Fournier’s Gangrene and Negative Pressure Wound Therapy: A Case Report

Introduction. Fournier’s gangrene is a rare disease that affects the genital, abdominal, and perineal regions and leads to death if not treated promptly. Case Report. A 42-year-old, obese woman presented to the authors’ department affected by Fournier’s gangrene. In order to treat her abdominal and genital regions, the authors performed a surgical debridement followed by combined therapy with antibiotics and topical negative pressure wound therapy (NPWT) with instillation plus saline solution. Results. The combined therapy, but most of all the application of the NPWT, cleaned and decontaminated the wounds. As a direct result of this decontamination, after 20 days, the patient was able to undergo surgery; after 40 days of follow-up, there was no sign of recurrence. Conclusion. Negative pressure wound therapy can be a good and useful treatment in the therapy of serious diseases and for the wound bed preparation in advance of surgery.

Fournier’s gangrene is a rare disease first mentioned in 1764 by Baurienne. In 1883, Jean Alfred Fournier, a French dermatologist, described it as a fulminant idiopathic necrotizing fasciitis of the genital region. Today, this disease has been associated with a local infection of the genital, perineal, and abdominal regions, which can progress to gangrene within hours; in 20% of cases the patient dies.¹ Obese patients and men aged 50 to 60 years are the most frequently affected patients.

This form of gangrene can be related to aerobic and anaerobic bacteria as Streptococci, Escherichia coli, Staphylococci etc. These microorganisms produce enzymes as collagenase, heparinase, streptokinase and others, which can destroy the tissues causing an obliterative endoarteritis and thrombosis of subcutaneous arteries. Unfortunately this disease is also featured by a late diagnosis and a late surgical treatment (ie, after the first 6 hours), due to the absence of early, clear symptoms (unspecific pain, no localized signs of infections). In order to obtain a good wound bed preparation, hyperbaric oxygen therapy (HBOT) or topical negative pressure can be used.²

A 42-year-old, obese woman (body mass index 55 kg/m²), with Fournier’s gangrene in the abdomen, the genital (the left labium majus), and the perineal regions, came to the authors’ department (Plastic Surgery Clinic) after 13 days from a previous admission in another hospital, where she underwent 2 sessions of surgical debridement and a cycle of HBOT. During admission in the authors’ facility, in order to have good wound bed preparation, the authors used a combination therapy of 1) antibiotic therapy with clindamycin 600 mg twice daily and piperacillin/tazobactam 4.5 g four times daily for the presence of E. coli; and 2) after 1 week, surgical debridement with negative pressure wound therapy (NPWT) with topical instillation plus saline solution (V.A.C. Ulta Negative Pressure Wound Therapy; KCI, An Acelity Company, San Antonio, TX) (pressure: -100 mm Hg; duration of cycle: 3.5 hours) was performed. The vacuum-assisted wound closure (VAC) system was changed 3x/week. After 15 days the authors ceased using VAC and substituted with daily dressing changes and with amukine 0.05%.

The use of combined therapy (antibiotics and NPWT) cleaned and decontaminated the wound of E. coli (Table 1); it demonstrated overall reduction of inflammation markers as erythrocyte sedimentation rate (Figure 1) and leukocytes (Figure 2). After 20 days of treatment, the necrotic tissue was surgically removed. At postoperative day 40, there was no sign of recurrence, and scarring was also good (Figure 3).

Fournier’s gangrene is a localized necrotizing fasciitis accompanied by pain, swelling, and erythema of the perineum and genitalia. Unfortunately, unclear symptoms at the first stages can delay the patient from seeking medical attention, leading to a late diagnosis and treatment that has an increased risk of morbidity and mortality.

Since 1883, studies have identified predispositions to Fournier’s gangrene, including diabetes, obesity, immunosuppression, poor urogenital hygienic condition, as well as the prognostic factors³ such as the age, comorbidities, progression of the disease, mean duration from onset of the symptoms to hospital admission, and gender.  The syndrome is typically seen in more men than women, with a ratio of 10:1. However, Czymek et al⁴ and Ho et al⁵ found that females could be a risk factor for mortality. According to both research teams, females have a high incidence of inflammation of the retroperitoneal space and abdominal cavity.  This great incidence and the rapid spread of infection can be explained with the female anatomy alone. Where the male genitalia are mostly outside the body, the female genitalia are mostly inside, which is a direct connection with the abdominal cavity via the fallopian tubes with an early consequent fatal outcome after 3 days from admission. 

In order to increase the chance of survival, it’s incumbent to immediately treat patients. It is necessary to remove all necrotic tissue and to clean the wounds using, if necessary, different therapies. In the authors’ case, NPWT plus saline solution was necessary for their patient and promoted quicker wound healing than traditional dressings. This treatment allowed them to perform surgery on healthy tissue with no recurrence to date. 

It is the opinion of the authors that the NPWT can be recommended to treat serious diseases in order to 1) obtain visible wound bed preparation before surgery; 2) increase the wound healing; and 3) decrease potential complications.

Affiliation: Clinic of Plastic Surgery, University of Padova, Padova PD, Italy

Correspondence:
Carlotta Scarpa, MD, PhD
Clinic of Plastic Surgery
University of Padova
Padova, Italy
carlotsc@tin.it 

Disclosure: Dr. Scarpa received personal fees and non-financial support from Storz Medical Italia, Roma, Italy. Dr. Bassetto received personal fees and non-financial support from KCI, an Acelity company, San Antonio, TX. The authors disclose no financial or other conflicts of interest.