Case Report: Implications for a Patient Diagnosed with Fournier’s Gangrene

Introduction Fournier’s gangrene (FG) is a type of necrotizing fasciitis (NF). FG specifically involves the perineum and is a rare mixed aerobic and anaerobic soft-tissue infection. FG generally causes the perineal tissue to slough; in male patients, this includes the skin, subcutaneous tissue, and fascia of the scrotum and penis.1 Risk factors for the development of FG include advancing age, malnutrition, obesity, alcoholism, intravenous drug use, diabetes mellitus, peripheral vascular disease, and immunosuppression.2–8 Patients at risk for FG typically have at least one comorbidity that results in some degree of debilitation, hypo-perfusion, or compromised host immunity.3,9–11 Etiology Usually local trauma or instrumentation creates a portal that allows skin flora to enter the subcutaneous tissue, which results in infection, although some cases of FG present without a clear mode of injury. Signs and Symptoms Signs and symptoms of FG include severe pain, nondemarcated wound edges, systemic toxicity, nausea, diaphoresis, vomiting, rigors, cloudy urine, dehydration, and cachexia.1,9,11–14 Wall, et al., found that tense edema and the presence of skin bullae are predictive physical examination findings, and elevated white blood cell count, elevated serum sodium levels, and elevated chloride levels are predictive lab findings of FG.15 Pathophysiology FG is most commonly caused by a polymicrobial infection of aerobic and anaerobic organisms, which are most often clostridium species, streptococci, and enterobacteriaceae.16 The destruction of tissue by bacteria results in the formation of gas and a foul odor. The advancement of necrosis into muscle tissue is apparent with a rise in creatine phosphokinase levels. Once thrombosis causes blood supply to be compromised, the skin turns blue-gray in color, bullae form, and the skin becomes anaesthetic, gangrenous, and may begin to slough.2,15,17–22 This extensive tissue death prevents penetration of antibiotics into the affected tissue, requiring extensive debridement.12,18,19,23 Medical Management Several diagnostic tools assist physicians in the medical management of FG. Although definitive diagnosis may only be made in the operating room when the typically adherent fascia shows no resistance to the blunt dissection of a probe, blood culture is an inexpensive initial method used to determine microbiology allowing for proper antibiotic coverage.14 A blood test is used to determine elevated levels of creatine phosphokinase, alerting physicians to the advancement of necrosis into the muscle tissue.7,18,24,25 Although radiographs are used to reveal subcutaneous air to determine the spread of the infection, computerized tomography (CT) scans more clearly establish the extent of the infection and allow for surgical management planning.6,14,20,22,26 Medical treatment of FG requires appropriate antibiotic therapy, monitoring of the level of electrolytes to prevent shock, doubling or tripling nutritional intake to prevent the loss of lean muscle mass, and care of preexisting comorbidities.12 Surgical debridement of all nonviable overlying skin, subcutaneous fat, and fascia should be prompt, extensive, and aggressive for managing and preventing the progression of FG.6,8,11,12,21,27,28 Without debridement of all necrotic tissue in a FG soft-tissue infection, the patient is at great risk for death.15,22 Subsequent debridements are necessary to ensure the wound bed is clean, which enhances the development of granulation tissue and allows for the application of a split-thickness skin graft (STSG) to provide wound closure.12,18 Physical Therapy Management For the physical therapist (PT), wound assessment and management to maximize tissue healing while also minimizing the risk of infection is of primary importance. In addition, the PT also addresses the patient’s functional mobility deficits to ensure the patient regains his or her level of function and the highest quality of life possible.29 Case Description Hospital admission and initial medical management. The primary complaints of the patient, a 51-year-old African American man, were pain of the groin and right lower extremity, fever, chills, nausea, and vomiting. The etiology was unclear as the patient denied any recent genitourethral trauma or instrumentation. The patient reported a history of alcohol and tobacco use. At the time of admission, the patient was taking insulin for diabetes control, several retroviral drugs for his human immunodifficiency virus (HIV)-positive status, and over-the-counter analgesics for the groin and right lower-extremity pain. The patient’s most recent viral load value was found to have increased from 41,677 HIV ribonucleic acid (RNA) copies/mL of plasma in 1998 to 86,444 HIV RNA copies/mL of plasma in 1999. Subsequent values were not available. The risk of death for a patient diagnosed with HIV increases by approximately 50 percent with every three-fold increase of his or her viral load.12 Thus, this increase did not indicate the patient was at great risk for the progression of his HIV status. The patient’s most recent CD4 count, or number of CD4 circulating lymphocytes, was obtained in August of 1999 and was low when one considered the normal range of 750+/250 cells/µL.12 A CD4 count of less than 200 CD4 lymphocytes/µL places a patient at great risk for opportunistic infections.12 See Table 1 for specific viral load and CD4 values. The patient was found to be hypotensive and tachycardic. Emergency room staff reported tense edema of the scrotum, the presence of black necrotic tissue on the left scrotum, and scrotal sloughing throughout. Blood values revealed an increased number of white blood cells, which indicated the presence of an infection or host immune response (Table 2). Blood tests also indicated an increased level of creatine phosphokinase, which signals necrosis of muscle tissue. All of these findings were significant as they suggested FG. The patient was taken to the operating room the day of admission for exploratory incision and debridement. Surgical debridement of the scrotum, penis, and lower abdominal wall was performed, as was a left orchiectomy (Figure 1). Cultures of tissue and fluid from the scrotal area were positive for the presence of multiple bacteria, including streptococcus and gram-negative bacteria. The following day, the patient was taken back to the operating room for a second surgical debridement, at which time additional necrotic tissue was excised (Figure 2). Physicians referred the patient to physical therapy with orders for evaluation and treatment. The patient received twice daily wound care, which included debridement and moist gauze dressings, until hospital day 18, when he received final surgical debridement and placement of a STSG by a plastic surgeon. Throughout the patient’s 29-day hospitalization, physicians and nurses monitored his diabetes and HIV status closely, as each greatly affected his healing potential. Nursing staff checked blood glucose levels four to six times daily and followed the sliding scale specified by his physicians. The patient was put on a 2200-calorie diabetes diet plan and was given a diabetic resource drink to promote wound healing. HIV medications were discontinued temporarily as they have the potential to cause a hyperglycemic state. Complications that arose throughout hospitalization included septic shock and an unexplained spiking of the patient’s temperature. The development of septic shock following surgical debridement required the provision of intravenous fluids accompanied by strict input and output monitoring. As part of the septic shock, the patient experienced atrial fibrillation and subsegmental atelectasis. The atrial fibrillation resolved following administration of digoxin, and the subsegmental atelectasis was determined to be a premorbid condition that did not pose a threat to the patient’s recovery. Additionally, the patient began experiencing temperature spikes of an unknown cause. Fearful it was due to the presence of an undetected abscess, the medical team ordered pelvic x-rays and CT scan, which ruled out an abscess. No specific cause was found for the temperature spikes, but physicians ultimately determined it was likely a reaction to prescription medications. Inpatient Physical Therapy Management Inpatient physical therapy wound care. On hospital day two, the PT completed an initial evaluation, which included examination of the wound. The wound borders were 10cm proximal to the penis with a 15cm diameter and included the penis circumferentially as well as the scrotum. Undermining was present on the left and right proximal edge of the wound extending 8cm and 5cm, respectively. There was a copious amount of sanguinous drainage present. No odor was noted. The wound bed appeared clean and red throughout with the exception of a small area of black necrotic tissue observed at the base of the penis, which constituted approximately 10 percent of the wound. The periwound was intact. Mild edema and decreased sensation were noted throughout the wound. The patient reported adequate pain control with use of a morphine patient-controlled analgesia pump. PT wound care consisted of twice daily dressing changes for the daily mechanical debridement and, as needed, sharps debridement of necrotic tissue, irrigation of the wound using warm 0.025-percent sodium hypochlorite solution, and application of gauze to decrease the risk of infection and promote healing during the first week of care. The plan of care was changed on hospital day seven, discontinuing the use of 0.025-percent sodium hypochlorite solution and initiating the use of 0.25-percent acetic acid solution for the control of Pseudomonas aeruginosa. On hospital day 13, a zinc oxide periwound protective ointment was added to the plan of care for the prevention of periwound tissue maceration. On hospital day 20, the wound bed was clean with granulation tissue present (Figures 3 and 4), and the STSG was applied by the plastic surgeon to the penis and scrotum. Following surgical placement of the STSG, the surgical dressing remained intact for five days until hospital day 25, when the plastic surgeon removed the dressing and discharged care of the intact STSG to nursing. Inpatient physical therapy functional training. On hospital day three, the patient’s functional mobility was evaluated. The PT assessed the patient to require minimal assistance for bed mobility, transfers, and gait training. The patient received physical therapy twice daily for therapeutic activity and gait training. The patient’s functional mobility progressed without complication. The patient was discharged after nine days of care by the PT, who addressed the patient’s functional mobility deficits, which ensured the patient was independent with functional mobility upon release. Inpatient physical therapy patient education. Patient education was primarily addressed by teaching the patient the importance of maintaining a clean wound as well as the clean technique for applying the wound dressing. The PT also educated the patient on the risks of developing hip flexion contractures if he continued to maintain a flexed posture. Concurrently, nursing staff educated the patient on the proper use and care of his foley catheter to decrease the risk of contamination of his wound. Outpatient Physical Therapy Management Outpatient physical therapy wound care. The patient was seen three times per week for four weeks in outpatient physical therapy. Upon his first visit, the patient was found to have moderate serosanguinous drainage on the remaining one layer petroleum-impregnated gauze and his clothing, as he had removed the gauze portion of his dressing prior to his appointment. The PT documented the presence of a foul odor and that the patient had assumed a flexed posture. Staple lines were approximated along the abdomen, and the sutures between the scrotum and anus were intact. Slight tissue separation was found along the base of the penis with a small, black necrotic area. The donor site of the left thigh was healed. Treatment included twice-daily spray and wipe method utilizing 0.25-percent acetic acid solution to moisten the wound and a sterile cloth for the debridement of the nonviable tissue to patient tolerance. The wound was covered with gauze soaked in warm 0.25-percent acetic acid solution and covered with dry gauze and cotton mesh underwear to hold the dressing in place. The plan of care was altered on outpatient day six to address the presence of black necrotic tissue at the base of the penis. Sharp debridement and the application of an enzymatic debridement ointment were added to the plan of care to hasten the removal of the necrotic tissue at the base of the penis. On outpatient treatment day seven, the patient again arrived with dressings soaked in urine and sweat. Due to patient noncompliance with his dressing changes and hygiene, the patient was reeducated on the importance of keeping his wound clean and free from contaminants by showering daily, cleaning his wound, and reapplying the dressings. Whirlpool at a temperature of 98? to 101?F for 15 to 20 minutes was added to the plan of care to ensure adequate cleansing of the perineum. Following these changes to the patient’s plan of care, the rate of healing improved dramatically. The physical therapist documented the wound was composed of approximately 50-percent viable tissue and 50-percent nonviable tissue on outpatient treatment day 12. By treatment day 16, the percentage had increased to approximately 90-percent viable tissue. On outpatient day 23, a small abscess in the area inferior to the penis was discovered. The PT expressed 20cc of purulent drainage and was instructed by the physician to wick the opening of the small wound using quarter-inch gauze to minimize the risk of infection and prevent further delay in healing. The small abscess healed without complication and the patient was discharged from outpatient physical therapy. The patient was instructed to attend his scheduled appointments at the outpatient urology, surgery, and plastic surgery clinics, as well as to resume care at the outpatient HIV/AIDS clinic. Conclusion The patient of this retrospective case report realized very favorable outcomes despite his life-threatening diagnosis, comorbidities that challenged his healing potential, and complications that arose following surgical debridement. The outcomes were a direct result of the comprehensive care delivered by the members of the interdisciplinary team, as ordered by the physicians overseeing the patient’s case. Physicians were required to initiate an aggressive treatment plan that began due to the destructive nature of FG. This included diagnostics, wide selective debridement of all necrotic tissue, and the use of appropriate antibiotics. The debridement of all necrotic and infected epithelial, adipose, fascia, and muscle tissue was required to eradicate the further spread of infection along the fascial planes. Failure to do so in a timely manner often results in the death of a patient diagnosed with FG. Following the surgical debridements and in preparation for STSG, the PT wound care team began twice-daily treatments including debridement and moistened gauze dressings in order to minimize the further risk of infection while maximizing tissue healing. The PT plan of care for the wound was altered several times to control Pseudomonas aeruginosa, a macerated periwound, and the presence of black necrotic tissue, all of which had the potential to delay healing. The use of 0.025-percent sodium hypochlorite, 0.25-percent acetic acid, a zinc-oxide periwound protective ointment, and an enzymatic debrider contributed to the positive outcome. Although the use of most topical antiseptics has long been debated, the patient exhibited positive outcomes with the initial use of 0.025-percent sodium hypochlorite and later for the control of Pseudomonas aeruginosa with 0.25-percent acetic acid. At either concentration, research is mixed with most clinical research studies concluding that these topical antiseptics are cytotoxic. Heggers reported that 0.025-percent sodium hypochlorite was bactericidal and nontoxic in vitro as well as in vivo.30 In regards to the 0.25-percent acetic acid, it was found to be bactericidal but also toxic in vitro and in vivo.30 Lineaweaver reported that 0.25-percent acetic acid decreased bacterial survival by only 20 percent for cultured human fibroblasts and was more damaging to fibroblasts than bacteria.29 Despite the presented clinical research findings, the use of these topical antiseptics were advantageous for the patient of this retrospective case report, warranting further research. Likely due to the moderate to maximal drainage, the patient developed slight tissue maceration at the periwound on inpatient day 13. To prevent further maceration of the thin and fragile periwound tissue, a zinc-oxide protectant was added to the PT plan of care. Maceration was decreased and the periwound remained intact. The use of an enzymatic debrider was initiated due to the presence of black necrotic tissue at the base of the penis. The debrider contained enzymatic (papain) and nonenzymatic (urea) agents. Clinical research conducted by Alvarez revealed that an enzymatic debriders that contains both enzymatic and nonenzymatic agents resulted in a significant reduction of nonviable tissue in a shorter time period than the products composed of strictly an enzymatic agent.31 Although the research conducted by Alvarez was performed on pressure ulcers, this finding is clinically relevant for additional types of wounds.31 This point is illustrated by the dramatic improvement of viable tissue from outpatient day six to outpatient day 16, when viable tissue improved from 50-percent viable tissue to 90-percent viable tissue, respectively. Despite the favorable outcomes, there were additional modalities that could have been utilized for the treatment of this patient that may have further hastened his healing time. First, the use of high-voltage pulsative current (HVPC) for the promotion of wound healing has been shown effective for each stage of wound healing as it potentially enhances the natural changes of polarity during wound healing stages. As a result, healing time is decreased.32–34 Secondly, hyperbaric oxygen therapy (HBO) has been shown to be an option to be considered in the treatment of necrotizing infections. One study recorded a 66-percent death rate for patients who did not receive HBO, while those receiving HBO had a 23-percent death rate.35 It was also reported that fewer surgical procedures were required for those patients receiving HBO.35 The patient of this retrospective case report received quality care that allowed him to return to his prior level of function with full wound closure. Without this care, the patient would have likely become a fatality to FG. His diagnosis, comorbidities, post-debridement complications, and his noncompliance as an outpatient all challenged the healing potential of his wound. Despite these impediments, the patient regained his prior health and mobility.