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Y-K Wang, Y-H Li, S-T Wu, E Meng, Fournier’s gangrene, QJM: An International Journal of Medicine, Volume 110, Issue 10, October 2017, Pages 671–672, https://doi.org/10.1093/qjmed/hcx124
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Fournier’s gangrene is a lift-threatening disorder and surgical emergency. Image studies typically demonstrate gas accumulation in the affected region. Once recognized, aggressive resuscitation, broad-spectrum antibiotics and prompt surgery implemented.
Case report
An 83-year-old woman, with a history of type two diabetes, presented to our emergency department with a 5-day history of supra-pubic pain and fever. Physical examination revealed redness, swelling, tenderness and crepitus over the right lower abdomen, extending to the right groin region. Laboratory test showed a C-reactive protein level of 258 mg per litre and a leukocyte count of 8.6 × 103 per litre. The abdominal radiograph (Figure. 1A, arrowheads) revealed a radiolucent area over the right side hip region, raising the suspicion of subcutaneous emphysema. The following computed tomography (CT) of the abdomen showed abnormal air collection in the right groin region (Figure. 1B, asterisk). Under the impression of Fournier’s gangrene, empiric broad-spectrum antibiotics were given and the patient underwent an extensive debridement. Cultures of pus from the patient’s abdomen wall showed Morganella morganii and Proteus mirabilis, which were both gram-negative and anaerobic bacterium. The patient recovered and the wounds were closed after a 20-day treatment during hospitalization.
Discussion
Fournier’s gangrene was a relative rare life-threatening urological emergency with an overall incidence rate of 1.6 in 100 000 and male predominance.1 The most common predisposing factors included diabetes mellitus and obesity; other risk factors were chronic alcoholism, renal failure, liver failure, smoking, malignancy and human immunodeficiency virus infection.1 The mortality rate was as high as 88% in the 1970s and decreased to 7.5–16% in the 2000s.2 Three most common pathogens included polymicrobial infections with mixed aerobes and anaerobes (54%), Escherichia coli (46.6%) and Streprococcus (36.8%).3
Typical clinical manifestations included fever, pain and swelling over the perineal, genital and anorectal areas. Because the pathogenic microbiology could be gas-forming organisms, the other common clinical features were crepitus due to pockets of gas extending from the perineum to anterior abdominal wall and even clavicles. The cornerstone of the diagnosis of Fournier’s gangrene mainly depended on the thorough physical exams and clinical assessments. Several laboratory and image studies were helpful tools for confirmatory diagnosis, risk stratification and surgical planning. For example, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, based on haemoglobin, white blood cell count, sodium, creatinine, glucose and C-reactive protein, was a useful adjunct in the clinical assessment to distinguish necrotizing fasciitis from soft tissue infection.4 Image studies, especially CT with highest specificity for the diagnosis of Fournier’s gangrene, were valuable to determine the extent of the disease.2 Taking our case as an example, radiography was the least costly facility and could provide the information of soft-tissue gas accumulation by radiolucency before presentation of crepitus on physical examinations. The limitation of radiography was the inability to detect the gas in the deep fascia.2
Immediate diagnosis and expedited treatment, including fluid resuscitation, broad-spectrum antibiotics and surgical debridement, were all critical for decreasing mortality. Both hyperbaric oxygen and the use of vacuum-assisted closure system dressing with negative pressure played some roles in shortening the healing period and reducing the length of hospital stay.2 After successful control of the systemic illness and optimization of the wound condition, further reconstruction for the genitalia and perineum could be considered for better functionalities and quality of life.
Conflict of Interest: None declared.