic bacterial infection by a combination non-clostridial aerobic and anaerobic organisms. We present a case of traumatic (pinprick induced) rapidly progressive perineal gas gangrene with documented bacterial synergism. It can be hypothesized that the magnitude of gangrene, necrosis and bacterial load was greater because of the bacterial synergism present. CONCLUSIONS: Improved survival can only be achieved by a high index of suspicion leading to prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics. Reference #1: Clinical Features of Non-Clostridial Gas Gangrene and Risk Factors for in-Hospital Mortality. Tokai J Exp Clin Med 40, no. 3 (Sep 20 2015): 124-9. Reference #2: Fatal Morganella morganii bacteremia in a diabetic patient with gas gangrene. Journal of Medical Microbiology(2009), 58: 965-967.Lamerton, A. J. “Fournier's Gangrene: Non-Clostridial Gas Gangrene of the Perineum and Diabetes Mellitus.” J R Soc Med 79, no. 4 (Apr 1986): 212-5. Reference #3: A Case of Fournier's Gangrene. Eplasty 17 (2017): ic25. DISCLOSURES: No relevant relationships by Padmastuti Akella, source=Web Response No relevant relationships by Imola Daniel, source=Web Response No relevant relationships by Himmat Grewal, source=Web Response