Fournier's gangrene and its emergency management

Volumetric computed tomography measurements as predictors for outcomes in a cohort of Fournier's gangrene patients

PURPOSE

This study evaluates the prognostic value of CT findings, including volumetric measurements, in predicting outcomes for patients with Fournier gangrene (FG), focusing on mortality, ICU admission, hospital stay length, and healthcare costs.

METHODS

A retrospective study was conducted on 38 FG patients who underwent CT scans before surgical debridement. We analyzed demographic data, CT volumetric measurements, and clinical outcomes using logistic and linear regression models.

RESULTS

No single CT measurement significantly predicted mortality or ICU admission. The best model for mortality prediction included age, air volume, NSTI score, and male sex, with an AUC of 0.911. Intubation likelihood was modeled with an AUC of 0.913 using age, NSTI score, and visceral to subcutaneous fat ratio. The ICU admission model achieved an AUC of 0.677. Hospital stay was predicted by air volume (β = 0.0002656, p = 0.0505) with an adjusted R-squared of 0.1287. Air volume significantly predicted hospital costs (β = 2.859, p = 0.00558), resulting in an adjusted R-squared of 0.2165.

CONCLUSION

Volumetric CT findings provide valuable prognostic insights for FG patients, suggesting a basis for informed clinical decisions and resource allocation. Further validation in larger, multi-center studies is recommended to develop robust predictive models for FG outcomes.

Variables that predict hospital stay and the outcome of Fournier gangrene at King Abdulaziz University Hospital: a retrospective study

BACKGROUND

The aggressive nature of Fournier gangrene and the associated health issues can result in a more complex clinical course and potentially a longer hospital stay. This study aimed to assess factors that affect the length of hospital stay (LHS) and its relation to the outcome of Fournier gangrene patients.

METHODS

A retrospective study was performed at King Abdulaziz University Hospital (KAUH), Saudi Arabia, on patients diagnosed with Fournier gangrene between 2017 and 2023. Data about length of hospital stay (LHS), age, BMI, clinical and surgical data and outcome was obtained.

RESULTS

The mean age of the studied patients was 59.23 ± 11.19 years, the mean body mass index (BMI) was 26.69 ± 7.99 kg/m2, and the mean duration of symptoms was 10.27 ± 9.16 days. The most common presenting symptoms were swelling or induration (64%), 88% had comorbidities with diabetes mellitus (DM) (84%), and 76% had uncontrolled DM. of patients, 24% had a poly-microbial infection, with E. coli being the most common (52%). The mean length of hospital stay (LHS) was 54.56 ± 54.57 days, and 24% of patients had an LHS of more than 50 days. Longer LHS (> 50 days) was associated with patients who did not receive a compatible initial antibiotic, whereas shorter LHS was associated with patients who received Impenem or a combination of vancomycin and meropenem as alternative antibiotics following incompatibility. Reconstruction patients had significantly longer LHS and a higher mean temperature. However, none of the studied variables were found to be predictors of long LHS in the multivariate regression analysis.

CONCLUSION

Knowledge of the values that predict LHS allows for patient-centered treatment and may be useful in predicting more radical treatments or the need for additional treatment in high-risk patients. Future multicenter prospective studies with larger sample sizes are needed to assess the needed variables and predictors of long LHS.

Meleney's gangrene managed with a single extensive debridement and resultant defect closure with abdominoplasty technique - a case report

Introduction

Meleney's gangrene, or progressive bacterial synergistic gangrene, is a life-threatening subcutaneous tissue infection and skin necrosis of the abdomen that is persistent and quickly progressing and has documented cultural characteristics of a symbiotic organism. The nobility of this case lies in the use of the modern technique, abdominoplasty, used to close the wound post-radical debridement for Meleney's gangrene. This uncommon illness has a high fatality rate and requires immediate diagnosis, aggressive antibiotic treatment, and extensive debridement.

Case presentation

We report the case of a 55-year-old female with no known comorbidities, who presented to our center with features of Meleney's gangrene and pleural effusion. Radical debridement was performed and empirical intravenous antibiotics were administered. The wound was closed using the abdominoplasty approach.

Clinical discussion

Meleney's gangrene should be identified quickly and treated with wide-spectrum antibiotics and rigorous surgical debridement. It is difficult to diagnose the illness early, and skepticism is strong during this process. An increased risk of death may follow a postponed diagnosis of Meleney's gangrene. A long-term hospital stay can result from extensive debridement. Furthermore, skin transplants may be required to close wounds in certain instances.

Conclusion

This case is presented to show how early intervention and radical debridement can improve the outcome in cases of Meleney's gangrene, which is rare and clinically significant. Additionally, this suggests that a cosmetic procedure known as abdominoplasty could be a viable option for wound closure.

Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?

INTRODUCTION

Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound.

MATERIAL AND METHODS

A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected.

RESULTS

A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality.

CONCLUSIONS

One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.

The role of C-reactive protein albumin ratio for predicting mortality in patients with Fournier's gangrene

BACKGROUND

Fournier's gangrene (FG) is a rapidly progressing and life-threatening necrotizing fasciitis of the genital and perineal regions. To estimate the mortality rate associated with FG, Laor et al. developed the FG severity index (FGSI), an index with proven prognostic significance. On the other hand, the C-reactive protein (CRP)/albumin (CAR) ratio is a proven objective marker of inflam-matory response. In light of the foregoing, the objective of this study is to assess the prognostic value of the CAR ratio in predicting mortality in patients with FG in comparison with FGSI.

METHODS

This retrospective study consisted of 58 patients who were operated on for FG between 2019 and 2022. Research data were obtained from electronic and paper patient files, surgery notes, clinical follow-up forms, anamnesis, intensive care forms, and laboratory test results obtained from the hospital automation system. The clinical course of each patient was reviewed based on these records. The relationships between patients' CAR ratios and their demographic and clinical characteristics, including age, gender, and comorbidities, whether ostomy was performed, length of hospital stay, growth in wound culture, isolated bacterial species, FGSI scores, and laboratory test results (hemoglobin, sodium, potassium, bicarbonate, glucose, blood urea nitrogen (BUN), creatinine, albumin, and CRP levels, white blood cell counts, hematocrit values, glucose-to-potassium, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-CRP ratios) and the prognostic power of CAR ratio in predicting the mortality associated with FG were investigated.

RESULTS

The mean age of the study group, 45 male and 13 female, was 57 (min. 17, max. 85) years. The most common predisposing factor was diabetes mellitus (DM), which was present in 32 (55.1%) patients. The most common symptoms at admission were erythema (89.6%), swelling/hardening (82.7%), pain (41.3%), fever (31%), and purulent discharge (37.9%). Of the 58 patients included in the study, six had died. The most common comorbidity, second to DM (55.1%), was cardiovascular disease (39.6%). The median ages of patients who had died and survived were 60 (min. 56, max. 85) and 56 (min. 18, max. 80) years, respectively. CAR ratio effectively differentiated FG patients who had survived from those who had died (area under the curve [AUC]: 0.907 [0.824-0.984]). The CAR ratio cutoff value of 2.8 effectively differentiated FG patients and FSGI scores who had survived from those who had died (AUC: 0.904 [0.823-0.992]).

CONCLUSION

The study findings demonstrated that the CAR ratio might serve as an effective biomarker in predicting the mortal-ity associated with FG.

Management of Fournier's gangrene: a practical guide for clinicians

Fournier's gangrene is a localised form of necrotising fasciitis affecting the external genitalia, perineal and perianal regions. Although rare, it is associated with high rates of morbidity and mortality, so clinician awareness is essential for prompt treatment. Risk factors include diabetes mellitus, hypertension, chronic alcoholism and immunosuppression. Perineal pain in patients with sepsis should be treated with a high level of suspicion and early surgical referral is required as prompt debridement can improve outcomes. Repeated surgical intervention and antimicrobial therapy are often needed and recovery can take a long time, with a long-term impact on quality of life. This article discusses the natural history of Fournier's gangrene, aetiology, risk factors, investigations and treatments with an algorithm to support clinical practice.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study

BACKGROUND

Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality.

METHODS

A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality.

RESULT

The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.

A Comprehensive Literature Review of Fournier's Gangrene in Females

Fournier gangrene (FG) is a rare but rapidly progressing disease with a higher mortality rate in women as compared to men. This study aims to perform a literature review about FG in females and associated mortality and morbidity. We searched databases including MEDLINE (Ovid), the National Library of Medicine (Medical Subject Headings (MeSH)), the Cochrane Database of Systematic Reviews (Wiley), as well as Embase (Ovid), Scopus, and Global Index Medicus (WHO), and reviewed literature from 2002 to 2022 and selected 22 studies that met our study's inclusion criteria, which included 134 female patients with a mean age of 55±6 years. The perineal abscess was a more common nidus (n=41, 35%; 95%CI 23-39%) than vulvar pathology (n=29, 22%; 95%CI 15-30%). The most common initial presentation was cellulitis (n=62, 46%; 95%CI 38-55%), followed by perineal pain (n=54, 40%; 95%CI 32-50%), fever (n=47, 35%; 95%CI 27-43%), and septic shock (n=38, 28%; 95%CI 21-37%). Escherichia coli was the most frequently identified bacteria (n=48, 36%; 95%CI 28-46%). All patients had treatment with a mean of three (SD 2) debridement and those with negative pressure dressings received fewer debridements than those who received a conventional dressing. However, of those who had surgical intervention, 28 (20%; 95%CI 14-29%) patients underwent diversion colostomy. General surgeons performed 78% (n=104) of cases out of which 20% (n=20) were consulted by obstetrician-gynecologists, 14% (n=18) were treated by urologists, and only 8% (n=10) by plastic surgeons. The mean length of stay in the hospital was 24±11 days, and the gross mortality rate was 27 (20%; 95%CI 14-28%). In conclusion, while females have a low incidence rate of FG, they carry a higher mortality rate. Lack of cardinal signs and delayed presentation to the hospital from the onset of symptoms are some possible causes for the increased mortality rate along with the disease process being under-recognized in women. A high index of clinical suspicion is essential to avoid delay in the definitive management coupled with an early surgical consult and establishing a common general care pathway could minimize mortality and morbidity.

The role of quick Sepsis-related Organ Failure Assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's Gangrene Severity Index: Analysis of 69 patients

Objective

Fournier's gangrene is a rare but life-threatening infection disease with high mortality rate. The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new and simpler scoring system that may identify patients with suspected infection who are at greater risk for a poor outcome. The purpose of this study was to find out role of qSOFA in determining prognosis of Fournier's gangrene patients.

Methods

This study is a case control with retrospective review of Fournier's gangrene patients treated at Hasan Sadikin Hospital from January 2013 to December 2017 who met inclusion criteria. Participants were divided into two groups according to qSOFA score as high qSOFA (2-3) and low qSOFA (0-1).

Results

From 69 patients, the mortality rate was 24.6%. The sensitivity of qSOFA score to predict mortality was 88.2%; the specificity was 94.2%; positive predictive value was 83.3%; negative predictive value was 96.1%; positive likelihood ratio was 15.2; negative likelihood ratio was 0.12; and the area under the receiver operating characteristic curve of qSOFA was 94.2%. There was significant association between qSOFA scale and mortality with p-value of 0.0001. The qSOFA score has strong positive correlation with Fournier's Gangrene Severity Index (p<0.0001, r=0.704).

Conclusion

qSOFA scoring system has a high prognostic value and can be used to determine prognosis of Fournier's gangrene patients.

Fournier's gangrene with retroperitoneal extension, a case report

BACKGROUND

Fournier's gangrene (FG) is a polymicrobial, both aerobic and anaerobic, synergistic necrotizing fasciitis of the perineal, genital, or perianal regions. It is a rapidly progressive and fulminant soft tissue infection and it is potentially fatal. Fournier's gangrene has been shown to be strongly associated with diabetes, chronic alcoholism, human immunodeficiency virus (HIV), lymphoproliferative diseases, chronic steroid abuse, and cytotoxic drugs.

CLINICAL PRESENTATION

A 25-year-old Ethiopian male patient with no previous medical history presented to the emergency department with a four-day history of perineal pain, swelling, and discharge. Associated with this he had a high-grade fever and one episode of vomiting of ingested matter. On examination, he was febrile, tachycardic, and hypotensive. He had a grossly necrotic scrotum and palpable crepitus extending to the left lower anterior abdominal wall.

CLINICAL DISCUSSION

On investigations, he had elevated leukocyte count, random blood sugar, low hemoglobin, and elevated creatinine levels. Subsequently, the patient was admitted and was started with broad-spectrum antibiotics and multiple debridements were done along with other supportive measures. Finally, the patient was discharged improved after 17 days of hospital stay.

CONCLUSION

Fournier's gangrene is a rapidly progressive, fulminant infection. Nevertheless, prompt diagnosis can be difficult and requires a high index of suspicion. Early diagnosis and appropriate management have paramount importance in reducing mortality and morbidity in these patients.

Progress in Multidisciplinary Treatment of Fournier's Gangrene

Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.

Fournier's Gangrene: A Rare Infectious Entity in an Adolescent with Type II Diabetes

Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external genital organs that is uncommon in the pediatric age group. We present a case report of a 17-year-old obese male with comorbidities of type II diabetes, hypertension, and tobacco use, who presented to the hospital with vague systemic symptoms and pain in the gluteal area. On examination, he was febrile and had erythema and induration of his left scrotum, perineum, and gluteal region. Imaging obtained due to rapid progression of symptoms was consistent with a diagnosis of Fournier's gangrene. He was managed with broad-spectrum antibiotics, aggressive surgical debridement, and a diverting colostomy. This case brings to light to a classically adult diagnosis that should be considered in adolescents, especially given the rising numbers of risk factors in this population, such as diabetes, obesity, and smoking.

Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades

INTRODUCTION

Fournier's Gangrene (FG) carries a high mortality and morbidity with underreported short and long-term outcomes. Our aim was to perform a review of the recent literature to evaluate the short and long-term outcomes in patients with FG in the acute setting from large-scale studies.

METHODS

A PubMed search was performed between January 2000 and December 2021 for studies reporting on patients with FG. Exclusion criteria included small samples (n < 100), review articles and animal studies. Primary outcomes of interest were mortality, number of operative episodes for surgical debridement and admission to intensive care unit (ICU). Other outcomes assessed included rate of faecal and urinary diversion, orchidectomy rate, penectomy rate and length of hospital stay.

RESULTS

From a total of 1182 studies, 18 were eligible for inclusion and included in this review. In total, data were analysed from 13,903 FG patients. Mean inpatient mortality rate was 7.3% (range 4.7-40.4%). Mean number of surgical debridement operations performed was 1.8 (range 1.5-4.2). On average, 6.8% (range 3.6-50.5%) and 7% (range 1.2-53.2%) underwent faecal and urinary diversions, respectively. Mean rate of orchidectomy was 5.6%, with rate of penectomy being lower at 0.2%. The mean length of hospital stay was 18.5 days (range 13.0-26.6). On average, 17.5% (range 10.1%-67.5%) required ICU admission for at least a single-system support.

CONCLUSION

Our review from the past twenty years of literature suggests that the mortality for FG, whilst still high, has fallen compared to previous years. Whilst inpatient metrics are well-covered in the literature there is a lack of large-scale studies detailing long-term patient outcomes.

Utility of Diagnostic Imaging in the Early Detection and Management of the Fournier Gangrene

Fournier gangrene represents a urologic emergency. It is a rapidly progressing necrotizing fasciitis that comprises the perineal, perianal, and genital regions and has a high mortality rate. Diagnosis is usually made clinically, but radiological diagnostics, such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI), can determine the extent of the disease in relation to pelvic structures. Early and accurate diagnosis precipitates the initiation of the effective treatment and, thus, affects the outcome of the therapy. The article reports an illustrative case study of a patient with Fournier gangrene, secondary to a perianal fistula and perianal abscess with a massive accumulation of fluid around the anus and testicles, requiring unilateral orchidectomy. Rapid radiological diagnosis via MRI enabled precise assessment of the degree of the disease, early surgical intervention, and a successful outcome.

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.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis

OBJECTIVE

Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services.

METHOD

This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period.

RESULTS

A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge.

CONCLUSION

The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.

Fournier’s Gangrene in a Female Diabetic Patient: A Case Report

Necrotizing fasciitis is a rare but potentially fatal deep infection involving subcutaneous tissue and fascia. The infection can occur in all parts of the body and can cause acute onset pain, swelling, fever, malaise, and tachycardia with or without evidence of skin inflammation. Risk factors include recent surgery, diabetes, trauma, intravenous drug use, alcoholism, and chronic illnesses. This case involves a 35-year-old female with a past medical history of hypertension, type II diabetes mellitus, and obesity presenting with a painful vulvar lump, which progressed rapidly into extensive necrotizing soft tissue infection despite the incision and drainage of the vulvar abscess, marsupialization, and antibiotic therapy. The patient underwent multiple surgical debridements with intense medical treatment and wound vacuum-assisted closure therapy. Uncontrolled diabetes and obesity significantly increase the risk of necrotizing fasciitis. Fournier’s gangrene should be suspected in patients with comorbid conditions and a presentation of a urogenital abscess. This case highlights the importance of prompt diagnosis and treatment of necrotizing fasciitis in a timely manner.

Fluorescent angiography imaging of intravitreal active bleeding, due to deep venous thrombosis concomitant to Fournier gangrene

Purpose:

To report a breakthrough bleeding in the vitreous cavity due to deep venous thrombosis, in a case of a middle-aged male patient who suffered concomitantly from Fournier’s gangrene. Fluorescent angiography imaging displayed the intravitreal hemorrhage as occurring.

Methods:

We performed fundus fluorescein angiography and optical coherence tomography at baseline and follow-up examinations.

Results:

During fluorescein angiography we identified, right eye fluorescent blockage corresponding to a pre-retinal, a subhyaloid, and an intraretinal hemorrhage in the posterior pole. Capillary non-perfusion, and capillary remodeling of the far temporal peripheral vasculature was detected as well, the left eye was unremarkable. A breakthrough bleeding in the vitreous cavity of the upper temporal vein branch was caught as it was happening. We did not observe leaking at the macula; our findings were confirmed with optical coherence tomography throughout the follow-up period.

Conclusion:

Active retinal bleeding has been reported only twice in the past, in these cases, it was attributed to superficial venous vessel rupture due to vitreous traction or Valsalva-like retinopathy at the site of neovascularization. Active retinal vein bleeding during a fluorescein angiography, secondary to deep venous thrombosis due to Fournier gangrene, has not been previously reported.

The effect of Fournier gangrene severity index and microbial culture results on hospital length of stay, frequency of debridement, and mortality

BACKGROUND

Fournier gangrene (FG) is a rapidly progressive soft-tissue necrosis that may be life-threating unless aggressive treatment is applied immediately. FG severity index was described first by Laor et al. to predict mortality rate but there are few studies on the prognostic significance of FG severity index and especially the microbial agents isolated from debridement on patient prognosis. Hence, in the present study, it has been aimed to investigate the significance of FG severity index and infective agents on hospital stay, frequency of debridement, and mortality.

METHODS

Thirty-four patients who were operated with the diagnosis of FG between January 2013 and January 2018 were retrospectively analyzed. FG severity index scores in admission were calculated and patient was divided into two groups according to the cutoff value of FG severity index. Patient was categorized according to the microbial agents isolated from debridement cultures. Patient characteristics were compared between the group of survivors and non-survivors. The effect of FG severity index and microbial agent type on hospital stay, frequency of debridement, and mortality was analyzed.

RESULTS

It was found that mortality rate was significantly higher in the group of FG severity index score >9 than the other group (100% vs. 6.7%; p=0.001>) and it was observed that FG severity index had predicted the mortality rate as 100% and survival rate as 93.3% but there were no significant relation between FG severity index with the frequency of debridement and hospital stay. The mortality rate (50% vs. 4.2%; p=0.005) and frequency of debridement (3.10±0.73 vs. 2.00±0.72; p=0.001) were significantly higher in the subgroup of patient infected with clostridial and atypical agents.

CONCLUSION

FG severity index was found to be insufficient in determining the frequency of debridement and the hospital stay but it accurately predicts the rates of mortality and survival. The patients who were infected with clostridial and atypical agents are more likely to develop mortality and tend to be need more aggressive surgical interventions than the others.

Perspectives From a Regional Plastic Surgery Centre on Evidence for the Purported Link Between SGLT2 Inhibitors and Fournier's Gangrene

Introduction: The recent report issued by the MHRA indicating an association of Sodium glucose linked transporter type 2 (SGLT2) Inhibitors with the contraction of Fournier's Gangrene (FG), has been drawn with insufficient supporting evidence and without an adequately powered study to make any meaningful assertions or recommendations. We aimed to look specifically at the currently available dataset used to link SGLT2 Inhibitors to FG and highlight what conclusions or inferences can meaningfully be made, in particular the power of any study that would be required to make sensible conclusions.

Methods: World literature review of SGLT2 Inhibitors and FG was performed. With a subsequent 10-year review of cases of FG seen in a regional burns and plastics centre. Data was collected retrospectively from the coding department at Whiston Hospital for all patients with necrotising fasciitis. An electronic document management system was used to identify patients with FG specifically as well as their diabetes state and medication history.

Results: Seventy-eight patients were admitted with FG, of whom 32 had diabetes mellitus (DM). Of those with DM none was taking an SGLT2 Inhibitor, 17 patients were taking metformin, a further nine patients were taking a second line medication and 14 required insulin injections.

Discussions: DM is a known major risk factor for FG, which is clearly observed in our patient cohort. The risk of patients with DM developing FG is irrespective of the medication patients are taking. The current articles and reports published have little ground to claim an association between SGLT2 Inhibitors and FG and are missing the crucial message that needs to be conveyed to the public: that DM is a major risk factor for FG and patients suffering with diabetes need to be extra vigilant.

Fournier’s Gangrene With Retroperitoneal Extension as the First Manifestation of the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)

Fournier’s gangrene (FG) is an atypical, life-threatening polymicrobial infection characterized by the rapid destruction of soft tissue, predominantly in the perineal region. Retroperitoneal spread of FG represents an uncommon condition described in a few case reports, and its presentation as the first manifestation of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is even more infrequent. Here, we present the case of a 40-year-old male who was admitted to the emergency department with a low-grade fever of 37.8°C, abdominal pain, and four-day history of sharp, bilateral testicular pain and swelling. On physical examination, the patient was hypotensive with necrotic tissue in the perineum. A computed tomography study displayed an extensive retroperitoneal spread of suspected FG. Due to the massive spread of the infection, an HIV test was requested, yielding positive results, which indicated that HIV/AIDS had first manifested as FG with retroperitoneal extension. This is an extremely rare initial presentation of HIV/AIDS. To treat the patient and address the severe necrosis, a peritoneal lavage, surgical debridement, right orchiectomy, and colostomy were performed. After the procedure, antiretroviral therapy was established with tenofovir, emtricitabine, and efavirenz.

Neonatal Fournier's gangrene; pattern and predisposing factors in a tertiary health facility in Southern Nigeria

Fournier's gangrene (FG), a necrotizing fasciitis of the genital and perineal region, is a serious and debilitating multi-infective pathological condition. More commonly seen in adults, its occurrence in neonates is uncommon. We share our experience with neonatal FG (NFG), highlighting potential factors which may predispose neonates to it.Ours is a five year retrospective review of cases of NFG in our service. Data obtained included health facility of birth, mode of delivery, symptoms and duration, investigation results, treatment and outcome. Sixteen neonates were included, comprising 13 males (M:F  =  4.3:1). Fourteen were delivered outside our centre; breech vaginal delivery, hot water massaging and application of native concoctions were common. All were treated with antibiotics and wound debridement, but five (37.5%) died.NFG is not that rare in our service. Early recognition is imperative to reduce mortality. Neonates delivered by breech vaginally may be particularly at risk.

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.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

[Rare emergencies in urology]

INTRODUCTION

The aim of this article was to cite rare but sometimes serious emergencies that may be encountered by any urologist during their practice, and to outline the main principles of their management.

MATERIAL AND METHOD

A systematic review of the literature using PubMed, Embase and Google Scholar was carried out between January 2000 and June 2021. The articles obtained were selected according to their age and type. The original articles, meta-analyses, recommendations and the most recent journal articles published in French and English have been retained. A total of 312 articles were identified and 58 selected from their abstracts. The articles were then analysed exhaustively by the authors, and 24 references were finally selected.

RESULTS

Several rare emergencies of an infectious nature (xanthogranulomatous pyelonephritis, emphysematous cystitis and pyelonephritis, malacoplasia, hydatiduria), ischemic nature (Fournier's gangrene, penile calciphylaxis), or hemorrhagic nature (hemospermia, hemorrhages of the upper urinary tract or adrenal gland spontaneous hematoma), or at the origin of painful manifestations (spermatic colic, venous thrombosis of the penis), can pose diagnostic and therapeutic difficulties, in the absence of consensus concerning their management.

CONCLUSION

These pathologies, rare but sometimes serious, must be recognized in order to not delay the treatment and to be able to reduce their morbidity and mortality. Combined with the constant improvement of our diagnostic and therapeutic arsenal, a better knowledge of these rare emergencies will help to preserve the functional and vital prognosis of patients.

Insights into the management of anorectal disease in the coronavirus 2019 disease era

Coronavirus 2019 disease (COVID-19) has created major impacts on public health. The virus has plagued a large population requiring hospitalization and resource utilization. Knowledge about the COVID-19 virus continues to grow. It can commonly present with gastrointestinal symptoms; initially, this was considered an atypical presentation, which led to delays in care. The pandemic has posed serious threats to the care of anorectal diseases. Urgent surgeries have been delayed, and the care of cancer patients and cancer screenings disrupted. This had added to patient discomfort and the adverse outcomes on healthcare will continue into the future. The better availability of personal protective equipment to providers and standard checklist protocols in operating rooms can help minimize healthcare-related spread of the virus. Telehealth, outpatient procedures, and biochemical tumor marker tests can help with mitigation of anorectal-disease-related problems. There is limited literature about the clinical management of anorectal diseases during the pandemic. We performed a detailed literature review to guide clinicians around management options for anorectal disease patients. We also highlighted the health challenges seen during the pandemic.

Validation of FGSI Scores in Predicting Fournier Gangrene in Tertiary Hospital

Background and Aim

Fournier gangrene (FG) is a necrotizing fasciitis of perineal and/or genital regions that may progressively spread; necrotic tissue may cause morbidity and mortality related to sepsis and multi-organ dysfunction. Surgical intervention required for patients with Fournier gangrene may vary according to the severity of the infection. A Fournier Gangrene Severity Index (FGSI) has been devised to assess the risk of mortality in patients with Fournier gangrene. The aim of this study was to validate the implementation of the FGSI in predicting mortality of FG patients in our hospital.

Methods

A retrospective study was performed on all patients with Fournier gangrene admitted and treated in Hasan Sadikin General Hospital during 2015–2019. Data were collected from the medical records of the emergency room and outpatient clinics. Sociodemographic variables, preexisting comorbidities, outcome, management, and FGSI score were included as variables.

Results

In this study, 83 patients were included from the period 2015–2019, divided into two groups. From the Charlson Comorbidity Index, we found the first group average score was 2.5 (0–9), and the second group this was 2 (1–8). From the FGSI, in the first group, we found the average score was 5.5 (2–15), and the average was 14 (10–19) in the second group, which is significantly higher than the first group (p = 0.001).

Conclusion

We find that the FGSI score system is a good tool for predicting severity of the disease and mortality risk of the patients, which is consistent with findings in other studies.

Imaging spectrum of common and rare infections affecting the lower genitourinary tract

In this review, we will discuss the imaging findings of common as well as uncommon lower genitourinary tract infections. For both clinicians and radiologists, it is imperative to understand etiopathogenesis, epidemiological information, clinical presentation, imaging findings and management options of such conditions. Knowledge of salient imaging features of these infections is of utmost importance because prompt recognition enables appropriate management.

Abdominoperineal Resection with Absorbable Mesh Repair of Perineal Defect for Fournier's Gangrene: A Case Report

Background

Fournier’s gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high.

Case Presentation

A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis.

Conclusion

Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

Fournier's gangrene with dapagliflozin in a rural hospital: a case report

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which are used for treatment of type 2 diabetes, are associated with risk of urogenital infections. FDA issued a black box warning about multiple case reports of Fournier’s gangrene (FG) observed in patients taking SGLT2 inhibitors. FG is a type of necrotising fasciitis that occurs in the anogenital area. We report a case of a 71-year-old woman with type 2 diabetes on dapagliflozin, presenting with foul-smelling discharge and a large abscess in the perianal area. Her risk factors for FG included her advanced age, obesity, diabetes and trauma to the site. During her stay, dapagliflozin was discontinued and she received procedural debridement, wound care and broad-spectrum intravenous antibiotics. Due to possible association between FG and SGLT2 inhibitors, patients presenting with signs and symptoms of FG who are taking SGLT2 inhibitors should be examined for infection in the urogenital area and treated promptly.

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

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.

Reconstruction of the Necrotic Scrotum with Hydrosurgery System and Pedicle DIEP Flap: A Case Report of Fournier Gangrene

Despite medical advances, the mortality rate associated with Fournier gangrene has remained largely unchanged and extremely high. In addition, conventional surgical treatment of Fournier gangrene of the scrotum requires excision of the testicles in some cases, which can result in loss of fertility. We report herein the favorable results of reconstruction of the scrotum following Fournier gangrene, using the hydrosurgery system and pedicled deep inferior epigastric perforator flap. A 60-year-old male patient was urgently transported to our hospital for fever, lower abdominal pain, and scrotal pain for several days. He was diagnosed with Fournier gangrene and underwent an emergency debridement procedure on the same day. Later, we performed a 2-phase reconstruction with a hydrosurgery system and pedicled deep inferior epigastric perforator flap under general anesthesia for the postoperative tissue defect. At 6 months postoperatively, there was no ulceration or scar contracture, and the results were aesthetically pleasing. There are no reported cases of reconstruction of the scrotum following Fournier gangrene using this procedure, and it might be an effective treatment option.

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.

A Case of Fournier's Gangrene in a Patient Taking Canagliflozin for the Treatment of Type II Diabetes Mellitus

Patient: Male, 72-year-old

Final Diagnosis: Fournier gangrene

Symptoms: Infection • pain • swelling

Medication: Canagliflozin

Clinical Procedure: Debriment

Specialty: Dermatology

Fournier's gangrene in a rectal cancer patient

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Rectal cancer induced Fournier's gangrene is mainly caused by cancer perforation.

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Vacuum assisted closure treatment helps to accelerate the healing of surgical wound.

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Prompt diagnosis and urgent surgery are crucial for patient’s favorable outcome.

Introduction

Fournier’s gangrene (FG) is caused by a variety of causes, but FG led by rectal cancer is rare.

Presentation of case

A 62-year-old man presented with perineal pain for several days. Multiple black spots on the scrotum and perineum surrounded by erythema were found on a physical exam. Computed tomography showed diffuse air density with subcutaneous edema in the perineum, scrotum, anus, and left lower abdominal wall and showed 4.1 cm-size mass in anus. He was diagnosed with FG caused by rectal cancer. He underwent extensive debridement of the perineum, scrotum, medial buttocks, and diverting loop colostomy of transverse colon. After repeated debridement of some residual necrotic tissue, abdominal perineal resection was performed after 24 days after initial surgery. The patient received reconstruction surgery of the soft tissue defect and discharged on postoperative day 84. He is being followed up without any recurrence for 10 months.

Conclusion

Prompt clinical diagnosis and urgent surgical management are crucial for patient’s favorable outcome. The patient in our case study could be recovered by a combined modality therapy we provided.

Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature

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.

Fournier Gangrene: A Review for Emergency Clinicians

BACKGROUND

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG.

DISCUSSION

Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications.

CONCLUSIONS

FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

Fournier Gangrene Associated With Sodium-Glucose Cotransporter-2 Inhibitors: A Review of Spontaneous Postmarketing Cases

BACKGROUND

Use of sodium-glucose cotransporter-2 (SGLT2) inhibitors has been associated with Fournier gangrene (FG), a rare urologic emergency characterized by necrotizing infection of the external genitalia, perineum, and perianal region.

OBJECTIVE

To describe and compare reported cases of FG in diabetic adults receiving treatment with SGLT2 inhibitors or other antiglycemic agents.

DESIGN

Descriptive case series.

SETTING

U.S. Food and Drug Administration (FDA) Adverse Event Reporting System and published case reports.

PATIENTS

Adults receiving SGLT2 inhibitors or other antiglycemic agents.

MEASUREMENTS

Clinical and laboratory data.

RESULTS

The FDA identified 55 unique cases of FG in patients receiving SGLT2 inhibitors between 1 March 2013 and 31 January 2019. The patients ranged in age from 33 to 87 years; 39 were men, and 16 were women. Time to onset after initiation of SGLT2-inhibitor therapy ranged from 5 days to 49 months. All patients had surgical debridement and were severely ill. Reported complications included diabetic ketoacidosis (n = 8), sepsis or septic shock (n = 9), and acute kidney injury (n = 4). Eight patients had fecal diversion surgery, 2 patients developed necrotizing fasciitis of a lower extremity that required amputation, and 1 patient required a lower-extremity bypass procedure because of gangrenous toes. Three patients died. For comparison, the FDA identified 19 FG cases associated with other antiglycemic agents between 1984 and 31 January 2019: metformin (n = 8), insulin glargine (n = 6), short-acting insulin (n = 2), sitagliptin plus metformin (n = 2), and dulaglutide (n = 1). These patients ranged in age from 42 to 79 years; 12 were men, and 7 were women. Two patients died.

LIMITATION

Inability to establish causality or incidence, variable quality of reports, possible underreporting, and confounding by indication.

CONCLUSION

FG is a newly identified safety concern in patients receiving SGLT2 inhibitors. Physicians prescribing these agents should be aware of this possible complication and have a high index of suspicion to recognize it in its early stages.

PRIMARY FUNDING SOURCE

None.

Management of Fournier's gangrene with skin grafting by bagging technique of testes: case report

Aim: To share our experience with the management of Fournier gangrene (FG) using the bagging technique of the testes, and to highlight the importance of implementing a multidisciplinary approach in managing FG.

Casepresentation: A 58-year-old male with type 2 diabetes mellitus (DM) was brought to the emergency department (ED) with necrotizing fasciitis involving the genitalia; he was managed in the ED with Intravenous (IV) fluid resuscitation and IV antibiotics. The surgical team was consulted and multiple debridement procedures were done. Healthy granulation tissue was formed within one month of the serial debridement. A split-thickness skin graft using bagging technique of the testes and vacuum-assisted closure (VAC) were applied. The patient was reassessed one year following presentation, and a result with a near normal appearance was achieved with complete preservation of functional outcome.

Conclusion: FG is a type of necrotizing fasciitis that could be managed either conservatively with IV antibiotics and/or hyperbaric oxygen, or surgically by debridement and applying VAC.

In our case, the testes were debrided and bagging technique of the testes was used. It’s believed that with this technique, the overall cosmetic and functional results are superior.

Recognizing Fournier's Gangrene in the Emergency Department

Fournier's gangrene is a rare disease with a significant mortality rate. The potentially fatal disease stems from both aerobic and anaerobic bacteria and primarily occurs in men. The majority of Fournier's gangrene cases are idiopathic or derived from perineal and genital skin infections. Comorbid risk factors include diabetes mellitus, alcohol misuse, and immunosuppression (). The infection initially presents as a cellulitis in the perineum or perianal area. As Fournier's gangrene progresses, the infected tissue becomes swollen, significantly painful, and necrotic. The progression of infection can lead to systemic symptoms, sepsis, and death. Early intervention is a key component in the treatment plan for Fournier's gangrene. The primary intervention is surgical debridement of the necrotic tissue. If an abscess is present, incision and drainage are indicated. In addition to surgical debridement, the administration of broad-spectrum antibiotics and hemodynamic stabilization are required (). Complications after treatment include chronic pain, sexual dysfunction, decreased sensation of the penile skin, and scarring ().

Fournier's gangrene: prospective study of 34 patients in South Indian population and treatment strategies

Introduction

Fournier's gangrene (FG) is a fulminant necrotizing fasciitis of the perineum and genitalia. The objective of this study was to study the etiology and microbiology associated with FG and to study the debridement and reconstructive procedures required in these patients.

Methods

This was a prospective follow up study conducted from September 2011 to November 2012 at Coimbatore medical college hospital, Coimbatore, India. Patients presenting to the outpatient department and emergency department with the clinical diagnosis of FG were included in the study.

Results

A total of 34 patients were studied in the study period. The mean age of presentation in years was 50±11.13. The male to female ratio was 33:1. The source of the infection was most commonly anorectal. Diabetes mellitus was the most common co morbid factor associated. Most commonly the disease was polymicrobial with escherichia coli being the commonest grown organism. The average number of wound debridement required was 2.9±1.42. Primary closure of the scrotal skin defect was the most common reconstructive procedure performed. Mortality associated with the disease in our series was 11.8%.

Conclusion

Although FG is a relatively rare disease, it is still prevalent in Indian population. Incidence of FG in HIV patients is high, even though it is not the commonest of the co morbid condition. The mortality can be kept to minimal with aggressive medical and surgical management. Extensive raw area following the infection and wound debridement can be managed by simple reconstructive procedures with good outcome.

Intestinal Perforation by a Toothpick as Reason for Necrotizing Fasciitis

Necrotizing fasciitis is an uncommon but often fatal disease. Given the various causes of necrotizing fasciitis, we report a case of sigmoid colon perforation caused by a toothpick subsequently resulting in fulminant necrotizing fasciitis of the retroperitoneum and right thigh successfully treated by hemipelvectomy and Hartmann´s procedure.

Fournier's Gangrene: Clinical Presentation of 13 Cases

BACKGROUND Fournier's gangrene (FG) is a fulminant form of infective, polymicrobial, necrotizing fasciitis of the perineal, genital, and perianal regions. It commonly affects men, but women and children may also develop this type of tissue necrosis. MATERIAL AND METHODS This study is a retrospective analysis of the management of 13 cases of Fournier's gangrene, diagnosed from among about 45 000 patients (men, women, and children) treated in the Department of General, Oncological, and Functional Urology (Medical University of Warsaw) from 1995 to 2013. All patients with Fournier's gangrene underwent adequate surgical debridement of the necrotic tissues. Additional procedures (suprapubic cystostomy and orchiectomy) were necessary in 10 out of 13 (77.0%) patients. Seven out of 13 (53.8%) patients required subsequent reconstructive surgery of the scrotum. RESULTS All 13 patients were males, with a median age of 59.6 years (range: 42-68 years). The average hospital stay was 31.9 days (range: 16-46 days). None of our patients died due to Fournier's gangrene. Bacteriological cultures of samples from the wounds showed polymicrobial flora, including the following genera of aerobes and anaerobes: Escherichia, Proteus, Klebsiella, Moraxella, Gemella, Enterococcus, Streptococcus, Staphylococcus, Bacteroides, Pseudoflavonifractor, Parabacteroides, Porphyromonas, Prevotella, Peptoniphilus, Peptostreptococcus, Actinomyces, Collinsella, and Lactobacillus. CONCLUSIONS Favorable outcome of FG treatment with low morbidity and no mortality can be achieved with rapid diagnosis, urgent surgical debridement of all necrotic tissues, and broad-spectrum empirical antimicrobial therapy, usually with combined antibiotics, against aerobic and anaerobic bacteria. Prevention of uroseptic shock by treating localized infection is compulsory.