Fournier's gangrene: a review of 1726 cases

Fournier’s gangrene

A hímvessző fulmináns gangrénáját Fournier több mint 200 éve leírta, kezelését illetően azonban fennállnak bizonyos ellentmondások. A betegséget ma már nem tekintjük idiopathiásnak, mert a legtöbb esetben urológiai, colorectalis vagy bőreredetű forrás kimutatható. A halálozási arány továbbra is magas, különösképpen kiterjedt folyamatok esetén. Hajlamosító tényezőnek tekintjük a cukorbetegséget, az alkoholizmust és az immunszuppressziós állapotokat, különös tekintettel a HIV-fertőzésre. A Fournier-gangréna kórisméje alapvetően a klinikai képen nyugszik, a genitoanális tájékon jelentkező súlyos, heveny gyulladásos folyamatokat indokolt a Fournier-gangréna kiindulási helyzetének tekinteni. Sürgős kezelés szükséges, amely az aerob és anaerob kórokozók ellen egyaránt hatékony, széles spektrumú antibiotikum-kezelést és a szeptikus állapotban lévő betegek intenzív osztályos ellátását igényli. Az azonnali sebészi beavatkozás elengedhetetlen: az elhalt szövetek kimetszése és az elégséges drenázs biztosítása. A sebészi kezelés rendszerint ismétlendő, majd a végleges szövethiány pótlása esetenként már speciális helyreállító, plasztikai műtéttel lehetséges.

Fournier's gangrene: is the female gender a risk factor?

OBJECTIVE

Fournier's gangrene is a necrotizing fasciitis that affects the perineal, genital, or perianal regions. The objective of this study was to highlight this uncommon condition with a particular focus on the disease course in females.

MATERIALS AND METHODS

From 1996 to 2008, we prospectively collected data from 38 patients with Fournier's gangrene (12 women, 26 men) and retrospectively analyzed relevant parameters.

RESULTS

The mean age was 60.9 +/- 11.3 years for females (group I) and 56.2 +/- 11.7 years for males (group II). In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). Twelve men (46.2%), but no women, had chronic alcoholism. The most commonly isolated agents were Escherichia coli (n = 22), streptococcal species (n = 18), Pseudomonas aeruginosa (n = 9), and Staphylococcus aureus (n = 7). Mortality was significantly higher among females (50%) than males (7.7%; p = 0.011). Peritonitis was present in seven group I patients (58.3%) and in two group II patients (7.7%). The retroperitoneum was involved in seven female patients (58.3%) and four male patients (15.4%).

CONCLUSION

The female gender is a risk factor for mortality in patients with Fournier's gangrene and is associated with a higher incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and the fatal outcome in women. Fournier's gangrene as a high-risk disease in females should attract exceeding attention.

Complication of a closed Colles-fracture: necrotising fasciitis with lethal outcome. A case report

We report a case of a 77-year-old female patient who died 4 days after a closed colles-fracture of the right wrist because of secondary emerged necrotising fasciitis. At the time of visiting our emergency department, the patient reports about untypical pain and progressive swelling of the entire right arm 3 days following a fall onto the outstretched hand where she sustained a closed distal radius fracture. Within 6 h, the patient developed hypotension and fever leading to cardiac and respiratory failure. The emergent-induced diagnostic presented a severe septic situation in the laboratory examination of the blood samples, an apparent before unknown diabetes mellitus and an unknown bronchial carcinoma with part of post-stenosis pneumonia of the right lung. After initial CPR and stabilisation, the patient underwent an urgent and aggressive surgical debridement with fasciotomies of the muscle compartments of the entire right upper extremity. The microbiological investigation of the intraoperative taken specimens presented plentiful group-A-beta-haemolytic streptococcus. Despite a broad spectrum intravenous antibiotic therapy, intensive care support and a second look operation 12 h later with exarticulation of the right arm in the shoulder joint, the patient died of septic shock and multiorgan failure 34 h after admission.

Recurrent Fournier's gangrene in a diabetic patient

Introduction. Fournier's gangrene (FG) is a fulminant form of infective necrotizing fascitis of the perineal, genital, or perianal regions caused by anorectal or urogenital and perineal trauma, more common in patients with diabetes mellitus and alcohol misuse. Despite contemporary management, mortality is still high and averages 20-30%. Case Outline. A 53-year-old extremely obese diabetic postmenopausal woman with the history of poorly regulated insulin-dependent diabetes mellitus lasting for 20 years, and gangrene followed by autoamputation of minor labia a year ago, was admitted due to severe suprapubic pain and septic fever. Gynaecological examination revealed suprapubic abscess spontaneously perforated few hours prior to admission. Contraincision was performed and purulent green-yellowish discharge appeared. Microbial evaluation of the obtained specimen identified Peptostreptoccocus, Enterococcus and E.coli. Antibiotics were administered according to the sensitivity test and suprapubic tumour formation was irrigated and drained. The procedure lasted seven days and resulted in the healing of the pathological process. Conclusion. FG is still a life-threatening condition; so, diagnosis should be prompt with early surgical intervention, along with antibiotics and good supportive care. Proactive management of the diabetic patient with perineal infections is of extreme importance, in order to prevent the development of FG, the entity associated with very high mortality. According to the literature data available, this is the first reported case of FG relapse.

Fournier's gangrene

BACKGROUND

Fournier's gangrene (FG) represents a necrotizing infection of the skin and subcutaneous soft tissue of the external genitalia and perineum. It arises as a result of propagation of anorectal, urogenital and skin infections. The principles of treatment include improving general condition of a patient, debridement of wound, excision of necrotic tissue, combined antibiotic therapy, hyperbaric oxygen therapy and reconstructive procedures. It is a rare but very serious condition which regardless to aggressive treatment can lead to a lethal outcome in up to 20-30% of patients.

CASE REPORT

Since the year 2000 we have treated six patients with FG. We presented the course and positive treatment outcome in a 65-year-old male patient with numerous comorbid conditions, nonregulated insulin-dependent diabetes, hypertension, previous myocardial infarction, chronic viral hepatitis and thrombocytopenia, rehabilitation was complicated with heart failure, atrial fibrillation and pulmonary thromboembolism. The treatment consisted of two extensive debridement of the wound with removing necrotic tissue, drainage, consolidation of state of health, correction of his blood sugar levels and thrombocytopenia, antimycotic and combination of three antibiotics and hyperbaric oxygen therapy. In two delayed surgical procedures reconstruction of a large defect of the urethra was performed.

CONCLUSION

A patient with numerous and serious comorbid conditions with FG could recover as a result of teamwork of urologists, infective medicine specialists, cardiologists, endocrinologist, vascular and plastic surgeons.

Fournier's gangrene: is it scrotal gangrene?

INTRODUCTION

Fournier's gangrene was originally described as scrotal gangrene in young males. Today, it is generally accepted as synergistic necrotizing fasciitis of perineal, genital, or perianal regions, and the epidemiologic data have changed. However, there are still limited data about females due to the lack of female patients, even in large case series.

METHODS

A retrospective review of the medical records of all patients who received surgery for emergency conditions over the past 22 years was performed to identify patients with Fournier's gangrene. Data from these patients were then reviewed to determine the age, gender, etiology, causative bacteria, predisposing factors, treatment modalities, length of hospital stay, and morbidity and mortality rates associated with Fournier's gangrene. Data were evaluated using multivariate analyses.

RESULTS

Sixty-five patients (20 female) were identified with the diagnosis of Fournier's gangrene. The mean age was 50.8 years. The most common etiology was hemorrhoidectomy in male and perianal abscess in female patients. The most commonly isolated microorganism in both male and female patients was Escherichia coli. Twenty-nine patients had diabetes mellitus, which was the most common predisposing factor. Mean hospitalization time was 24.4 days and the overall mortality was 27.70%.

CONCLUSION

Fournier's gangrene is still an important disease with high mortality rates in spite of the developments in intensive care units and new-generation antibiotics. It seems that there are no major differences between male and female patients in the characteristics of the condition.

Relation between the area affected by Fournier's gangrene and the type of reconstructive surgery used. A study with 80 patients

OBJECTIVE

To assess the affected skin area and the reconstructive techniques used in 80 patients affected by Fournier's gangrene.

MATERIALS AND METHODS

Eighty patients ranging in age from 19 to 85 years (mean = 51) affected by Fournier's gangrene were studied. When admitted to the emergency room the patients were submitted to clinical and laboratory examinations to analyze the gravity of the case. All patients were submitted to an extensive debridement of the lesion, urinary derivation by cystostomy and colostomy whenever necessary.

RESULTS

Only 13 patients (16.25%) died. From the 67 remaining patients, in 44 (65.6%) debridement was restricted to the scrotum, in 10 (14.9%) there has been scrotum and penile lesions and in 13 (19.3%) there has been a debridement of the scrotum and the perineal region. In 11 cases (16.4%) there was no need for reconstructive surgery with wound closing by second intention, in 16 cases (23.8%) reconstructive surgery was performed with mobilization of local skin, in 19 (28.3%) we have used skin grafts, 20 patients (29.8%) needed reconstructive surgery with the use of skin flaps and in 1 case (1.4%) there has been the use of skin flaps and grafts simultaneously.

CONCLUSIONS

Fournier's gangrene is a serious pathology and should be treated aggressively with an extensive debridement of the area with necrosis. The use of precocious reconstructive surgery of the genitals present good results and tends to greatly reduce the length of hospital stay and improve the psychological conditions of these patients.

Validation of the Fournier's gangrene severity index in a large contemporary series

PURPOSE

In this study we identified prognostic factors for survival and validated the accuracy of the Fournier's gangrene severity index in patients with Fournier's gangrene.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients diagnosed with Fournier's gangrene between 1996 and 2006. Fournier's gangrene severity index scores were assessed using a receiver operating characteristic curve. Using an outcome variable of inpatient mortality, univariate analyses were performed using the Mann-Whitney U, chi-square and Fisher exact tests.

RESULTS

A total of 68 patients (79.4% male, mean age 55.8 +/- 15.2 years) diagnosed with Fournier's gangrene met the criteria for review. The inpatient mortality rate was 10% (7 patients). The mean Fournier's gangrene severity index score for survivors was 5.4 +/- 3.5 vs 10.9 +/- 4.7 for nonsurvivors (p = 0.006). Isolated Fournier's gangrene severity index and individual laboratory parameters associated with mortality included heart rate (p = 0.05), respiratory rate (p = 0.02), serum creatinine (p = 0.03), serum bicarbonate (p = 0.001), serum lactate (p = 0.001) and serum calcium (p = 0.03). Although mean total body surface area was only suggestive of an association (p = 0.169), abdominal wall (p = 0.004) or lower extremity (p = 0.005) involvement was associated with increased mortality. Using a Fournier's gangrene severity index score threshold of 9 (sensitivity 71.4%, specificity 90%) there was a 96% survival rate in patients with a Fournier's gangrene severity index of less than 9 and a 46% mortality rate in those with a Fournier's gangrene severity index of 9 or greater (p = 0.001, OR 22, 95% CI 3.5-139.7).

CONCLUSIONS

The Fournier's gangrene severity index remains an objective and simple method to quantify the extent of metabolic aberration at presentation in patients with Fournier's gangrene. A Fournier's gangrene severity index threshold value of 9 is sensitive and specific for predicting mortality in this patient population.

The clinical features of Fournier's gangrene and the predictivity of the Fournier's Gangrene Severity Index on the outcomes

Fournier's gangrene (FG) is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal and perineal regions. Several factors have been reported to contribute to the clinical outcomes. The primary aims of this study were to examine the clinical features of patients with FG and evaluate the predictivity of the Fournier's Gangrene Severity Index (FGSI) score on the outcomes. We carried out a collective retrospective chart review of patients diagnosed and treated for FG in three reference centers between January 1995 and July 2007. Seventy-two patients with FG with were included to the study. Data were collected on medical history, symptoms, physical examination findings, admission and final laboratory tests, timing and extent of surgical debridement and antibiotic therapy. Perianal and perirectal abscess, scrotal abscess and urethral stenosis were the leading etiological factors. Diabetes mellitus was the predominant risk factor. Etiological factors and risk factors did not significantly contribute to survival or mortality, and duration of the symptoms was significantly longer in the non-survivor's group (P < 0.05). The FGSI scores were higher in the non-survivor's group. Regression analysis showed a FGSIS score of 10.5 as the cut-off to the outcome. Based on these results, we conclude that a patient's metabolic status and the extent of disease at presentation are the most important factors determining the prognosis of FG. The FGSI score may be considered as an objective and simple tool to predict the outcome in the patient with FG and should be used in further studies of FG patient series for comparison purposes.

Regional Necrotizing Fasciitis and its Outcome

Necrotizing fasciitis, a devastating progressive destructive infection of subcutaneous tissue and fascia, is a surgical emergency with a high mortality and morbidity. To analyze the location of necrotizing fasciitis, mode of presentation, microbiological characteristics, comorbid conditions, morbidty and mortality, records were reviewed retrospectively of all ninety-five patients admitted with necrotizing fasciitis to the surgical intensive care unit of Hamad General Hospital between January 1995 and February 2005. Fifteen patients died (15.1%). All patients had leucocytosis and fever on admission with a mean SOFA score varying from 8 to 10.3 according to the type of necrotizing fasciitis involved (Type 1 or 2) and the regions affected. All received aggressive fluid replacement therapy and all underwent debridement at least twice. The most common comorbid condition was Diabetes mellitus. Type 1 necrotizing fasciitis was common in gluteal, cervical and perineal regions; Type 2 was common in chest, axilla, leg and foot regions. Necrotizing fasciitis of the chest, axilla and gluteal regions had the highest mortality while necrotizing fasciitis of the perineum and genitalia had the lowest mortality.

[Vacuum-assisted abdominal closure: its role in the treatment of complex abdominal and perineal wounds. Experience in 48 patients]

INTRODUCTION

Vacuum-assisted closure (VAC) is a promising approach for the management of complex abdominal and perineal wounds. This paper summarizes our experience with this therapeutic modality and demonstrates its efficacity in difficult situations.

PATIENTS AND METHODS

From January 2003 until December 2005, 48 patients (age 30-89) were treated with VAC therapy for open abdomen, infected laparotomy wounds, or tissue loss due to debridement of Fournier's gangrene. Wound dressings were changed every 2-3 days.

RESULTS

Thirty-eight patients (79%) had major co-morbid conditions liable to impact negatively on wound healing. The treatment duration with VAC varied from 20-30 days with an average of eleven dressing changes (minimum 3-maximum 18). Treatment was effective in all patients. Spontaneous closure was achieved in 36 cases (75%); nine patients (19%) required a split-thickness skin graft, and three (6%) underwent delayed secondary closure.

CONCLUSION

In our institution, VAC has become the treatment of choice for complex abdominal and perineal wounds. It is a safe, simple, and effective technique to speed wound healing and it has reduced the duration of hospital treatment in difficult clinical situations and in patients whose general condition is often severely compromised.

Fournier gangrene: role of imaging

Fournier gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.

Fournier's gangrene: management at a regional burn center

Fournier's gangrene (FG) describes necrotizing infections of the perineum in both sexes. Controversies in treatment of FG include the roles of orchiectomy, urinary and/or fecal diversion, and hyperbaric oxygen (HBO). Because burn centers often treat these patients, we reviewed our experience with FG during a 14-year period. With Institutional Review Board approval, we reviewed our TRACS/ABA database for patients treated for FG during 1992 to 2005. Data was recorded on demographics, preexisting medical conditions, treatment, and outcomes. Thirty patients (20 men) were identified. Mean age was 54.3 +/- 14.1 years. Predisposing conditions included diabetes in 16 patients (53%), and morbid obesity and immunosuppression in 6 each. Twenty-two patients were transferred from outside hospitals, 12 after initial surgery. Sixteen patients presented with shock (blood pressure <90/60 mm Hg). Patients underwent a mean of 4.1 surgical procedures. Ten infections penetrated the deep fascia of the perineum or abdominal wall. Suprapubic cystostomy was performed in three patients, colostomy in seven, orchiectomy in one. HBO was not used. Hospitalization averaged 25.3 +/- 15.6 days. Mean charges ($1000) were $131.5 +/- 108.3. Definitive wound closure was obtained before discharge with suture repair and/or skin grafting in 18 of 25 survivors (72%). Five patients died (17%). In logistic regression analysis, the presence of shock on admission and female gender (mortality 40%) were significantly associated with mortality. FG remains a devastating infection, which occurs primarily in compromised patients. In this series, aggressive burn center care produced outcomes equivalent to those published in other series with or without use of HBO. Colostomy and urinary diversion can be used very selectively in these patients; orchiectomy is rarely required.

Fournier's gangrene progressing from the buttocks to the scrotum following a perianal abscess

We describe a case of gas-producing infection following a perianal abscess. A 61-year-old man was admitted to our hospital complaining of perineal pain and was found to have a perianal abscess. He was diabetic but had not received treatment for the disease. Although the perianal abscess was drained and antibiotic treatment started, severe swelling of the scrotum, with crepitation, redness, and partial necrosis progressed rapidly. Computed tomography revealed subcutaneous gas formation in the scrotum. A culture study revealed Clostridium, Enterococcus, and numerous other types of bacteria. The patient was diagnosed with Fournier's gangrene caused by infection with Clostridium in combination with other species of bacteria. The infection was refractory to drainage and antibiotic therapy. Thus, repeated extensive debridement of all necrotic tissue in the scrotum was required until healthy granulation was present in the wound. Our case shows that, in patients with Fournier's gangrene caused by infection with Clostridium in combination with other species of bacteria, the mainstay of treatment should be open drainage and aggressive surgical debridement of all necrotic tissue, followed by broad-spectrum antibiotic therapy.

Fatal Fournier's gangrene in a young adult with acute lymphoblastic leukemia

Fournier's gangrene (FG) is a fulminant necrotizing fasciitis of the external genitalia. Few reports of FG exist in patients with hematologic malignancies. We describe a case of fatal FG in a 21-year-old man with acute lymphoblastic leukemia who was receiving remission-induction chemotherapy. Despite early local surgery, administration of appropriate antibiotics, resurgery for wider debridement and aggressive ICU support he succumbed while pancytopenic to septic shock, 26 days after initiation of chemotherapy. Multi-drug resistant Pseudomonas aeruginosa was isolated from blood and scrotal cultures obtained at initial surgery. FG is a fulminant infection, especially in the face of profound cytopenias.

A 12-month-old infant with Fournier gangrene associated with varicella

Fournier gangrene is a progressive infection of the genital and perianal regions. It is a truly rare entity in association with varicella. There is only a single case published in the literature. We present the second case of a Fournier gangrene associated with varicella in an infant.

[Life-threatening necrotizing fasciitis colli caused by Serratia marcescens]

Necrotizing fasciitis colli is a rare, but life-threatening disease. A 43-year-old female patient was admitted to our department because of increasing dysphagia and slight swelling of the left side of her neck due to severe necrotizing pharyngolaryngitis. Initial treatment with cephalosporin I was ineffective. The patient developed a rapidly spreading necrotizing fasciitis of the neck requiring open surgery for débridement and drainage as well as tracheostomy. Microbiological analysis revealed Serratia marcescens, thus allowing targeted and ultimately successful antibiotic therapy. The case shows that even saprophytes like Serratia marcescens may cause a necrotizing fasciitis. Therefore, the initially calculated antibiotic treatment should include a wide spectrum of aerobic and anaerobic germs.

Management of Fournier's gangrene: review of 45 cases

PURPOSE

Fournier's gangrene is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women.

METHODS

The clinical and operative records of 45 patients with Fournier's gangrene during a 14-year period were analyzed.

RESULTS

The etiology of the infection was identified in 39 patients. The most common causes were colorectal diseases and urogenital diseases. Four patients died with an overall mortality of 8.8%. The mortality rate was higher in patients with diabetes mellitus, but it was not statistically different. The age, duration of the symptoms, and the presence of rectal abscess were not found to be significant factors regarding mortality rate.

CONCLUSIONS

Surgery with extensive debridement of all necrotic tissue is the main stay of treatment.

Factors affecting mortality of Fournier's gangrene: review of 70 patients

BACKGROUND

Fournier's disease is a potentially fatal, acute, gangrenous infection of the scrotum, penis or perineum associated with a synergistic bacterial infection of the subcutaneous fat and superficial fascia.

METHODS

The clinical records of 70 patients treated for Fournier's gangrene were evaluated retrospectively to determine prognostic indices and to stress Fournier's Severity Index (FSI), influencing outcome.

RESULTS

The mortality rate in this study was 22.8%. Length of the hospitalization time and FSI were detected as effective factors on mortality of Fournier's gangrene (P < 0.05) by Binary Logistic Regression analysis and the area under the receiver operating characteristic curve of these variables was also found to be significant (P < 0.001). The average FSI was determined as 4.66 +/- 2.31 in survivors and 11.56 +/- 2.68 in non-survivors and 5.11 +/- 2.83 in patients with primary genito-urinary infection but 7.56 +/- 4.35 in primary anorectal infection. The FSI was also found predictive of hospitalization time and number of debridements among survivors.

CONCLUSION

Fournier's Severity Index is a simplified way of comparing patients with this disease and may also have some significance in predicting outcome. The FSI is a more significant and predictive tool that should be popularized to predict the prognosis in Fournier's gangrene.

Bilateral testicular gangrene: does it occur in Fournier's gangrene?

Fournier's gangrene (FG) is an infective necrotizing fascitis of the perineum, genital and perianal area leading to gangrene of the overlying skin and subcutaneous tissue. Testis and epididymis tend to be spared. We report a case of a young male with bilateral gangrene of the testis.

Incarcerated Inguinal Hernia in the Presence of Fournier's Gangrene: A Novel Approach to a Complex Problem

Fournier's gangrene is an aggressive, polymicrobial soft tissue infection that specifically affects the genital and perineal region. Treatment requires early recognition, broad-spectrum intravenous antibiotics, and radical surgical debridement of all infected tissues. Optimal therapy may necessitate multiple debridements that leave the patient with large tissue defects that require skin grafting for scrotal and perineal reconstruction. The presence of other surgical emergencies, such as an incarcerated inguinal hernia, in the face of Fournier's gangrene presents a rare and challenging dilemma to the general surgeon. With the widespread acceptance of tension-free repair utilizing prosthetic mesh in uncomplicated hernia surgery, outcomes have been improved. However, surgical options for hernia repair may become limited in the face of a regional necrotizing soft tissue infection, for which mesh use in an open repair after debridement of infected tissues is generally contraindicated. In this report, the authors describe three consecutive cases of incarcerated inguinal hernia in the presence of concomitant Fournier's gangrene using a laparoscopic approach and natural biomaterial mesh for abdominal wall reinforcement.

Diabetes mellitus

Dermatologic problems are common in diabetes, with approximately 30% of patients experiencing some cutaneous involvement during the course of their illness. Skin manifestations generally appear during the course of the disease in patients known to have diabetes, but they may also be the first presenting sign of diabetes or even precede the diagnosis by many years. The skin involvement can be autoimmune in nature, such as acanthosis nigricans, necrobiosis lipoidica, diabetic dermopathy, scleredema, and granuloma annulare, or infectious in the form of erythrasma, necrotizing fasciitis, and mucormycosis. Pharmacologic management of diabetes, in addition, can also result in skin changes, such as lipoatrophy and lipohypertrophy, at the site of injection of insulin, and oral antidiabetic agents can cause multiple skin reactions as adverse effects. The management of these cutaneous manifestations is tailored according to the underlying pathophysiology, but a tight control of blood glucose is a prerequisite in all management strategies.

Fournier's gangrene and its emergency management

Fournier's gangrene (FG) is a rare but life threatening disease. Although originally thought to be an idiopathic process, FG has been shown to have a predilection for patients with diabetes as well as long term alcohol misuse; however, it can also affect patients with non-obvious immune compromise. The nidus is usually located in the genitourinary tract, lower gastrointestinal tract, or skin. FG is a mixed infection caused by both aerobic and anaerobic bacterial flora. The development and progression of the gangrene is often fulminating and can rapidly cause multiple organ failure and death. Because of potential complications, it is important to diagnose the disease process as early as possible Although antibiotics and aggressive debridement have been broadly accepted as the standard treatment, the death rate remains high.

Fournier's gangrene: report of thirty-three cases and a review of the literature

BACKGROUND

Fournier's gangrene (FG) is an extensive fulminant infection of the genitals, perineum or the abdominal wall. The aim of this study is to share our experience with the management of this difficult infectious disease.

METHODS

Thirty-three male patients were admitted to our clinic with the diagnosis of FG between February 1988 and December 2003. The patient's age, etiology and predisposing factors, microbiological findings, duration of hospital stay, treatment, and outcome were analyzed. The patients were divided into two groups. The first 21 patients (Group I) were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and then they underwent split-thickness skin grafts or delayed closure as needed. The other 12 patients (Group II) were treated with unprocessed honey (20-50 mL daily) and broad-spectrum triple antimicrobial therapy without debridement. Their wounds were cleaned with saline and then dressed with topical unprocessed honey. The wounds were inspected daily and the honey was reapplied after cleaning with normal saline. Then, the patients' scrotum and penis were covered with their own new scrotal skin. The mean age of the patients was 53.9 +/- 9.56 years (range = 23-71).

RESULTS

The source of the gangrene was urinary in 23 patients, cutaneous in seven patients, and perirectal in three patients. The predisposing factors included diabetes mellitus for 11 patients, alcoholism for 10 patients, malnutrition for nine patients, and medical immunosuppression (chemotherapy, steroids, malignancy) for three patients. The mean duration of hospital stay was 41 +/- 10.459 (range = 14-54) days. Two patients in Group I died from severe sepsis. The clinical and cosmetic results were better in Group II than Group I.

CONCLUSION

Necrotizing fasciitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. Traditionally, good management is based on aggressive debridement, broad-spectrum antibiotics, and intensive supportive care but unprocessed honey might revolutionize the treatment of this dreadful disease by reducing its cost, morbidity, and mortality.

Fournier's gangrene: a radiologic emergency

Fournier's gangrene (FG) is a life-threatening, necrotizing infection involving the soft tissues of the scrotal area. Because of potential severe complications, it is important to diagnose the disease as early as possible. We present the CT findings of FG in a young male that came to the Emergency Department for genital pain and tenderness.

Necrotizing Soft Tissue Infection of the Thigh: Consider an Abdominal Cause

BACKGROUND

Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved.

METHODS

Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance.

RESULTS

Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus.

CONCLUSIONS

High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.

Reconstruction of wide scrotal defect using superthin groin flap

INTRODUCTION

Grafts and flaps have been widely used to reconstruct scrotal defects due to Fournier's gangrene. Controversy still exists concerning the use of grafts and flaps because of the low protection provided by the grafts and the high volume of the flaps. We describe the use of an expanded groin flap for scrotum reconstruction.

TECHNICAL CONSIDERATIONS

Three patients were treated for total scrotal tissue loss using this method. An expander was installed through an incision from the inferolateral aspect of the groin, and superthin flaps obtained after 3 weeks were dissected starting from the medial side. Care was taken during dissection, because the skin was thin on the lateral side, and dissection was performed in a subfascial fashion. Finally, the defect was covered with the lateral part of the expanded flap and the donor site was primarily closed.

CONCLUSIONS

To cover the testes, both the aesthetic and functional state should be taken into consideration. Therefore, a thin and durable cover is required for scrotal reconstruction. The expanded superthin groin flap possesses these features and is a good option.

Prognostic factors in Fournier gangrene

AIMS

Fournier gangrene is a rapidly progressive necrotizing fasciitis involving the genitalia. It can be treated with antibiotics and immediate debridement along with treatment of the predisposing condition. We evaluated the prognostic factors, clinical characteristics and treatment of patients of the Fournier gangrene.

METHODS

The subjects were 40 male patients diagnosed with Fournier gangrene who visited Wonkwang University Hospital, Iksan, Korea between January 1991 and December 2000. Their medical records were reviewed with respect to demographics, medical history, symptoms and signs, physical examination, laboratory data, bacteriology, extent of disease, clinical course, and therapy. The extent of disease was quantified for each patient using a modification of the diagram used to assess the extent of burns.

RESULTS

The average age was 55.3 years (range 29.6-92.8). Of the 40 patients, 11 died (36%) and 29 survived (64%). Anorectal infections were the underlying local disease most commonly associated with high mortality (75%). Although the most common associated illness was diabetes, it was not related to the prognosis (death rate: 20.0%). In contrast, the death rate was highest in chronic renal failure, reaching 50%. The mortality rate increased with the duration of symptoms before hospitalization. Patients with <6% surface area involvement were more likely to survive. On admission, serum blood urea nitrogen (s-BUN) and serum creatinine were significantly higher in the patients who died.

CONCLUSION

Survival is associated significantly with anorectal infection, chronic renal failure, the duration of symptoms before hospitalization, the extent of gangrene, and s-BUN and creatinine level on admission.

Fournier's gangrene exposed

Necrotising fasciitis is a condition associated with significant morbidity and mortality. Fournier's gangrene is a variant of the condition affecting the perineum. Although presentation is usually acute, it may also present in an insidious manner. Following radical surgical debridement, meticulous attention to wound management is required.

[Balanitis: diagnosis and treatment]

Balanitis refers to a variety of unrelated conditions. It results from infective, irritative, allergic, traumatic, or inflammatory causes; pre-malignant lesions have been also identified. All these causes are successively reviewed regarding their positive diagnosis and their treatment. Normal aspects of the balanopreputial area will be explained because they may cause some anxiety in certain patients. The difference between the circumcised and uncircumcised penile skin that cause differences in the incidence and appearance of dermatoses of the glans and corona will be studied. Pre-malignant lesions of the balanopreputial area, although not frequent, represent a difficult diagnosis and therapeutic challenge. The major problem is the earliness of the diagnosis that may avoid the occurrence of squamous cell carcinoma. Moreover, lichen sclerosus may develop into squamous cell carcinoma and therefore a lifelong follow-up must be implemented. Thus, any fixed, chronic or suspicious Lesion must be rapidly assessed by a biopsy.

[Necrotizing cutaneous infections and Fournier's gangrene]

Fournier's gangrene is a necrotizing infection of skin and soft tissue of the perineum. Several sources of contamination have been described: cutaneous, urological or anorectal. Anatomy of the perineum helps in the prediction of the extension of the infection. The bacterial flora (usually mixed aero-anaerobic flora) depends on the source of infection: gram-positive cocci (skin source) combined with gram-negative bacilli and anaerobes (urological or anorectal source). CT scan and echography are useful tools for the diagnosis without delaying surgery. In the diagnostic procedure and the management, proctological examination, retrograde uretrography, bowel and urine derivation should be discussed.

Fournier's gangrene

BACKGROUND

A 59-year-old man presented with a 4-day history of scrotal pain and swelling and the rapid development of moist, black, foul-smelling lesions on the scrotum and penis. As a liver-transplant recipient, he was immunosuppressed. He also had type 1 (insulin-dependent) diabetes and poor nutrition, which might have compromised immunity further.

INVESTIGATIONS

Physical examination, blood and tissue cultures, full blood count, urea and electrolytes, liver function tests, coagulation profile, C-reactive protein, and examination under anesthesia.

DIAGNOSIS

Fournier's gangrene originating from an infected cutaneous lesion in an immunocompromised patient.

MANAGEMENT

Resuscitation and triple broad-spectrum antibiotics, urgent surgical debridement, serial examinations under anesthesia with further debridements, and split-skin grafting. Phallic reconstruction is planned.

Necrotizing fasciitis: pathogenesis and treatment

Necrotizing fasciitis is a rapidly progressive, life-threatening infection and a true infectious disease emergency. Despite much clinical experience, the management of this disease remains suboptimal, with mortality rates remaining approximately 30%. Necrotizing fasciitis rarely presents with obvious signs and symptoms and delays in diagnosis enhance mortality. Therefore, successful patient care depends on the physician's acumen and index of suspicion. Prompt surgical debridement, intravenous antibiotics, fluid and electrolyte management, and analgesia are mainstays of therapy. Adjunctive clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulin are frequently employed in the treatment of necrotizing fasciitis, but their efficacy has not been rigorously established. Improved understanding of the pathogenesis of necrotizing fasciitis has revealed new targets for rationally designed therapies to improve morbidity and mortality.

Necrotising fasciitis of the leg following a simple pelvic fracture: case report and literature review

Necrotising fasciitis is a rare complication following pelvic fracture, but has a high mortality rate. Topical negative pressure and maggot debridement therapy can be used alongside the usual treatment of surgical debridement and antibiotic therapy.