Fournier's gangrene secondary to intra-abdominal processes

Conceptos para la identificación y abordaje de la gangrena de Fournier

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing”, “wound infection”, "therapy"[subheading] y “GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

Fournier's gangrene after missed acute perforated appendicitis: A case report

Fournier's gangrene (FG) is a rare progressive necrotizing fasciitis (NF) with high mortality rate. This case report describes a young patient with FG with no known history of disease or invasive therapeutic interventions.

Fournier gangrene: pictorial review

Fournier gangrene is an emergency condition that is associated with a high mortality rate. It is defined as a rapidly progressing infective necrotizing fasciitis of the perineal, perianal, and genital regions. Early diagnosis, broad-spectrum antibiotic coverage, and adequate surgical debridement are crucial and lead to better prognosis and patient survival. There is increasing utilization of computed tomography (CT) in the initial evaluation of Fournier gangrene. CT can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent. In this pictorial review, we discuss the pathogenesis of Fournier gangrene and display the imaging spectrum with an emphasis on CT findings, including asymmetrical fascial thickening, soft tissue stranding, soft tissue gas, collection, and abscess formation. The infection originating from colorectal pathology, the affected anatomy, and the involvement of the abdominal wall are important predictors of mortality. The familiarity of the varied imaging appearance of Fournier gangrene is necessary to provide an accurate diagnosis, and evaluation of disease extent is crucial for optimal surgical debridement.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Mimicry of Appendicitis Symptomatology in Congenital Anomalies and Diseases of the Genitourinary System and Pregnancy

INTRODUCTION

Appendicitis is a prevailing cause of acute abdomen, but is often difficult to diagnose due to its wide range of symptoms, anatomical variations, and developmental abnormalities. Urological disorders of the genitourinary tract may be closely related to appendicitis due to the close proximity of the appendix to the genitourinary tract. This review provides a summary of the urological complications and simulations of appendicitis. Both typical and urological symptoms of appendicitis are discussed, as well as recommended diagnostic and treatment methods.

METHODS

Medline searches were conducted via PubMed in order to incorporate data from the recent and early literature.

RESULTS

Urological manifestations of appendicitis affect the adrenal glands, kidney, retroperitoneum, ureter, bladder, prostate, scrotum, and penis. Appendicitis in pregnancy is difficult to diagnose due to variations in appendiceal position and trimester-specific symptoms. Ultrasound, CT, and MRI are used in diagnosis of appendicitis and its complications. Treatment of appendicitis may be done via open appendectomy or laparoscopic appendectomy. In some cases, other surgeries are required to treat urological complications, though surgery may be avoided completely in other cases.

CONCLUSION

Clinical presentation and complications of appendicitis vary among patients, especially when the genitourinary tract is involved. Appendicitis may mimic urological disorders and vice versa. Awareness of differential diagnosis and proper diagnostic techniques is important in preventing delayed diagnosis and possible complications. MRI is recommended for diagnosis of pregnant patients. Ultrasound is preferred in patients exhibiting typical symptoms.

Fournier's gangrene secondary to an acutely inflamed appendix herniating into the deep inguinal ring

Fournier's gangrene (FG) requires prompt recognition and management. We report the case of a 68-year-old man who presented with extensive pain and purple discolouration from the right iliac fossa to perineum. Computed tomography demonstrated gas within the right hemiscrotum extending into the inguinal canal and right buttock, with a right pelvic fluid and air collection. At debridement necrotic fluid was arising from the superficial inguinal ring so laparotomy was performed, revealing a grossly inflamed appendix herniating into the inguinal canal; a right hemicolectomy was performed. Unfortunately, the patient went into cardiac arrest and passed away on the operating table. Histological analysis demonstrated acute-on-chronic inflammation involving the appendix. The condition where appendicitis is implicated in FG is usually due to retroperitoneal rupture and tracking into the perineal spaces. This is the first case reported of an inflamed appendix herniating into the inguinal canal and thus causing FG.

Necrotizing fasciitis caused by a primary appendicocutaneous fistula

We report a case of necrotizing fasciitis in the loin of a 76-year old man with several coexisting or past health issues, including diabetes mellitus, hypertension, alcohol-related liver cirrhosis, gastrectomy for gastric cancer, subarachnoid hemorrhage, normal pressure hydrocephalus, and cerebral infarction. Incision of the necrotizing fasciitis was successful, but it revealed an appendicocutaneous fistula; thus, we performed appendectomy and fistulectomy. We think that the necrotizing fasciitis was caused by appendicitis perforation involving the retroperitoneum, inducing the formation of an appendicocutaneous fistula. Necrotizing fasciitis and appendicocutaneous fistulae are rare complications of appendicitis. Moreover, to our knowledge, this is the first report of fluoroscopic examination demonstrating that a primary appendicocutaneous fistula had caused necrotizing fasciitis. Our search of the literature found 12 cases of necrotizing fasciitis caused by preoperative appendicitis. We discuss the characteristics and findings of these cases.

Fasciitis and septic shock complicating retrocecal appendicitis

INTRODUCTION

A case of fasciitis and septic shock complicating retrocecal appendicitis is presented.

CASE REPORT

A 52-year-old man presented to the Emergency Department with lumbar pain, fever of recent onset and subsequently developed septic shock attributed to fasciitis of abdominal, flank and groin region. On intensive care unit, he was managed with broad-spectrum intravenous antibiotics and surgical debridement. An abdominal computed tomography scan confirmed the findings of fasciitis and was negative for intra-abdominal pathology. In the following days, an enterocutaneous fistula with foul smelling fluid was noted. A new surgical exploration revealed the presence of a ruptured retrocecal appendix, and right hemicolectomy was performed. The postoperative period was long but uneventful.

CONCLUSION

Retrocecal appendicitis can rarely be presented as deteriorating cellulitis-fasciitis in the right abdominal, flank or groin region, with or without abdominal symptoms.

Necrotizing fasciitis due to acute perforated appendicitis: case report

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in treatment increases the likelihood of complications such as perforation, which is associated with an increase in morbidity and mortality rates. We herein present the case of a 76-year-old woman presenting with necrotizing fasciitis of the abdominal wall and right flank regions due to a perforated appendix. Such complication is extremely rare but life-threatening. It may be confused with cellulitis, causing a delay in aggressive treatment. This case represents an unusual complication of a common disease. Also, acute appendicitis or intra-abdominal pathologies should be taken into consideration in determining the cause of necrotizing fasciitis presenting over abdominal, flank, or perineal regions.

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.

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.

Rapid infectious killers

Central to the practice of emergency medicine is the ability to identify patients in whom immediate intervention is needed to prevent long-term morbidity and mortality. This article has highlighted some of the characteristics of several infectious diseases that may become fatal quickly if not treated quickly and appropriately by physicians. Bacterial meningitis,necrotizing soft tissue infections, invasive gram-negative disease, pneumo-coccal pneumonia, and West Nile encephalitis all require prompt recognition and treatment by emergency care providers.

Fournier's gangrene

Fournier's gangrene can still be a life-threatening condition with a high mortality rate. Diagnosis and treatment should be prompt and adequate. Radiological studies may help to define the extent of the disease preoperatively in cases in which this is unclear. Surgery with extensive debridement of all necrotic tissue is the mainstay of treatment.

Fournier's gangrene: changing face of the disease

PURPOSE

Our experience with ten cases of Fournier's gangrene prompted us to review the related literature to highlight the current status of the disease.

METHODS

Data from ten patients with the diagnosis of Fournier's gangrene treated at our center from January 1997 until December 1998 were analyzed. These patients were treated by aggressive resuscitation, triple antibiotics, and urgent surgery. The English-language medical literature for the past 30 years was reviewed.

RESULTS

The epidemiologic features of our patients were similar to those reported in other recent studies. Mortality rate was 20 percent. Currently, the disease affects both genders and a wide range of ages, has a more insidious onset than in the past, and is not idiopathic. Associated systemic disorders (diabetes, alcoholism, and immunosuppression) are common. Perianal infection is the commonest cause and is associated with more moribund features.

CONCLUSION

The epidemiology of Fournier's gangrene is changing from its original description. Population aging worldwide--as a result of improving health care--and therefore the increasing prevalence of associated medical disorders may explain these changes. These factors may also explain the consistently high mortality rate during more recent years, masking any survival benefits from improved medical care. Better understanding of the pathophysiology has reduced the ratio of idiopathic cases to a minimum.

Fournier's gangrene: a review of 1726 cases

BACKGROUND

Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene.

METHOD

Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features.

RESULTS

Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation.

CONCLUSION

Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.

[Fournier's gangrene. Our clinical experience, etiopathogenesis and management]

We report 12 cases of Fournier's Gangrene treated over an 19-month period; at Division Urology of the Hospital Gral. de Agudos Dr. José M. Ramos Mejia. We emphatized 58.3% of the patients had an urology origin. We considered diagnostic and therapeutic issues, and bibliografic review.

Necrotizing fasciitis due to appendicitis

Necrotizing fasciitis, although rare, is one of the more serious, life-threatening complications of missed acute appendicitis. Patients who are predisposed to developing necrotizing fasciitis, regardless of the cause, are typically immunocompromised. We present a case of a 49-year-old immunocompetent female whose diagnosis of acute appendicitis was missed and who subsequently developed necrotizing fasciitis of the abdominal wall and flank. She recovered 1 month after admission due to aggressive surgical and medical therapy.

Fournier's gangrene with an unusual urologic etiology

Fournier's gangrene is a necrotizing infection affecting the male genitalia and perineum, caused by synergistic aerobic and anaerobic organisms. We report on a previously undescribed upper urinary tract etiology for this life-threatening infection.

Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene

Epididymo-orchitis is a relatively common diagnosis in elderly men, often related to prostatic outflow obstruction. A 70-year-old man presented with a 4-day history of swelling and pain in the scrotum, fevers, dysuria and frequency. He had severe symptoms of prostatic hypertrophy. Physical examination and urine microscopy confirmed the diagnosis of left epididymo-orchitis and antimicrobial therapy was commenced. Subsequently, however, he developed severe necrotizing fasciitis (Fournier's gangrene) of the scrotum requiring surgical debridement, and at laparotomy, a perforated carcinoma of the sigmoid colon was found at the level of the left deep inguinal ring. Despite further radical surgery the gangrene extended, his condition deteriorated and he died. There has been no other similar case reported in the literature, and thus, although rare, intra-peritoneal causes of infection should be considered in patients with Fournier's gangrene.

Fournier's Gangrene: a clinical and bacteriological study

Bacteriological studies were conducted in patients presenting with Fournier's Gangrene (FG) in our Department during a period of 11 years. These studies showed high numbers of anaerobes (96%) and the ratio of aerobes to anaerobes was reported to be 1.4: 3.2. Among the anaerobes,Peptostreptococci, Bacteroides and Prevotella were more frequently isolated. The predominant facultative aerobic microorganisms were Streptococci and Escherichia coli. Clinical investigation showed necrotic cellulitis and fasciitis of the scrotum due to mixed aerobic-anaerobic infection. Patients with complicated paraproctitis and periurethral abscesses and urinary phlegmones who also presented with symptoms of FG were treated during this same period. Microbiological studies gave similar results and clinical studies showed that the process had spread to the scrotum. The question was then raised whether FG should be diagnosed as an independent nosological entity in cases where the underlying cause of the disease was obscure or if FG should be the result of different pathological processes which occurred within the scrotal surfaces. In other cases, FG is secondary and occurred after reaching the scrotum per continuitatem.

Necrotizing soft-tissue infections

Necrotizing soft-tissue infections may be rapidly fatal because of toxin-induced circulatory collapse. Because of the often nonspecific clinical presentation, prompt diagnosis may be difficult but is imperative as prompt treatment can be lifesaving. This article discusses necrotizing fasciitis and clostridial myonecrosis, and highlights pathogenesis, clinical presentation, diagnosis, and treatment.

Necrotizing fasciitis in children: prompt recognition and aggressive therapy improve survival

Necrotizing fasciitis (NF) is a bacterial infection of the soft tissues with a fulminant course and a high mortality rate. The authors performed a review to define the diagnosis, bacteriology, and management of NF in the pediatric population. This report of 20 cases treated over 18 years represents the largest reported pediatric experience. These infections were attributable to secondary infection of varicella lesions (5), omphalitis (4), extremity lesions (4), perineal infections (3), head and neck lesions (2), inguinal herniorrhapy (1), and breast abscess (1). Nineteen of the 20 children were healthy, without chronic disease or immunosuppression. All patients presented with an altered sensorium and signs of systemic toxicity. Fever (40%), tachycardia (70%), and abnormal white blood cell count (50%) were not uniformly present. There was marked tissue edema in all patients, with a characteristic peau d'orange appearance in 18. Seven infections were caused by streptococcus; the remainder were polymicrobial, involving multiple aerobes and anaerobes. Initial gram stain was of limited utility; in 14 of 19 cases the result was negative or showed only one of many organisms present. Fifteen patients survived and five died. All survivors underwent aggressive surgical debridement within 3 hours of admission. The survivors required of a mean of 3.8 operations. Fascial excision of up to 35% of total body surface area was required. One patient required amputation, two had colostomies, and six required extensive skin grafting for reconstruction. All five patients who died had delayed initial management.

CONCLUSION

NF is a serious cause of death in previously healthy children. The diagnosis should be considered in the presence of any soft tissue infection presenting with signs of toxicity and marked wound edema, even in the absence of fever or abnormal white blood cell count. Immediate surgical debridement and coverage with penicillin, an aminoglycoside, and metronidazole are essential. Subsequent changes in antibiotics should be based on culture data because gram stain results are not reliable. More than one operation is required in almost all cases.

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.