Fournier's gangrene: is it scrotal gangrene?

Risk Factors for Mortality Among Patients With Fournier Gangrene: A Systematic Review

Background: Fournier gangrene (FG) is a form of necrotizing fasciitis involving the perineal, peri-anal, and genital structures, and has exceptionally high mortality rates. To help in early detection of high-risk patients, we aimed to systematically review factors associated with mortality from FG. Patients and Methods: Searches were conducted in PubMed, Embase and Scopus. In our review, a minimum of five patients were required and this was to exclude studies with exceedingly small sample sizes, such as case reports and small case series, with minimal relevance in comparison to larger scale studies. Patient characteristics, causative microbes, anatomic areas of infection, presence of comorbidities, severity scores, causes of FG, and complications were extracted and compared to identify factors related to mortality. Results: A total of 57 studies were included in the review. Across 3,646 study participants, the mortality rate of FG was 20.41%. The mean age of non-survivors was 61.27 years. There were more total male deaths, however, the mortality rate was higher in females. Diabetes mellitus was the most common comorbidity in those who died, but the highest mortality rate was seen in HIV patients (54.17%). Mortality rates did not differ widely among antibiotic agents. Regarding causative organisms, fungal infections had the highest rates of mortality (68.18%) and the most common microbe leading to death was Escherichia coli. Conclusions: Female gender, comorbidities, anatomic distribution, development of sepsis, and fungal infection all increased risk for mortality. Early identification of risk factors, and provision of appropriate treatment are crucial in reducing mortality rates of high-risk patients with FG.

Treatment outcome of Fournier's gangrene and its associated factors: A retrospective study

INTRODUCTION

Fournier's gangrene (FG) is a rapidly progressive necrotizing infection that affects the perineal and abdominal regions and is known for its high mortality rate. This study aims to present the practical experience of managing FG patients and identify factors that may affect their clinical outcomes.

MATERIALS AND METHODS

A retrospective study was conducted from April 2009 to December 2020 at General Military Hospital in Sana'a, Yemen including 26 patients who were diagnosed with FG and treated on. Data on demographic characteristics, time to admission, surgical intervention, and treatment outcomes were collected. Univariate analysis was performed to determine factors that affect patient outcomes.

RESULT

The mean age of the patients was 65.77 ± 5.04 years, and 65.4% of them were over the age of 65. Most patients (57.7%) presented after five days of experiencing symptoms, and 65.4% were in septic conditions. Of the patients, 17 (65.4%) survived, and the total mortality rate was 34.6%. Univariate analysis showed that delayed presentation (p = 0.001), a history of diabetes mellitus (p < 0.001), end-stage renal disease (p < 0.001), heart failure (p < 0.001), cerebrovascular accident (p = 0.032), liver cirrhosis (p < 001), presence of multiple comorbidities (p < 001), involvement of lager area (p < 001), septic conditions (p = 0.009), advanced age (p = 0.018), and intensive care unit admission (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

FG is a potentially life-threatening medical condition, even with aggressive and specialized treatment. Our study revealed a mortality rate of 34.6%. Factors such as older age, the presence of multiple comorbidities, septic conditions, the abdominal spread of the disease, intensive care unit admission, and delayed presentation contribute to higher mortality rates.

Fournier's gangrene and sodium-glucose co-transporter-2 inhibitors: A meta-analysis of randomized controlled trials

Fournier's gangrene (FG) is a rare, life-threatening necrotizing fasciitis of the perineum. The US Food and Drug Administration (FDA) released a Drug Safety Communication regarding the risk of FG associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i), relying on the FDA Adverse Event Reporting System. To verify this association, we performed a meta-analysis of all randomized controlled trials enrolling patients with type 2 diabetes, comparing SGLT2i with placebo or different therapies, collecting cases of FG reported as a serious adverse event. Risk of abscess, cellulitis and erysipela were secondary outcomes. We retrieved 84 trials enrolling 42 415 patients in the SGLT2i group and 27 158 patients in comparator groups. No difference was observed between SGLT2i and comparators in the risk of FG (Mantel-Haenzel odds ratio [MH-OR] 0.41 [0.09, 1.82]), abscess (MH-OR 0.94 [0.54, 1.65]), cellulitis (MH-OR 0.90 [0.71, 1.13] or erysipela (MH-OR 0.89 [0.45, 1.77]). The number of events was small, leading to a wide confidence interval that does not allow ruling out an increase in FG or skin and subcutaneous tissue infections.

Fournier's gangrene: a fulminant subcutaneous infection

A 73-year-old man with a history of diabetes was urgently referred to our emergency department because of severe pain of his genitalia and pubical region. Physical examination revealed an extensive subcutaneous emphysema and edema of his abdomen. Computer tomography confirmed an extensive necrotizing fasciitis, diagnosed as Fournier's gangrene. Despite the efforts made, the patient did not survive. And a review of the medical approach of this short of a life-threatening form of necrotizing soft tissue infection with a high mortality rate.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Clinical efficacy of vacuum-sealing drainage in treatment of Fournier's gangrene

AIM: To assess the clinical effects of vacuum-sealing drainage technology in the treatment of Fournier's gangrene.

METHODS: Forty patients with Fournier's gangrene treated from September 2013 to September 2014 at our hospital were randomly divided into either an observation group or a control group. The observation group was treated by vacuum-sealing drainage, and the control group was treated by conventional debridement. Fournier's gangrene severity index (FGSI), debridement frequency, time to body temperature recovery, healing situation and hospitalization time were compared for the two groups.

RESULTS: FGSI on days 7 and 14 after treatment was significantly lower in the observation group than in the control group (P < 0.05). The average debridement times in the observation group was 3.8, significantly less than that in the control group (P < 0.05). Body temperature recovery was faster in the observation group (P < 0.05). All the 20 patients in the observation group were cured, including 17 cases of wound healing after secondary suture under local anesthesia and 3 cases of healing after inguinal flap grafting. Sixteen patients in the control group were cured, and 4 cases died. The hospitalization time was significantly shorter in the observation group (P < 0.05).

CONCLUSION: Vacuum-sealing drainage is an effective method for the treatment of Fournier's gangrene.

Fournier's gangrene

Fournier's gangrene (FG) is a synergistic polymicrobial gangrenous infection of the perineum, scrotum and penis which is characterised by obliterative endarteritis of the subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-threatening disease, and despite therapeutic advances in recent years, the mortality rate is 3%-67%, with an incidence of 1:7500-1:750,000. Anorectal, genitourinary and cutaneous sources of infection are the most common causes of FG, with diabetes mellitus being the most common risk factor. The clinical condition presents evolution from 2 to 7 days and is characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. Current imaging techniques for initial evaluation of the disease include radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful in uncertain diagnosis and when clinical findings are ambiguous. Treatment of FG is based on a multimodal approach which includes intensive fluid resuscitation to stabilise the patient and correction of electrolyte imbalance, if any. This is followed by extensive debridements and resections in order to remove all necrotic and infected tissue, wide spectrum antibiotics and reconstructive surgery, whenever required. However, despite all the advances in treatment today, FG remains a surgical emergency, hence, early recognition with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and urgent surgical debridement are the mainstay of treatment.

Increased risk of diabetes following perianal abscess: a population-based follow-up study

PURPOSE

It remains unclear whether perianal abscess is a prediabetes condition or the initial presentation of type 2 diabetes. Using a population-based dataset, this study aimed to explore the risk of type 2 diabetes following perianal abscess.

METHODS

We used data sourced from the Longitudinal Health Insurance Database 2000. In total, there were 1,419 adult patients with perianal abscess in the study group and 7,095 randomly selected subjects in the comparison group. Stratified Cox proportional hazards regressions were carried out to evaluate the association between being diagnosed with perianal abscess and receiving a subsequent diagnosis of diabetes within 5 years.

RESULTS

Of the total 8,514 sampled subjects, the incidence rate of diabetes per 100 person-years was 1.87 (95 % confidence interval (CI) = 1.74-2.01); the rate among patients with perianal abscess was 3.00 (95 % CI = 2.60-3.43) and was 1.65 (95 % CI = 1.52-1.79) among comparison patients. Stratified Cox proportional hazards analysis revealed that patients with perianal abscess were more likely to have received a diagnosis of diabetes than comparison patients (hazard ratio = 1.80, 95 % CI = 1.50-2.16, p < 0.001) during the 5-year follow-up period after censoring cases that died from nondiabetes causes and adjusting for patient geographic location, urbanization level, monthly income, hypertension, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome at baseline.

CONCLUSIONS

Our results suggest that patients with perianal abscess have a higher chance of contracting type 2 diabetes mellitus within the first 5 years following their diagnosis.

A case of intravascular lymphoma complicated with Fournier's syndrome due to multidrug-resistant Pseudomonas aeruginosa

Fournier's syndrome is the fulminant necrotizing fasciitis of the external genitalia. The occurrence of Fournier's syndrome in patients with hematologic malignancies has been reported. Here we report a case of an intravascular lymphoma complicated with Fournier's syndrome due to multidrug-resistant Pseudomonas aeruginosa (MDRP). A 71-year-old Japanese man received intensive chemotherapy for recurring intravascular lymphoma. Blood culture revealed MDRP, and physical examination led to the diagnosis of Fournier's syndrome. Aggressive treatment that comprised granulocyte transfusion, granulocyte stimulating factor, endotoxin filtration, appropriate antibiotic coverage, and aggressive surgical therapy was administered, and this lead to the successful recovery from sepsis and Fournier's syndrome.

Fournier gangrene presenting in a patient with undiagnosed rectal adenocarcinoma: a case report

Introduction

Fournier gangrene is a rare necrotising fascitis of the perineum and genitals caused by a mixture of aerobic and anaerobic microorganisms. The first case was described by Baurienne in 1764 but the condition was named by Fournier in 1883 who reported the cases of five men with the condition with no apparent etiology. Infection most commonly arises from the skin, urethra, or rectal regions. Despite appropriate therapy, mortality in this disease is still high. We report a case of a low rectal malignancy presenting as Fournier gangrene. This case report serves to highlight an extremely unusual presentation of rectal cancer, a common surgical pathology.

Case presentation

The patient is a 48 years old Afghanian male that admitted with Fournier gangrene. In the course of medical and surgical treatment the presence of extensive rectal adenocarcinoma was discovered. After partial recovery, standard loop colostomy was inserted. Skin grafting of necrotic areas was performed and systemic rectal cancer chemotherapy initiated after full stabilization.

Conclusion

Fournier gangrene is an uncommon but life threatening condition with high associated mortality and morbidity. Usually there is an underlying cause for the development of Fournier gangrene, that if addressed correctly, can lead to a good outcome. Early diagnosis and treatment decrease the morbidity and mortality of this life threatening condition. Good management is based on aggressive debridement, broad spectrum antibiotics and intensive supportive care.

The clinical characteristics of female patients with Fournier's gangrene

INTRODUCTION AND HYPOTHESIS

Our aim was to review our experience with Fournier's gangrene in female patients.

METHODS

A retrospective review of ten consecutive female patients with Fournier's gangrene was performed. Etiological and predisposing factors, causative microbiological organisms, and clinical outcome were investigated.

RESULTS

Mean age of the patients was 52.7 years, and the mean duration of hospitalization was 17.6 days. The etiologic origin of the gangrene was anorectal, dermatological, and urogenital infection in 50%, 20%, and 10% of patients, respectively. All patients underwent aggressive surgical debridement and a diverting colostomy. Nine patients survived, and one patient died for an overall mortality rate of 10%.

CONCLUSIONS

Fournier's gangrene occurred in females with a pattern similar to that in males. We believe that a colostomy is an integral part of management for patients requiring extensive debridement, especially if the infection arises in the anorectal region.