Fournier's Syndrome Research Articles

The Role of Biomarkers and Scores in Describing Urosepsis.

Background and Objectives: Patients with urinary tract obstruction (UTO) and systemic inflammatory response syndrome (SIRS) are at risk of developing urosepsis, whose evolution involves increased morbidity, mortality and cost. The aim of this study is to evaluate the ability of already existing scores and biomarkers to diagnose, describe the clinical status, and predict the evolution of patients with complicated urinary tract infection (UTI) and their risk of progressing to urosepsis. Materials and Methods: We conducted a retrospective study including patients diagnosed with UTI hospitalized in the urology department of" Sfântul Apostol Andrei" County Emergency Clinical Hospital (GCH) in Galati, Romania, from September 2019 to May 2022. The inclusion criteria were: UTI proven by urine culture or diagnosed clinically complicated with UTO, fever or shaking chills, and purulent collections, such as psoas abscess, Fournier Syndrome, renal abscess, and paraurethral abscess, showing SIRS. The exclusion criteria were: patients age < 18 years, pregnancy, history of kidney transplantation, hemodialysis or peritoneal dialysis, and patients with missing data. We used the Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) and qSOFA (quick SOFA) scores, and procalcitonin (PCT) to describe the clinical status of the patients. The Charlson Comorbidity Index (CCI) was used to assesses pre-existing morbidities. The hospitalization days and costs and the days of intensive care were considered. Depending on the diagnosis at admission, we divided the patients into three groups: SIRS, sepsis and septic shock. The fourth group was represented by patients who died during hospitalization. Results: A total of 174 patients with complicated UTIs were enrolled in this study. From this total, 46 were enrolled in the SIRS group, 88 in the urosepsis group, and 40 in the septic shock group. A total of 23 patients died during hospitalization and were enrolled in the deceased group. An upward trend of age along with worsening symptoms was highlighted with an average of 56.86 years in the case of SIRS, 60.37 years in the sepsis group, 69.03 years in the septic shock, and 71.04 years in the case of deceased patients (p < 0.04). A statistically significant association between PCT and complex scores (SOFA, CCI and qSOFA) with the evolution of urosepsis was highlighted. Increased hospitalization costs can be observed in the case of deceased patients and those with septic shock and statistically significantly lower in the case of those with SIRS. The predictability of discriminating urosepsis stages was assessed by using the area under the ROC curve (AUC) and very good specificity and sensitivity was identified in predicting the risk of death for PCT (69.57%, 77.33%), the SOFA (91.33%, 76.82%), qSOFA (91.30%, 74.17%) scores, and CCI (65.22%, 88.74%). The AUC value was best for qSOFA (90.3%). For the SIRS group, the PCT (specificity 91.30%, sensitivity 85.71%) and SOFA (specificity 84.78%, sensitivity 78.74%), qSOFA scores (specificity 84.78%, sensitivity 76, 34%) proved to be relevant in establishing the diagnosis. In the case of the septic shock group, the qSOFA (specificity 92.5%, sensitivity 82.71%) and SOFA (specificity 97.5%, sensitivity 77.44%) as well as PCT (specificity 80%, sensitivity 85.61%) are statistically significant disease-defining variables. An important deficit in the tools needed to classify patients into the sepsis group is obvious. All the variables have an increased specificity but a low sensitivity. This translates into a risk of a false negative diagnosis. Conclusions: Although SOFA and qSOFA scores adequately describe patients with septic shock and they are independent prognostic predictors of mortality, they fail to be accurate in diagnosing sepsis. These scores should not replace the conventional triage protocol. In our study, PCT proved to be a disease-defining marker and an independent prognostic predictor of mortality. Patients with important comorbidities, CCI greater than 10, should be treated more aggressively because of increased mortality.

Conhecimento empírico versus ciência: obstáculos a um bom prognóstico

Medicine, in its beginnings, was based on knowledge based on historical reports and personal experiences, which still persists today. The modern concept that opposes empiricism is Evidence-Based Medicine, which serves as a basis for clinical decisions. The aim was to discuss the relationship between science, empiricism and good care prognosis from an experience lived in a hospital environment. This is an experience report of a descriptive and critical-reflexive nature, carried out in a medium-sized hospital in the Zona da Mata region, in Minas Gerais. Data were collected through anamnesis and analysis of the medical records of a 53-year-old male patient with Fournier Syndrome. The situation of vulnerability in which the majority of the population living in rural areas is found is an aggravating factor for the emergence and poor prognosis of the pathology, highlighting the difficult access to information, precarious housing conditions and scarcity of treatment and qualified resources. . Therefore, it is worth emphasizing the importance of new research in the area, to develop specific and methodological knowledge in order to build an adequate and effective strategy for patients with the disease.

Efficiency of Hyperbaric Oxygen Therapy Combined with Negative-Pressure Wound Therapy in the Treatment Strategy of Fournier's Gangrene -A Retrospective Study.

Fournier's gangrene (FG) is a serious, aggressive, and often fatal multi-organism infection that affects the soft tissues of the perineum, rectum, and external genitalia. This study aimed to analyse the treatment's strategies of FG. This was a retrospective study of 35 patients with a diagnosis of FG admitted between 2016 and 2021. The diagnosis of FG was established on a clinical basis. Data on patient's age, sex, comorbidities, laboratory results (C-reactive protein (CRP), white blood cell (WBC), hematocrit (HCT), platelets (PLT), sodium, potassium, creatinine, procalcitonin, international normalized ratio (INR), and gangrene culture), extent of resection, antibiotics used, and hospitalisation time were obtained. The extent of resection was assessed on a scale of 1-5. The study group consisted of all men (n=35) aged 24-85 (mean, 58) years. In 13/35 (37%) patients, hyperbaric oxygen therapy (HBOT) combined with negative-pressure wound therapy (NPWT) was used as a treatment for wound healing in Fournier's syndrome (group 1), and in 22/35 (63%) patients, open standard wound care was used (group 2). There were no fatalities in group 1, but four deaths (18%) were noted in group 2.The median extent of resection was 3 in group 1 and 2 in group 2. There was a correlation between the extent of resection and use of HBOT combined with NPWT. The hospitalisation time was much shorter in group 2 (mean, 23days) than in group 1 (mean, 26days). HBOT and NPWT (group 1) showed advanced wound healing with a high efficiency rate. The longer median hospitalisation time in this group may be related to the severity of injury.

Fournier Syndrome-Surgical and Intensive Care Treatment

Fournier’s Gangrene, also referred to as necrotising fasciitis, Mellene Syndrome or Fournier Syndrome (FS), is a soft-tissue acute infection of the perinium with secondary necrotising cellulitis caused by anaerobic germs or gram-negative bacilli or both. This infection may develop in apparently normal skin, affects the tegumentary and fascial planes but it affects the muscle - aponeurotic plane very rarely dissecting the necrotic tissues, as it rapidly moves towards sepsis, with multiple failure of the organs and death. Treatment consists of agressive surgical debridement, broad spectrum antibiotic therapy, hyperbaric oxiygen therapy (OHB) and other complementary actions.

The Importance of Hyperbaric Oxygen Therapy in Patients with Fournier Syndrome.

Abstract Fournier syndrome is a synergistic polymicrobial infection that mainly affects the perianal, perineal and genital regions. It is a relatively rare disease with high mortality and an estimated overall incidence of 1.6/100,000 men. Diagnosis is clinical and an early detection is crucial to improve patient outcomes. Treatment is based on three pillars: initial patient stabilization, broad-spectrum antibiotic therapy and extensive surgical debridement of the entire necrotic area. Currently, hyperbaric oxygen therapy has been used as an adjunctive treatment. This study aimed to report the case of a patient with Fournier syndrome who underwent the three-pillar treatment and also hyperbaric oxygenation with a satisfactory result.

Fournier gangrene - a challenge for the surgeon.

Fournier gangrene (FG) is life - threatening condition, defined as the necrotizing fascitis of perineum and can spread to the adjacent areas. It is rare disease and infection is caused by mixed bacterial flora, seldom by fungal infection. Risk factors are: male sex, diabetes, hypertension, malignant neoplasms, alcoholism, immunospression. The analysis of four group patients treateted for Fournier gangrene was made about diagnostic and therapeutic process, assessment of prognosis based on Fournier's Gangrene Severity Index). All patients were males. Average age at the moment of diagnosis was 60 years. All of them had comorbidities resulting with the higher risk of susceptibility to FG. Morbitity was 50%, despite of all of patients had less than 9 points in FGSI. The FG, despite of better diagnostic tools and technological progres remaines the significant clinical issue because of the mortality - 80%. "The golden standard" is surgical excision of necrotic tissues, antibiotics support, equation of fluid, electrolytes and base - acid balance, level of glycemia is very important. The treating results were assessed on the base of FGSI. The significance has the moment of performing the surgical intervention - it is proven, that should be carried out during 24 hours. The hyperbaric oxygen therapy is controversial. Seem to be appropriate if the infection is caused by anaerobic bacteria. Fournier syndrome is significant clinical issue. Its treatment requires early surgical approach with exicision of necrotic tissues, antibiotics support and treatment of hyperbaric oxygen in some cases.

Epidemiological study on Fournier syndrome in a tertiary hospital in Jundiaí-SP from October 2016 to October 2018†

IntroductionFournier’s gangrene is a polymicrobial infection caused by aerobic and anaerobic microorganisms, which determine a fast and progressive necrotizing fasciitis, compromising mainly the perineal region and the genital region, being able to evolve to sepsis, multiple organ failure and death. Treatment consists of early surgical diagnosis and debridement, associated with broad-spectrum antibiotic therapy and hyperbaric oxygen therapy. ObjectiveCompare the most prevalent epidemiological data of patients with Fournier's Syndrome with the data examined in the literature in order to evaluate the incidence in the analyzed service, treatment form and evolution of the patients with the disease. Materials and methodsObservational transversal study from the medical records of patients diagnosed with the disease at the São Vicente de Paulo Charity Hospital in Jundiaí, SP, from October 2016 to October 2018. Results23 patients with Fournier’s Syndrome, all included in the study, and were analyzed. The most prevalent epidemiological data on the disease, such as age, sex, association with other comorbidities, treatment performed, mortality and early surgical procedure, had obtained a similar data as compared as the medical literature that was in studied. ConclusionDespite the recognized severity of Fournier’s Syndrome, early diagnosis combined with extensive surgical debridement, broad-spectrum antibiotic therapy and measures and oxygen therapy when available are important measures to contain the rapid progression of the disease, thus decreasing its levels of mortality.

Perfil clínico de pacientes com Síndrome de Fournier em um hospital terciário

Introdução: A Síndrome de Fournier consiste em uma fasciite necrosante que afeta tecido subcutâneo e pele do períneo e genitais externos. Caracterizada como uma urgência cirúrgica, seu tratamento é baseado em três pilares: debridamento de tecidos necróticos e infectados; controle sistêmico e antibioticoterapia; e reparação dos tecidos afetados. Objetivo: Identificar o perfil clínico de pacientes diagnosticados com Síndrome de Fournier em um hospital de urgências. Métodos: Trata-se de um estudo descritivo, retrospectivo e de abordagem quantitativa. A amostra consistiu de pacientes diagnosticados com Síndrome de Fournier acompanhados pela comissão de curativos do hospital no período de agosto de 2016 a agosto de 2017, que receberam alta ou foram a óbito. Resultados: A amostra do estudo foi composta por 14 pacientes, sendo em sua totalidade pacientes do sexo masculino, entre 21 e 82 anos e idade média de 55 anos. Em 50% dos casos, foi necessário internação em Unidade de Terapia Intensiva (UTI). Quanto ao desfecho, 78,6% (11) receberam alta hospitalar e 21,4% (3) evoluíram para óbito. Conclusão: A assistência a pacientes com Síndrome de Fournier ocorre de forma despadronizada, o que ocasiona altas taxas de mortalidade. A elaboração de protocolos específicos é necessária.

Necrosis de pene por calcifilaxis en paciente nefrópata

Necrosis of the penis secondary to calciphylaxis is an infrequent entity that has been associated with chronic degenerative diseases due to intravascular calcium deposits. Few cases have been described in the literature. We describe herein the management of and complications in a 61-year-old man presenting with this pathology secondary to terminal chronic kidney disease.The 61-year-old patient had a high smoking index of long progression and a past history of diabetes mellitus and high blood pressure, both uncontrolled, and terminal kidney disease presently being treated with hemodialysis. He also had a history of acute myocardial infarction (AMI), femoropopliteal bypass, and the amputation of the right lower extremity. He first presented with glans penis necrosis that was treated with partial surgery, but upon observing urethral and surrounding tissue involvement, a lack of irrigation, and tissue infection, the decision was made to perform a total penectomy with perineal urethrostomy. The patient had the complication of Fournier's syndrome with poor progression, resulting in his death. Penile necrosis due to calciphylaxis is not very well known and its management is complicated due to the fact that the general condition of patients is poor. Partial or total phallectomy is a therapeutic option for this type of patient because they present with peripheral microangiopathy. However, there is a high complication rate due to complications from uncontrolled underlying pathologies.

化学放射線療法後にフルニエ症候群を発症した肛門管癌の1例

フルニエ症候群は，会陰部に生じる急性壊死性筋膜炎で，急激な経過をたどり，早期に適切な治療を施さなければ予後不良となる疾患である．今回われわれは，肛門管癌に対し，化学放射線療法（chemoradio therapy；CRT）を施行後，フルニエ症候群を発症した症例を経験したので報告する．症例は79歳の男性で，肛門管癌に対し，S状結腸双孔式人工肛門を造設したのち，S-1併用（100mg/body）にて50.4GyのCRTを施行した．CRT終了後一旦退院となったが，退院10日目に発熱，肛門部痛を主訴に外来を受診し，フルニエ症候群の診断で入院となった．広範囲ドレナージ術，抗生剤投与，追加ドレナージおよび局所洗浄の継続にてフルニエ症候群は軽快した．フルニエ症候群発症後3ヵ月目のCTで多発肝転移の出現があり，全身化学療法の方針となり転院となった．これまで，肛門管癌を含む直腸癌に対するCRT後に発症したフルニエ症候群の報告はなく，文献的考察を加え報告する．

Retalho fasciocutâneo de região interna de coxa para reconstrução escrotal na síndrome de Fournier

A síndrome de Fournier é uma doença grave e que deve ser agressivamente tratada com desbridamentos e antibioticoterapia de amplo espectro. Geralmente causa perda de grande área de tecido, podendo espalhar-se para outras áreas além do períneo, como abdome, membros inferiores, dorso, tórax e retroperitônio. A perda da bolsa escrotal é uma situação frequente nessa doença. São relatados dois casos de reconstrução de bolsa escrotal com retalho fasciocutâneo de região interna de coxas, com excelente recuperação, bom resultado estético e poucas complicações.

A Case of Intravascular Lymphoma Complicated with Fournier's Syndrome Due to Multidrug-Resistant Pseudomonas aeruginosa

Fournier's syndrome is the fulminant necrotizing fasciitis of the external genitalia. The occurrence of Fournier's syndrome in patients with hematologic malignancies has been reported. Here we report a case of an intravascular lymphoma complicated with Fournier's syndrome due to multidrug-resistant Pseudomonas aeruginosa (MDRP). A 71-year-old Japanese man received intensive chemotherapy for recurring intravascular lymphoma. Blood culture revealed MDRP, and physical examination led to the diagnosis of Fournier's syndrome. Aggressive treatment that comprised granulocyte transfusion, granulocyte stimulating factor, endotoxin filtration, appropriate antibiotic coverage, and aggressive surgical therapy was administered, and this lead to the successful recovery from sepsis and Fournier's syndrome.

Anesthetic experience of patients with Fournier's syndrome

Fournier’s syndrome is defined as a suppurative bacterial infection of the perineal, genital, or perianal regions. Those conditions often lead to thrombosis of subcutaneous vessels and with infection, resulting in the development of gangrene of the overlying skin and subcutaneous tissue [1]. This rare syndrome is a rapidly progressive and potentially lethal necrotizing fasciitis caused by invasive infections of the lower part of the genitourinary tract, anorectal soft tissue, and genital skin [1,2]. The devastating rapidity is typical, as evidenced by the fact that the mean duration of symptoms to become the target of emergency operation is just a few days, and a majority of patients are seriously ill at the time of admission. Anesthetic management of patients with this syndrome is often difficult, due to its devastating nature as well as significant comorbid diseases. However, because of the infrequency of the syndrome, there is limited information regarding the anesthetic management of this disease. We recently encountered the anesthetic management in three cases of patients with Fournier’s syndrome. There were three initial emergency and six additional elective operations under general anesthesia, except one spinal anesthesia in an elective case. Therefore, we report these cases and review the relevant literatures. Immediate and, if required, repetitive operation is important for saving lives in patients with this syndrome [1-3]. Fournier’s syndrome is frequently associated with certain diseases and conditions. Diabetes mellitus is probably the most common comorbid disease, as evidenced by our cases [1]. Even when the patient has diabetes, as in our two patients, Fournier’s syndrome might be the first clinical disease to be detected. The second common condition is alcoholism, such as in all our patients, because any disorder that compromises the immunity

Manejo da gangrena de Fournier: experiência de um hospital universitário de Curitiba

To analyze the results obtained in the Department of General Surgery, Cajuru University Hospital-PUCPR, with the treatment of Fournier's gangrene. We reviewed the charts of 40 patients diagnosed with Fournier's gangrene admitted to the Cajuru University Hospital from November 1999 to April 2006, analyzing gender, age, predisposing factors, etiology, lesion location, laboratory tests, surgical procedures, antibiotic use and hyperbaric oxygen therapy. The most common etiology was the anorectal origin. The most prevalent etiological agent was E. coli. The predominant predisposing factor was diabetes mellitus. The majority of patients were male. The location and extent of injury was usually in the perineum. All underwent surgical debridement, 17 with associated colostomy and two with combined cystostomy. All patients received antibiotics, the most used being metronidazole and gentamicin. Twenty-six patients underwent hyperbaric therapy. The overall mortality was 20%. Fournier's syndrome, despite all the advances in treatment today, continues to show high mortality rates. Early recognition of infection associated with invasive and aggressive treatment are essential for attempting to reduce these prognostic indices.

Síndrome de Fournier secundária a adenocarcinoma de próstata avançado: relato de caso

A Síndrome de Fournier é uma fasciite necrotizante rapidamente progressiva que acomete a genitália e região perineal. Mesmo com os avanços na terapêutica, a morbidade e a mortalidade desta afecção permanecem elevadas. É relatado caso de paciente masculino, 70 anos, com diagnóstico de adenocarcinoma de próstata avançado. Há um dia com dor e aumento de volume escrotal associado a febre. Ao exame físico, paciente séptico com gangrena gasosa do pênis e escroto; ao toque retal, lesão ulcero-vegetante em parede anterior do reto estendendo-se de 3 a 7 cm da borda anal. Realizado desbridamento cirúrgico, com identificação de fístula reto-escrotal transtumoral. Estudo histo-patológico da lesão retal confirmou infiltração por adenocarcinoma de próstata. Recebeu alta hospitalar no vigésimo dia de internação, atualmente em acompanhamento oncológico ambulatorial.

Colon Cancer

Purpose: To compare the clinical profile of colon cancer patients with those of asymptomatic people submitted to colonoscopy starting at the minimal age of 50. Methods: Between December 2003 and November 2005, 390 consecutive colonoscopies were performed in a prospective study in 152 asymptomatic people over the age 50 Group A and in 238 colon cancer patients with diagnosis done at the time of endoscopy Group B. Biopsies, polypectomies and mucosectomies were carried out as needed. Age, family history FH, symptoms, Body Mass Index BMI, location of tumor and histopathology were analyzed. Student's t and chi-square tests were used. P value <0.05 was considered significant. Results: Mean age Group A 62 ± 9 years and 61 ± 13 Group B p > 0.05. 79 patients (31%) of colon cancer had positive FH for cancer and positive FH was present in 34 patients without cancer (23%) p>0,05.BMI was 26 ± 4 Group A and 27 ± 4 for B p>0.05. 9 patients (5%) from Group A was found to have cancer, being one of then superficial (11%). Adenoma was diagnosed in 45 patients (29%) in this group. Left colon cancer was seen in 6 (66%). On Group B 21 patients (8%) had superficial cancer. On the total of malign lesions diagnosed in this Group, 168 (69%) were on the left colon. Adenoma was found in 61 patients (25%). Synchronous malign lesions were detected in 6 (2%). None of then in Group A. Change of bowel habits with bleeding was more common on the left colon cancer, being 56 (60%) against 13 (31%) on the right p < 0.01. Important weigth loss and anemia occurred more frequently on the right when compared to the left 30 (44%)X31 (17%) and 36 (46%)X 15 (8%) p < 0.01. In two patients, right colon cancer was associated with Fournier syndrome and in another one, tumor was in the appendix. 157 patients (63%) had symptoms for more than 6 months and acute obstruction was seen in 21 (8%). In one, tumor was associated with massive bleeding from diverticular disease. Moderated-differentiated adenocarcinoma was found in 166 (67%), well-differentiated 63 (25%), mucinous and poorly-differentiated in 18 (7%) of patients. Conclusions: We need to improve our methods to diagnose colon cancer better.

Necrosis de pene: Revisión de 18 casos en el Hospital de Especialidades Centro Médico nacional Siglo XXI

To report the experience in the management of penile necrosis at our hospital. We performed a review of the medical records with the diagnosis of penile necrosis at the Department of the Urology of the Hospital de Especialidades Centro Médico nacional Siglo XXI from January 1995 to March 2005. 18 cases of penile necrosis were found, with ages from 28 to 78 years (mean age 58.1 yr.). Diabetes mellitus and end stage renal disease were the most frequent associated diseases, with 10 and 11 cases respectively. Reasons for consultation were penile scars in 5 cases, purulent exudation, inflammation of the glans penis and prepuce in 3, ischemic priapism in 2, Fournier's syndrome in 2, urethral bleeding in one, penile necrosis secondary to extrinsic compression in one, and periurethral abscess in another. Thirteen out of the 18 cases underwent partial or complete penectomy, and three of them died. Five patients were managed conservatively with antibiotics, one of them died. The pathology report showed ischemic necrosis in 3 cases, arterial and venous thrombosis, ischemic necrosis and dystrophic arterial and venous calcifications in 10 cases. Occlusive vascular changes are a conditioning factor in most patients with penile necrosis. This is more evident in patients with end stage renal disease, diabetes mellitus and hypertension. Clinical features of penile necrosis include scars, mummification, self-amputation, and superinfection, so that an early diagnosis and proper treatment are decisive for the evolution of this disease.

Extraperitoneal Surgical Approach in Two Cases of Fournier Syndrome with Extensive Pelvic and Retroperitoneal Abscesses

Extraperitoneal Surgical Approach in Two Cases of Fournier Syndrome with Extensive Pelvic and Retroperitoneal Abscesses

ＨＩＶ感染者に発症したＦｏｕｒｎｉｅｒ症候群の１例

症例は53歳男性,35年前に痔瘻手術,その後数年に一度肛門周囲膿瘍の切開術を受けていた.平成14年1月,肛門痛が再発し前医で切開を受けたが奏効しないため受診.CTで骨盤直腸窩膿瘍と診断しドレナージ術施行したが,術後6日目より肛囲組織に壊死を確認,その後壊死部は徐々に拡大し発熱もみられたが,全身状態が急激に悪化することはなかった.CTで膿瘍の残存を疑い術後18日目に再ドレナージ術および人工肛門造設術を施行したが小膿瘍腔を数カ所認めるのみで,術後も壊死部は拡大,DICとなった.再手術後14日目にCTでFournier症候群と診断,大阪大学特殊救急部に転院,HIV抗体陽性が確認された.デブリードメント,高圧酸素療法等施行されるも敗血症を併発,2ヵ月後に死亡した.本症例ではFournier症候群がHIV感染症の初発症状と考えられた.また,今後HIV感染症はFournier症候群の基礎疾患として重要度を増してゆくものと予想され,注意が必要である.

The first cut is the deepest? Medicolegal aspects of male circumcision.

The first cut is the deepest? Medicolegal aspects of male circumcision.