Sudden death due to atypical Fournier’s gangrene following Methicillin-resistant Staphylococcus aureus (MRSA) infection: a forensic case

Abstract

Fournier’s gangrene is a rare and progressive necrotizing infection affecting the perineal, periureteral, perianal, or genital area associated with high mortality rates. A 34-year-old obese man went to the emergency room, complaining of painful perianal and perineal swelling. He was hospitalized and the computed tomography (CT) scan revealed large bilateral anorectal abscesses, anteriorly extended to the base of the scrotum and on the right to the ischiorectal fossa. A diagnosis of Fournier’s gangrene was made and broad-spectrum antibiotic therapy was started. After the abscesses drainage, microbiological examinations were performed. However, the clinical conditions furtherly worsened and the patient was moved to the medical intensive care unit. The microbiological analyses tested positive for Methicillin-resistant Staphylococcus aureus (MRSA) and the antibiotic therapy was modified accordingly. Despite the treatment, the hypotension worsened and the patient died from sepsis and multi-organ failure. Upon autopsy, we observed an external macroscopic picture devoid of the typical destructive lesions that usually characterize Fournier’s gangrene. Therefore, we found ourselves faced with an atypical case which, in the absence of the clinical data, would certainly have been difficult to diagnose based on the autopsy findings only. The presented case is deemed of interest for both clinicians and medical examiners since it is about a highly aggressive and fatal Fournier’s gangrene in the absence of destructive external manifestations. Moreover, this atypical case of Fournier’s gangrene was sustained by an emerging and highly aggressive microbial agent, eventually evolved into sudden death.