The Case Files

Abstract

A 63-year-old woman presented to the ED via ambulance with complaint of a draining abscess from her groin that had worsened over the past day. She also reported subjective fever and chills. The patient said she first noticed the abscess two days earlier. The patient had had an appendectomy in 1994 and a hysterectomy in 2000, and she had type II diabetes, hypercholesterolemia, and hypertension. The patient was not compliant with her medications, and was not sure what they were. Her body mass index was 33.2, respiration rate was 18 bpm, oral temperature was 100.5°F, pulse was 108 bpm, blood pressure was 173/94 mm Hg, and pulse oximetry was 97% on room air. Physical examination was significant for a foul-smelling draining abscess in the perineal region that was tender, erythematous, and edematous with crepitus surrounding the site of drainage and copious amounts of pus that were expressed with light pressure during palpation. Laboratory results were significant for a blood glucose level of 395 mg/dL and a white blood count of 20.3 cells/ml. A CT scan of the abdomen and pelvis with contrast showed multiple foci of air in the right lower anterior pubic region that was suspicious for a gas producing infection. (Photo.) The diagnosis of Fournier's gangrene was confirmed, and the patient was immediately started on broad-spectrum IV antibiotics, insulin, and IV fluids.Figure: CT of the abdomen and pelvis.The patient was transferred to surgery where, after consulting with urology, a decision was made to perform a radical debridement of necrotic tissue and to drain the area surgically. The patient was stabilized after debridement and released from the ICU. The patient underwent reconstructive surgery, and was released three weeks after admission. The patient also received education on managing her chronic conditions. Because of immediate identification and intervention, the patient recovered. Fournier's gangrene is a rare form of necrotizing fasciitis with rapid onset and progression. Venereologist Jean Alfred Fournier was the first to describe a rapidly progressing case of necrotizing fasciitis in 1883. (AJR Am J Roentgenol 1998;170[1]:163.) This form of necrotizing fasciitis is caused by anaerobic and aerobic microorganisms. The infection often begins as a simple cellulitis from a defect or break in the skin of the perineal or genital region, providing entry for bacteria. Because of the aggressive nature of the bacteria, even with early intervention, mortality rates remain high. Multiple organisms can be present in the infection and may act synergistically, encouraging growth. The most common bacteria present are Escherichia coli, Bacteroides, Proteus, Staphylococcus, Enterococcus, Streptococcus, Pseudomonas, Klebsiella, and Clostridium species. (EMN 2005;27[5]:24.) The byproducts of an anaerobic metabolism lead to soft tissue gas formation that is composed of hydrogen, hydrogen sulfide, and nitrous oxide. (AJR Am J Roentgenol 1998;170[1]:163.) It is important that surgical debridement be performed as soon as possible once Fournier's gangrene is identified. Diagnosis can be made through physical examination, blood tests such as a CBC, imaging such as sonograms and CT scans that can provide evidence of the extent of subcutaneous infection, and a thorough history to help establish comorbidities such as diabetes, alcohol abuse, or immunodeficiency. Treatment consists of broad-spectrum antibiotics, surgical debridement of necrotic tissue, and surgical drainage. Hyperbaric oxygen therapy is not a mainstay of treatment, but it can be beneficial and reduce mortality. (J Urol 1997;158[3 Pt 1]:837.) Primary closure of the skin is done once granulation tissue begins to form after surgical debridement. Depending on the amount of debridement, local skin flap coverage or skin grafts can be used for closure of surgical site. Differential diagnosis of Fournier's gangrene includes cellulitis, abscess, hernia, hydrocele, orchitis, testicular torsion, balanitis, fungal infections, and vulvovaginitis. Patients should have appropriate surgical and urological follow-up.