Fournier’s Gangrene Does Not Spare Young Adults

Introduction. Fournier’s gangrene is a rare but severe form of necrotizing fasciitis, primarily affecting the perianal, genital, and perineal regions. It is a rapidly progressive disease and can be potentially fatal; therefore, it should be treated as an emergency. Case Report. Presented herein is the case of a 30-year-old man, without significant medical history, who presented to general surgery with complaints of swelling and pain in the gluteal area. The patient underwent emergency surgery on the day of admission to the emergency department where excessive fasciectomy and necrectomy were performed; broad-spectrum parenteral antibiotic therapy also was administered. Conclusions. Fournier’s gangrene is a surgical emergency, and the main cornerstones of treatment are patient resuscitation, broad-spectrum parenteral antibiotic therapy, and, most importantly, surgical debridement. Any delay in treatment can dramatically increase mortality.

Fournier’s gangrene is a rare but severe form of necrotizing fasciitis, primarily affecting perianal, genital, and perineal region.¹ It is a rapidly progressing disease that can be potentially fatal; therefore, it should be treated as an emergency.² Men are more often affected than women, with a ratio of 10:1, and the disease can affect people of all ages (mean age, 50 years).³ The incidence of the disease is estimated at 1.6 men per 100 000. Mortality rate remains high at 20% to 40% despite improvements in medical care.⁴

Presented herein is the case of a 30-year-old man, without significant medical history, who presented with swelling and pain in the gluteal area.

A 30-year-old man without significant medical history presented to the outpatient clinic of the Department of Surgical Infections, University Medical Centre Ljubljana (Slovenia), complaining of swelling and pain in the gluteal area. The patient stated that he fell down the stairs 3 days prior. He mentioned he had a perianal abscess in that area in the previous medical history, but not on the day of inspection. He received antibiotics (clindamycin 600 mg every 8 hours and ciprofloxacin 500 mg every 12 hours) for 10 days and then was discharged home.

One day following discharge, he returned to the Emergency Services Department of the University Medical Centre Ljubljana with a high axillary temperature of 38°C and pain and swelling extending to the scrotum and pubic area (Figure 1). His blood pressure was 93/53 mm Hg and heart rate was 109 bpm. Clinical examination revealed swelling and redness of the skin in the inguinal, perianal, and scrotal areas with a 2-cm wound on the right side of the gluteus. Initial laboratory exam showed elevated levels of white blood cells (32.5 x 10⁹/L [normal value 4.0–10.0 x 10⁹/L]), C-reactive protein (362 mg/L [normal value < 5 mg/L]), and procalcitonin (24.83 µg/L [normal value < 0.5 µg/L]). Computed tomography (CT) scan showed fluid collection in the perineum and massive emphysema that extended posteriorly to the gluteal area. Fluid collection extended anteriorly to a massively edematous scrotum and testes. Signs of local inflammation were seen in the left groin area.

The patient was urgently operated on the day of admission to the emergency department, and excessive fasciectomy and necrectomy were performed (Figures 2, 3, 4). Soft tissue samples were intraoperatively sent for pathohistological and microbiological examination. He suffered acute kidney failure before surgery. Intravenous imipenem/cilastatin 500 mg every 6 hours and intravenous clindamycin 600 mg every 8 hours were administered for the following 10 days. Two days after surgery, Esherichia coli, Bacteroides fragilis, Prevotella oralis, and Streptococcus anginosus were isolated from fascial tissue. Pathohistological changes confirmed necrotizing fasciitis. On postoperative day 3, an additional necrectomy was performed, and wounds were covered with an alginate dressing (Kendall; Medtronic, Minneapolis, MN) (Figure 5). Systemic inflammatory indicators decreased (white blood cells to 13 x 10⁹/L, C-reactive protein to 46 mg/L, and procalcitonin to 0.1 µg/L) followed by delayed closure of the wound with sutures on postoperative day 12. Later, on postoperative day 13, the patient admitted he did not fall down the stairs but instead rode for 10 hours on a motorbike.

On postoperative day 16, he was afebrile with stable cardiopulmonary functioning and was discharged home from the hospital (Figure 6). The first follow-up visit was 2 weeks later to remove wound stitches; additional follow-up visits occurred monthly for the next 6 months. During this time, the patient did not have any functional or neurological deficits and he did not develop a relapse of the infection.

Proper recognition of the clinical picture and diagnosis is crucial for effective treatment of Fournier’s gangrene. It is difficult to diagnose in the early course of the disease when only modest changes can be seen externally. The patient herein did not honestly relay his entire history of prolonged motorbike use, which caused elevated pressure on the tissue and reduced blood flow, allowing the infection to spread faster. Hemodynamic stabilization, administration of broad-spectrum antibiotics, and early surgical therapy are modalities that can improve survival of patients.

Etiology and pathogenesis

At first, Fournier’s gangrene was thought to be idiopathic, but research has shown that < 25% is now considered idiopathic.⁵ The disease often stems from perirectal and perianal abscesses as well as from infection and trauma to genital skin.^5-7 In 95% of cases, the primary site of infection cannot be identified.³

Diabetes has been identified as a predisposing factor in up to 66% of cases.⁶ The microorganisms that cause Fournier’s gangrene are normally found in the genital and anal areas. The most common bacteria are Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, and Bacteroides fragilis.⁵ In some studies, cultures have shown there can be more than 3 organisms present in the wound.^5,7 Recently, a case of Fournier’s gangrene caused by Candida spp and Lactobacillus gasseri was reported.⁵

The main pathological feature is obliterating endarteritis, which results from inflammatory response to microorganisms. Obliterating endarteritis with vascular necrosis leads to local ischemia and promotes further spread of bacteria.⁵

The spread of infection is determined by the fascial anatomy and the entry location. Infection can ascend cranially through the fascia to the torso or descend caudally to the thigh.⁶ The superficial Colles’ fascia is connected to the penis and scrotum through Buck’s fascia and dartos fascia and to the anterior abdominal wall through Scarpa fascia. Therefore, the spread of infection can follow all these routes. In the posterolateral part, Colles’ fascia is connected to pubic rami, fascia lata, and urogenital diaphragm, so the progress of the disease in this direction is limited.

Testicles are rarely affected due to the blood supply that comes from the aorta.⁶ Penile skin sloughs off, but involvement of corpora is rare.⁵

Signs and symptoms

The disease presents as cellulitis in its first stage. The infected area is red, swollen, and painful, and sometimes there can be a purulent discharge.⁵ Crepitus is common when the causative microorganism is a gas-forming anaerobic bacteria.⁴ But as opposed to cellulitis, systemic signs of infection are often present, such as fever > 38°C, tachypnea, tachycardia, and changes in mental state.^5,7

Within a few hours, the disease progresses rapidly, leading first to skin discoloration and later to purulent discharge and necrosis.⁷ Patients can rapidly deteriorate to sepsis and multiorgan failure.⁵

Diagnostics

History of trauma and invasive urologic diagnostics can help in further evaluation. Clinicians should ask the patient about any recto-anal problems, such as hemorrhoids, anal fissures, or any other infection in the genital area. The diagnosis of Fournier’s gangrene is based on clinical features; therefore, clinical examination is crucial in patients that are prone to the disease or have risk factors.

Laboratory findings are not specific and include anemia, azotemia leukocytosis, thrombocytosis, electrolyte imbalances, hypoalbuminemia, hyperglycemia, and elevated creatinine levels.⁵ In one of the studies, significant levels of alkaline phosphatase and albumin at admission were indicated in mortality prediction.⁴

Ultrasound has a very high sensitivity and is superior to conventional x-ray imaging. It shows a thickened, edematous scrotal wall containing hyperechogenic foci that represent gas in the scrotal wall. Doppler ultrasound examination of blood flow also can be useful in diagnosis. These examinations can differentiate Fournier’s gangrene from other scrotal pathologies.^5,6

Conventional x-ray imaging can show thickened soft tissue as well as presence of subcutaneous emphysema extending from the perineum and external genitalia to the thigh and anterior abdominal wall. The absence of emphysema does not rule out the disease.^5,6

The main aim of CT is identifying the origin of the infection and delineating the extent of the disease. The pathological features of Fournier’s gangrene include soft tissue thickening and inflammation. A CT scan also can demonstrate fascial thickening, fluid collection, abscesses, and subcutaneous emphysema.^5,6,8 The extent of fascial thickening and fat stranding seen on CT scans has been found to correlate well with the affected tissue at surgery.⁸

Even though magnetic resonance imaging is great for soft tissue imaging, it is not used very often, mainly because of longer scan times.⁶

Management

Fournier’s gangrene is a surgical emergency, and the main 3 cornerstones of treatment are patient resuscitation, parenteral broad-spectrum antibiotic therapy, and, most importantly, surgical debridement. Any delay in the treatment can dramatically increase mortality.

Broad-spectrum parenteral antibiotics that can later be adjusted according to the results of the bacterial culture and sensitivity of microorganisms are required. Typically, broad-spectrum penicillin or third-generation cephalosporins, an aminoglycoside and metronidazole, or clindamycin are administered empirically.⁵

Surgical debridement and drainage need to be performed as soon as possible. Even tissues with a doubtful viability should be excised, otherwise they can cause even greater necrosis of the genital region and spread to other areas of the body.⁴ It has been suggested that an average of 3.5 debridement operations are necessary for infection control.⁶

Negative pressure wound therapy (NPWT) has been proven to speed up the healing process of lesions and minimize skin defects.⁴ Patients treated with NPWT also had a lower mortality.⁵

Debridement can leave behind large defects of tissues in previously infected areas. Therefore, plastic reconstruction is often necessary.⁶

Fournier’s gangrene is a rare but rapidly progressive disease that mostly affects men with certain risk factors. Despite all progress in medical care, it still remains a disease with high mortality. The initial debridement of necrotic tissue is the most important factor for survival.

The authors thank the colleagues and personnel of University Medical Centre Ljubljana, Slovenia.

Affiliations: Department of Surgical Infections, University Medical Centre, Ljubljana, Slovenia; and Medical faculty, University in Ljubljana, Ljubljana, Slovenia

Correspondence: Danijela Semenič, MD, PhD, UKC LJ, Zaloška cesta 7, 1000 Ljubljana, Slovenia;
danijela.semenic@kclj.si

Disclosure: The authors disclose no financial or other conflicts of interest.