1
|
Ongaro L, Claps F, Rizzo M, Di Cosmo G, Traunero F, D’Andrea E, Garaffa G, Cai T, Zucchi A, Trombetta C, Liguori G. Procalcitonin as prognostic factor in patients with Fournier’s gangrene. Urologia 2022; 90:157-163. [PMID: 36527222 DOI: 10.1177/03915603221142665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Fournier’s Gangrene (FG) has still a mortality rate up to 45%. Several studies identified prognostic factors but there is a knowledge gap concerning procalcitonin (PCT) levels and mortality risk in FG. This study is aimed to assess the role of PCT as prognostic factor in FG. Materials and methods: The medical records of 20 male FG patients admitted at the Department of Urology of “Cattinara” Hospital, University of Trieste between January 2019 and November 2020 were retrospectively reviewed. Clinical, demographic, microbiological data were collected. The Fournier’s Gangrene Severity Index (FGSI) was calculated for each patient. Results: Thirteen (65%) of 20 patients survived. Median age was 58 years (IQR 51–88), 15 patients (75%) had a Charlson Comorbidity Index (CCI) score ⩾2, 1 (5%) equal to 0, 4 to 1 (20%). Median FGSI score was 6 (IQR 2–12) and median PCT 0.8 ng/ml (IQR 0.04–2.12). At multivariate analysis PCT levels >0.05 ng/ml were associated with an increased overall mortality risk (OR 2.14, CI 1.25–4.27, p = 0.002). CCI score ⩾2 (OR 1.51, CI 1.01–2.59, p = 0.04), Streptococcical etiology (OR 3.41, CI 2.49–4.61, p = 0.002) and FGSI score >9 (OR 1.41, CI 1.19–2.21, p = 0.004) were associated with unfavorable outcome. Conclusion: PCT might be a prognostic factor in FG. CCI and FGSI are useful tools in mortality risk stratification. Streptococcical etiology is associated with unfavorable outcome. Further larger clinical trials are pending.
Collapse
Affiliation(s)
- Luca Ongaro
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Francesco Claps
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Michele Rizzo
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Giacomo Di Cosmo
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele Turro, Milan, Italy
| | - Fabio Traunero
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Eugenia D’Andrea
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Giulio Garaffa
- Department of Urology, University College London Hospitals, London, UK
| | - Tommaso Cai
- Department of Urology, Santa Chiara Hospital, Trento, Italy
| | - Alessandro Zucchi
- Department of Translationals Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Carlo Trombetta
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| | - Giovanni Liguori
- Department of Urology, University of Trieste, Cattinara Hospital – ASUGI, Trieste, Italy
| |
Collapse
|
2
|
Yang Y, Wang LC, Yu XY, Zhang XF, Yang ZQ, Zheng YZ, Jiang BY, Chen L. How likely is septic shock to develop in a patient with Fournier's gangrene? A risk prediction model based on a 7-year retrospective study. Gastroenterol Rep (Oxf) 2022; 10:goac038. [PMID: 35966629 PMCID: PMC9368829 DOI: 10.1093/gastro/goac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Fournier's gangrene (FG) is a rare life-threatening form of necrotizing fasciitis. The risk factors for septic shock in patients with FG are unclear. This study aimed to identify potential risk factors and develop a prediction model for septic shock in patients with FG. Methods This retrospective cohort study included patients who were treated for FG between May 2013 and May 2020 at the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou, China). The patients were divided into a septic shock group and a non-septic shock group. An L1-penalized logistic regression model was used to detect the main effect of important factors and a penalized Quadratic Discriminant Analysis method was used to identify possible interaction effects between different factors. The selected main factors and interactions were used to obtain a logistic regression model based on the Bayesian information criterion. Results A total of 113 patients with FG were enrolled and allocated to the septic shock group (n = 24) or non-septic shock group (n = 89). The best model selected identified by backward logistic regression based on Bayesian information criterion selected temperature, platelets, total bilirubin (TBIL) level, and pneumatosis on pelvic computed tomography/magnetic resonance images as the main linear effect and Na+ × TBIL as the interaction effect. The area under the ROC curve of the probability of FG with septic shock by our model was 0.84 (95% confidence interval, 0.78-0.95). The Harrell's concordance index for the nomogram was 0.864 (95% confidence interval, 0.78-0.95). Conclusion We have developed a prediction model for evaluation of the risk of septic shock in patients with FG that could assist clinicians in identifying critically ill patients with FG and prevent them from reaching a crisis state.
Collapse
Affiliation(s)
| | | | - Xin-Yang Yu
- Department of Applied Mathematics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Xiao-Fei Zhang
- Department of Critical Care Medicine, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Zhong-Qing Yang
- Department of Applied Mathematics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Yang-Zi Zheng
- Department of Applied Mathematics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Bin-Yan Jiang
- Corresponding authors. Lei Chen, Department of Critical Care Medicine, the Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-13570236595; and Bin-Yan Jiang, Department of Applied Mathematics, The Hong Kong Polytechnic University, Hong Kong SAR, China. Tel: +852-27666349;
| | - Lei Chen
- Corresponding authors. Lei Chen, Department of Critical Care Medicine, the Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-13570236595; and Bin-Yan Jiang, Department of Applied Mathematics, The Hong Kong Polytechnic University, Hong Kong SAR, China. Tel: +852-27666349;
| |
Collapse
|
3
|
Erickson BA, Flynn KJ. Management of Necrotizing Soft Tissue Infections (Fournier’s Gangrene) and Surgical Reconstruction of Debridement Wound Defects. Urol Clin North Am 2022; 49:467-478. [DOI: 10.1016/j.ucl.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
4
|
Paladini A, Cochetti G, Tancredi A, Mearini M, Vitale A, Pastore F, Mangione P, Mearini E. Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity. Basic Clin Androl 2022; 32:12. [PMID: 35850577 PMCID: PMC9294754 DOI: 10.1186/s12610-022-00162-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background Fournier’s gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed. We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching “Fournier’s gangrene”, “necrotizing fasciitis” on PubMed and Scopus was performed. Case presentation A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier’s Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day. Conclusions FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.
Collapse
Affiliation(s)
- Alessio Paladini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Giovanni Cochetti
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy.
| | - Angelica Tancredi
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Matteo Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Andrea Vitale
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Francesca Pastore
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Paolo Mangione
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Ettore Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| |
Collapse
|
5
|
He X, Xiang X, Zou Y, Liu B, Liu L, Bi Y, Kan D. Distinctions between Fournier's gangrene and lower extremity necrotising fasciitis: microbiology and factors affecting mortality. Int J Infect Dis 2022; 122:222-229. [PMID: 35598736 DOI: 10.1016/j.ijid.2022.05.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/03/2022] [Accepted: 05/17/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES In this study, we aimed to illustrate distinctions between Fournier's gangrene (FG) and lower extremity necrotising fasciitis (NF) and screen out possible risk factors of poor prognosis for each cohort. METHODS The medical records of qualified patients with NF admitted to the Second People's Hospital of Yibin from January 2016 to June 2021 were retrospectively reviewed. All participants were anatomically categorised into FG and lower extremity NF groups, and their baseline data and microbiological results were compared. Further comparisons of critical parameters were conducted between survivors and nonsurvivors within each group. RESULTS A total of 49 patients were included in the study with a median age of 58 years, and overall mortality was 20.4%. There were 18 patients with FG and 31 patients with lower extremity NF. A microbiology distinction was found-the predominance of gram-negative infection in FG and gram-positive infection in lower extremity NF. High Fournier's gangrene severity index scores (greater than 7), advanced age, procalcitonin and D-dimer value were identified as risk factors for FG, and the presentation of sepsis was an alarming indicator for lower extremity NF. CONCLUSIONS The distinction of microbiology might provide advice for appropriate antibacterial administrations. In addition, with practical prognostic predicting tools, clinicians might be able to identify patients at increased risk and intervene promptly to avoid unfavourable outcomes.
Collapse
Affiliation(s)
- Xuefeng He
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China.
| | - Xin Xiang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Yong Zou
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China.
| | - Bing Liu
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
| | - Lili Liu
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
| | - Yaodan Bi
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Daohong Kan
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
| |
Collapse
|
6
|
Elahabadi I, Bazmandegan G, Salehi H, Jafari A, Ahmadi J, Kamaib Z. Fournier's gangrene after missed acute perforated appendicitis: A case report. Clin Case Rep 2021; 9:e04989. [PMID: 34721858 PMCID: PMC8530021 DOI: 10.1002/ccr3.4989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 09/21/2021] [Accepted: 10/08/2021] [Indexed: 01/10/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ismail Elahabadi
- Department of SurgeryAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Gholamreza Bazmandegan
- Clinical Research Development UnitAli‐Ibn Abi‐Talib HospitalRafsanjan University of Medical SciencesRafsanjanIran
- Department of Family MedicineAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Hossein Salehi
- Department of SurgeryAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Amin Jafari
- Department of SurgeryAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Jafar Ahmadi
- Department of RadiologyAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Zahra Kamaib
- Clinical Research Development UnitAli‐Ibn Abi‐Talib HospitalRafsanjan University of Medical SciencesRafsanjanIran
- Department of Family MedicineAli‐Ibn Abi‐Talib HospitalSchool of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| |
Collapse
|
7
|
Auerbach J, Bornstein K, Ramzy M, Cabrera J, Montrief T, Long B. Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives. Open Access Emerg Med 2020; 12:353-364. [PMID: 33204184 PMCID: PMC7665443 DOI: 10.2147/oaem.s238699] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.
Collapse
Affiliation(s)
- Jonathan Auerbach
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kasha Bornstein
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorge Cabrera
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA
| |
Collapse
|
8
|
Zingaro MD, Boni A, Vermandois JARD, Paladini A, Lepri E, Ursi P, Cirocchi R, Turco M, Gaudio G, Nogara A, Mearini E. Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature. Open Med (Wars) 2019; 14:694-710. [PMID: 31934634 PMCID: PMC6947763 DOI: 10.1515/med-2019-0114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022] Open
Abstract
Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.
Collapse
Affiliation(s)
- Michele Del Zingaro
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Boni
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | | | - Alessio Paladini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Emanuele Lepri
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties “Paride Stefanini”;, Sapienza University of Rome, Rome, Italy
| | - Roberto Cirocchi
- Division of General Surgery, Department of Surgical and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Morena Turco
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Gianluca Gaudio
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Nogara
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Ettore Mearini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| |
Collapse
|
9
|
Fournier Gangrene: Association of Mortality with the Complete Blood Count Parameters. Plast Reconstr Surg 2018; 143:443e-444e. [PMID: 30516745 DOI: 10.1097/prs.0000000000005240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Reply: Fournier Gangrene: Association of Mortality with the Complete Blood Count Parameters. Plast Reconstr Surg 2018; 143:444e. [PMID: 30516752 DOI: 10.1097/prs.0000000000005241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|