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Suleimanov V, Al Hawaj K, Al Rebh FN, Naser H, Al Noaim S. A Challenging Case of Fournier's Gangrene With Multiple Complications. Cureus 2023; 15:e48036. [PMID: 38034187 PMCID: PMC10688236 DOI: 10.7759/cureus.48036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Fournier's gangrene, a not-so-common urological emergency, is a fast-progressing necrotizing bacterial infection that affects the perineum and external genitalia and can be rapidly fatal unless diagnosed and aggressively managed promptly. Fever, erythematous edema of the scrotum, and palpation of classic scrotal crepitation are among the clinical symptoms. The treatment involves rapid administration of empirical broad-spectrum antibiotics with gram-positive, gram-negative, and anaerobic coverage and rigorous surgical debridement down to the bleeding tissues. The medium-term complications of this condition are primarily associated with extended stay in an intensive care unit and cardiorespiratory, thromboembolic, and cutaneous complications, whereas the long-term complications are mainly functional, aesthetic, and psychological. Also, there are complications inherent to ancillary interventions such as penectomy, orchidectomy, reconstructive surgery, and restoration of digestive continuity. Herein, we present the case of a 40-year-old diabetic male who was admitted with an initial diagnosis of scrotal abscess, which turned out to be Fournier's gangrene. Despite developing multiple complications and numerous surgeries, he made a full recovery and was discharged home after a prolonged hospital stay.
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Affiliation(s)
| | | | | | - Husain Naser
- General Surgery, Jubail General Hospital, Jubail, SAU
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Zhang KF, Shi CX, Chen SY, Wei W. Progress in Multidisciplinary Treatment of Fournier's Gangrene. Infect Drug Resist 2022; 15:6869-6880. [PMID: 36465810 PMCID: PMC9717591 DOI: 10.2147/idr.s390008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/10/2022] [Indexed: 07/27/2023] Open
Abstract
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.
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Affiliation(s)
- Ke-Fan Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Chuan-Xin Shi
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Wei Wei
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
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Chowdhury T, Gousy N, Bellamkonda A, Dutta J, Zaman CF, Zakia UB, Tasha T, Dutta P, Deb Roy P, Gomez AM, Mainali A. Fournier’s Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy. Cureus 2022; 14:e27773. [PMID: 36106208 PMCID: PMC9450557 DOI: 10.7759/cureus.27773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used for the management of type II diabetes mellitus targeting the kidneys. Within the last decade, several warnings have been issued regarding the development of severe genitourinary infections, including necrotizing fasciitis, or Fournier’s gangrene, in those with pre-existing type II diabetes and concomitant use of this drug class. Objective: The purpose of this review is to highlight and discuss the factors contributing to the development of Fournier’s gangrene, its pathogenesis, and a review of existing literature describing patient outcomes, treatment, and future directions regarding early detection of this complication. Methods: Articles and studies addressing effective treatment adherence and key factors contributing to Fournier’s gangrene with SGLT2 inhibitors were identified by effective keyword searches in PubMed Central, Google Scholar, and Cochrane, as well as the references found within these articles. Results: Using the keywords provided, 55 case reports, review articles, and meta-analysis reports written within the last 20 years were utilized as the source of the data presented in this systematic review article.
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Practical Review of the Current Management of Fournier’s Gangrene. Plast Reconstr Surg Glob Open 2022; 10:e4191. [PMID: 35295879 PMCID: PMC8920302 DOI: 10.1097/gox.0000000000004191] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/18/2022] [Indexed: 12/18/2022]
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Lewis GD, Majeed M, Olang CA, Patel A, Gorantla VR, Davis N, Gluschitz S. Fournier's Gangrene Diagnosis and Treatment: A Systematic Review. Cureus 2021; 13:e18948. [PMID: 34815897 PMCID: PMC8605831 DOI: 10.7759/cureus.18948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
Fournier's gangrene (FG) is a perineal and abdominal necrotizing infection. It is most commonly found in middle-aged men with comorbidities such as diabetes mellitus. Initial symptoms are often indistinct and can rapidly progress to overwhelming infections with a relatively high mortality rate. It is crucial to make a prompt diagnosis so that the patient receives appropriate treatment. Given the importance of the identification of FG, we explored what were the most common signs and symptoms associated with FG, as well as distinguished the gold standard treatment. This systematic review utilized articles identified exclusively through PubMed using key terms such as Fournier's gangrene, signs, symptoms, and treatment. A total of 37 studies, including a total of 3,224 patients (3,093 males and 131 females), fit our inclusion parameters for relevance that included either the most identifiable presentation of FG or the most effective treatment. From our search, the most common clinical presentation was scrotal and labial pain, fever, abscesses, crepitus, erythema, and cellulitis. Diagnosis is made from clinical findings in conjunction with imaging. The gold standard for treatment was found to be a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids. Further, patient survival was found to be directly related to the time from diagnosis to treatment when they underwent surgical debridement. The importance of early identification for improved outcomes or survival highlights the need for further studies or measures to enhance the identification of the signs and symptoms of FG.
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Affiliation(s)
- Gregory D Lewis
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Maliha Majeed
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Catherine A Olang
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Arjun Patel
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Vasavi Rakesh Gorantla
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Nelson Davis
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Sarah Gluschitz
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
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Creta M, Longo N, Arcaniolo D, Giannella R, Cai T, Cicalese A, De Nunzio C, Grimaldi G, Cicalese V, De Sio M, Autorino R, Lima E, Fedelini P, Marmo M, Capece M, La Rocca R, Tubaro A, Imbimbo C, Mirone V, Fusco F. Hyperbaric oxygen therapy reduces mortality in patients with Fournier's Gangrene. Results from a multi-institutional observational study. MINERVA UROL NEFROL 2020; 72:223-228. [PMID: 32083420 DOI: 10.23736/s0393-2249.20.03696-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Massimiliano Creta
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Nicola Longo
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Davide Arcaniolo
- Unit of Urology, Luigi Vanvitelli University of Campania, Naples, Italy
| | | | - Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
| | | | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Giovanni Grimaldi
- Uro-Gynecological Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, IRCCS, G. Pascale Foundation, Naples, Italy
| | | | - Marco De Sio
- Unit of Urology, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Riccardo Autorino
- Unit of Urology, Luigi Vanvitelli University of Campania, Naples, Italy
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, USA
- Division of Urology, McGuire VA Medical Center, Richmond, VA, USA
| | - Estevao Lima
- Department of Urology, Braga Hospital, Braga, Portugal
| | - Paolo Fedelini
- Department of Urology, A. Cardarelli Hospital, Naples, Italy
| | - Mariano Marmo
- Department of Anesthesia, Intensive Care and HBOT Unit, A. Cardarelli Hospital, Naples, Italy
| | - Marco Capece
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Roberto La Rocca
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Andrea Tubaro
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Ciro Imbimbo
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Vincenzo Mirone
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy
| | - Ferdinando Fusco
- Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy -
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Sparenborg JD, Brems JA, Wood AM, Hwang JJ, Venkatesan K. Fournier's gangrene: a modern analysis of predictors of outcomes. Transl Androl Urol 2019; 8:374-378. [PMID: 31555561 DOI: 10.21037/tau.2019.03.09] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Fournier's gangrene (FG) is a rapidly progressing necrotizing fasciitis that carries a significant morbidity and mortality. The present study sought to identify the predisposing factors related to FG and validate the Fournier's Gangrene Severity Index (FGSI) score as a prognostic tool in the care of the Fournier's patient. Methods Medstar Washington Hospital Center records were searched from January 2003 to February 2015 for all patients with a diagnosis code of FG, n=42. Epidemiologic data was collected for patients and used to calculate an FGSI score. Results The average age was 53.45 yrs and M/F ratio was 39:1. Patients presented with an average 2.675 predisposing factors; the most common was diabetes mellitus (n=21) followed by hypertension (n=18). The most common etiology was periscrotal (n=25) next to perirectal (n=9). Streptococcus was the most common source of infection (n=14). Patients on average required three surgical interventions. The average and median hospitalization period was 19.625 and 11.5 days respectively. Eleven patients developed sepsis. Twenty-four (60%) patients experienced a complication. The overall mortality was 5% (n=2). The average FGSI on admission was 5.368. Multivariate analysis showed FGSI score correlates with more surgical intervention, longer hospitalization, sepsis, complication and mortality. Conclusions The FGSI score predicts a greater likelihood of more surgical interventions, longer hospitalization period, sepsis, complications and mortality within this patient population. Diabetes mellitus continues to be the most common predisposing factors in FG patients. The mortality rate of 5% is much less than the historically reported 20-30% and may reflect improved understanding and care of this aggressive disease.
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Affiliation(s)
| | - Jacob A Brems
- MedStar Georgetown University Hospital, Washington, DC, USA
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Abstract
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 ().
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Affiliation(s)
- Tracie Gadler
- Georgetown University, Washington, District of Columbia
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