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

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.

Management of Fournier's gangrene in a newborn: A rare case report and literature review

INTRODUCTION

Fournier's gangrene (FG) in neonates is less common than in adults, but this case can lead to a poor prognosis. FG is a disease of the genital, perianal, and perineal areas characterized by necrotizing infections. Here, we report a case of a 24-day-old male infant diagnosed with Fournier's gangrene involving the scrotum.

CASE PRESENTATION

The patient presented with scrotal swelling, fever, erythema, and insect bites on the penile tip that had gradually extended to the proximal area and bilateral scrotum. On physical examination, indurated grayish and blackish-brown scrotal skin with sharp distinction from the surrounding normal skin, erythema, purulence, ulceration, and necrotic tissue were observed. Abdominal X-ray and scrotal ultrasonography revealed gaseous distension of the scrotal region, free fluid on bilateral testes, and enlargement of bilateral testicles. Immediate surgical debridement, along with broad-spectrum antibiotics, was initiated, and a microbiological culture identified the presence of Pseudomonas aeruginosa. The patient demonstrated the completed healing of the surgical wound after thirty days of surgical intervention.

DISCUSSION

Fournier's gangrene in neonates is a sporadic case. Our patient presented with multiple predisposing factors, including insect bites and poor hygiene, underscoring the need for heightened clinical suspicion in vulnerable populations. Prompt recognition and intervention are critical, given the rapid progression of FG.

CONCLUSION

This case underscores the importance of timely diagnosis and early initiation of surgical and medical interventions in neonatal Fournier's gangrene, particularly in cases involving the scrotum.

Development of Fournier's gangrene after chemotherapy for the recurrence of testicular cancer despite the absence of anorectal lesions: A case report

BACKGROUND

Fournier's gangrene usually occurs when a specific bacterium intrudes into soft tissue, causing a wound or tumor. We encountered a patient with Fournier's gangrene due to severe myelosuppression after chemotherapy, despite the absence of an initial lesion on the anus and rectum.

CASE PRESENTATION

A 54-year-old man with a left testicular cancer recurrence had undergone chemotherapy. He had asymptomatic hepatitis and high hepatitis B virus DNA levels, which were normalized by administering tenofovir alafenamide fumarate. Twelve days after the start of chemotherapy, he complained of severe pain around the anus. The following day, he went into septic shock. Visual inspection showed dark purple skin discoloration on the left side of the anus. Laboratory data revealed severe neutropenia. Computed tomography showed a high density of soft tissue on the left side of the anus and gas bubbles in the left femoral ring. We diagnosed the patient with Fournier's gangrene due to a severe immunosuppressive state resulting from chemotherapy. We emergently removed necrotic tissue to the fullest extent possible. However, because the patient was in severe sepsis status, careful management in the intensive care unit was required for 32 days. After the first emergency operation, we performed several additional excisions. Finally, 391 days after the initial surgery, the patient was discharged from our hospital. The tumor has not recurred, and he is under outpatient observation in the urology department.

CONCLUSION

Fournier's gangrene should be considered in patients who are in a severe myelosuppressive state due to chemotherapy, have normal hepatitis B virus DNA levels but high hepatitis B surface antigen after tenofovir administration, complain of severe pain in the perianal area, and have a dark purple skin discoloration around the anus, despite having no initial anorectal lesions.

Fournier's Gangrene Surgical Reconstruction: A Systematic Review

Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.

Early Diagnosis and Treatment Outcomes of Fournier Gangrene in a Tertiary Center

INTRODUCTION

Fournier gangrene is an uncommon urological emergency caused by microbial agents, resulting in necrosis of the genitalia and perineum. This study aims to evaluate the outcomes of early diagnosis and management of Fournier gangrene at KAMC in Riyadh, Saudi Arabia.

METHODS

A retrospective cohort study was conducted at KAMC, Saudi Arabia. The study population included all adult patients diagnosed with Fournier gangrene between 2015 and 2022. Data analysis was performed using RStudio (RStudio, Boston, MA). Frequencies and percentages were used to present categorical data, while medians and interquartile ranges were used to express numerical variables.

RESULTS

The study included 41 patients with Fournier gangrene, the majority (95.12%) being male with a median age of 60 years. The most prevalent comorbidity was diabetes mellitus (85.37%). Ten patients presented to the hospital with sepsis, two of whom were in shock. Within 90 days of admission, two of them had expired. This resulted in a 20% mortality rate among septic patients. The mean FGSI in patients who had died during hospital stays was approximately two times the mean in surviving patients (8.17 and 4.32, respectively). The most utilized imaging study was a CT scan (70.7%). Most patients had undergone multiple debridements (87.7%). The median number of debridements per patient was three, and the interval between each debridement was three days. The most frequent tissue culture finding was mixed organisms, followed by Escherichia coli. Regarding empiric antibiotics, tazocin was the most used, accounting for 22.0%. The most frequently performed adjunctive procedure was the placement of a suprapubic catheter, accounting for 41.5%. Roughly 43.90% required a blood transfusion. Within 90 days of admission, six patients had died, which makes the mortality rate 14.6%. Four of them had died within 30 days of admission (9.76%).

CONCLUSION

Fournier gangrene is a surgical emergency that requires prompt attention and resuscitation, antibiotic therapy, and surgical debridement. The study identified the demographic factors of patients who presented with the disease and provided the incidence, mortality rate, and outcomes of the disease. It also identified specifics of the pharmacological and surgical management and hospital courses.

Nursing care plan for a patient with Fournier's gangrene: Clinical case

INTRODUCTION

Fournier's gangrene, a relatively rare form of necrotizing fasciitis, is a rapidly progressive disease affecting the deep and superficial tissues of the perineal, anal, scrotal, and genital regions. Despite the significant evolution in medical knowledge, there is still scarce evidence regarding the nursing care plan in patients affected by this pathology, which hinders its correct management. For this reason, we present the following clinical case of a 53-year-old male patient with Fournier's gangrene who was admitted to the emergency department for 3 days of pain in the perineal area and fever.

OBJECTIVE

The objective was to establish an individualized care plan for the patient detailing the diagnoses, expected outcomes and interventions through nursing taxonomies.

CASE DEVELOPMENT

A systematic assessment was performed using Marjory Gordon's model of functional health patterns as a reference. After drawing inferences, three collaborative problems and two nursing diagnoses were established with their outcome criteria and interventions. Once the plan was executed, the results obtained highlighted that the interventions were consistent in achieving the objectives set out in the problems present in the case patient.

CONCLUSIONS

The development of an individualized plan made it possible to detect problems, establish realistic objectives and define interventions that optimized nursing care in this patient with Fournier's gangrene.

A Case of Fournier's Gangrene Following the Initiation of Dapagliflozin

Since being approved by the United States Food and Drug Administration (FDA) in 2013, sodium-glucose cotransporter-2 inhibitors (SGLT2is) have emerged as an appealing therapeutic choice for patients with diabetes due to their favorable effects on renal and cardiac health. Recent trials have further expanded the application of these drugs by showing a decrease in mortality rates among patients with both reduced and preserved ejection fraction heart failure, even in those without diabetes. Common adverse effects of SGLT2is include increased urinary frequency and urinary tract infections stemming from elevated glycosuria. Here, we present a case report involving a 66-year-old man who developed Fournier's gangrene (FG) shortly after initiating dapagliflozin - a rare but dangerous adverse effect associated with this medication.

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.

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

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

Fournier's gangrene with Streptococcus Anginosus in the setting of hidrandenitis suppurativa perineal abscess: A case report

INTRODUCTION

Fournier's gangrene is a rare but life-threatening form of necrotizing soft tissue infection involving the perineal, genital, or perianal region, commonly caused by a mix of aerobic and anaerobic organisms. Initially discovered in dental abscesses, Streptococcus anginosus have been increasingly reported in pyogenic and systemic infections with abscess formation. We present a rare case of perineal abscess that developed into Fournier's gangrene in which the causative pathogen isolated was S. anginosus.

PRESENTATION OF CASE

A 58-year-old male with uncontrolled type 2 diabetes, hypertension and hidradenitis suppurativa of the groin, presented with worsening testicular pain. He was found to have a necrotizing soft tissue infection of the perineum, consistent with Fournier's gangrene. He was successfully treated with multiple surgical debridement and broad-spectrum intravenous antibiotics. He was transitioned to oral antibiotics before transferring to a tertiary care facility for reconstruction.

DISCUSSION

The setting of uncontrolled diabetes and hidradenitis suppurativa may be the likely etiology for this peculiar case of Fournier's gangrene secondary to S. anginosus. Compromised tissue integrity and impaired local immune defenses from these etiologies predisposes to the development of Fournier's gangrene. Historically, these abscesses typically resolve after intravenous antibiotics and incision and drainage. However, the abscess in this case did not resolve but rather progressed to Fournier's gangrene. Perineal abscesses that grow S. anginosus should raise a high index of suspicion for worse outcomes.

CONCLUSION

In conclusion, we recommend a multidisciplinary approach and rapid diagnosis for the management of S. anginosus in the setting of a perineal abscess, with early aggressive surgical debridement and broad-spectrum antibiotics.

Favorable Safety Outcomes of Delayed Primary Closure of Large Fournier's Gangrene Skin Defects

OBJECTIVE

To assess the feasibility and safety of delayed primary closure (DPC) in Fournier's gangrene (FG) patients with large genital defects.

METHODS

A single institution retrospective review was performed from October 2020 to December 2022 of adult males that underwent DPC for FG. All patients underwent standard medical management and were assessed for DPC eligibility by the urology service. Clinical data on patient factors and outcomes were collected, and descriptive statistics were assessed.

RESULTS

Of 16 patients that underwent DPC, the average age was 61.1years and body mass index was 34.6 kg/m2. Median Charlson Comorbidity Index was 3.5 (IQR 2-5.3) and Fournier's Gangrene Severity Index was 6.5 (IQR 4.8-8). Median number of debridements was 2.5 (IQR 2-3), with a time to closure of 6.5days (IQR 3-11) and length of stay of 13days (IQR 9-16.3). Mean genital defect size was 119 cm2 (range 44-346 cm2). Eight patients (50%) were closed using scrotal flaps alone while other patients had advancement flaps using the inner thigh, lower abdomen, and perineum. The majority of patients were discharged home directly (63%). There were four Clavien-Dindo III complications: two partial flap necrosis, one wound dehiscence, and one instance of bleeding. Of patients with follow-up, 6/15 (40.0%) had no known complications.

CONCLUSION

DPC is safe and effective for a range of patients presenting with FG. Patients with large defects may benefit from less complex wound management and direct discharge home.

PoCUS for the management of Fournier's gangrene in the emergency department: A case report

Serious soft tissue infections in the spectrum of rapidly progressive necrosis of the fascia and subcutaneous tissue represent a clinical challenge in emergency department clinical practice. Fournier's gangrene (FG) is a presentation thereof that compromises the urogenital area. A low threshold of clinical suspicion complementary to laboratory evaluation and imaging is necessary to act rapidly and perform diagnostic and therapeutic surgical intervention for this condition. The present study reported the case of a 63-year-old woman who was admitted with buttock skin changes for 72 h. The diagnostic impression was septic shock due to FG. Point-of-care ultrasound (PoCUS) was performed, indicating free fluid in the muscle planes, discontinuity of the muscle fascia and the presence of gas in the subcutaneous cellular tissue. The patient was taken to surgery 2 h after admission. PoCUS was indicated to have an acceptable diagnostic performance that may optimize the care of this type of patient depending on the conditions of the emergency department and the availability of other resources.

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULT

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

CONCLUSIONS

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

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.

Fournier Gangrene Management: Is a Stoma Mandatory?

Fournier gangrene is a rare life-threatening surgical emergency mainly due to a polymicrobial infection of the perineal, genital, or perianal region. It is characterized by rapid tissue destruction and systemic signs of toxicity. It is more frequent in males and immunocompromised patients, such as patients with poorly controlled diabetes, alcoholism, or human immunodeficiency virus (HIV) infection. Treatment often involves surgical intervention, broad-spectrum antibiotic therapy, fecal diversion surgery, and negative pressure wound therapy (NPWT). Delays in diagnosis are associated with high mortality due to rapid progression to septic shock.

Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases

Introduction

Fournier's gangrene (FG) is an infection of the subcutaneous tissue and fascia that progresses quickly and leads to necrosis. It is more prevalent in male patients and immunocompromised individuals, such as those suffering from uncontrolled diabetes. It has a high mortality rate, which makes its early identification and clinical suspicion critical. This study aimed to compare two laboratory parameters, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and to predict the mortality of FG in a tertiary care hospital.

Methods

In a retrospective study, data was retrieved from medical records for the period from January 2014 to December 2020, of patients diagnosed with FG. Recorded data that is age, sex, comorbidities, mortality, and laboratory results (PLR and NLR) were used to assess determinants of survival.

Results

There were 23 (17.04%) nonsurvivors among the 135 subjects studied. The mean age was 50.9 ± 14.9 years and men were 103 (83%) patients. Among the participants, diabetes mellitus was the most frequent comorbidity at 74 (54.81%) patients. NLR ≥8 was statistically significant (P = 0.013) for identifying mortality, while PLR >140 was not. In multivariate analysis, NLR ≥8 was found to be a reliable predictor of the FG mortality rate (adjusted odds ratio 12.062, confidence interval 95% 2.115-68.778, P = 0.005).

Conclusion

NLR had prognosis predictive value for FG, whereas PLR did not.

Abdominal Extension of Fournier Gangrene From Undiagnosed Crohn's Disease: A Case Report

Cellulitis and abscess are common skin infections in military populations. Although complications of necrotizing soft tissue infections (NSTIs) such as Fournier Gangrene (FG) are rare, they are associated with significant morbidity and mortality. Laboratory and radiological studies may aid in the evaluation of NSTI; however, focus should remain on physical examination and prompt surgical consultation, as these infections can spread rapidly with significant increases in mortality with delayed management. We present the case of a 37-year-old male soldier with reported history of two distant left inguinal hernia repairs, complaining of increasing buttock pain despite outpatient antibiotic therapy for perineal cellulitis from his primary clinician. Despite normal vital signs and low risk from established NSTI calculator scores, examination revealed crepitus and severe tenderness extending from the buttock through the perineum and scrotum characteristic of FG. Preoperative computed tomography found additional spread of subcutaneous air from these areas into the lower abdomen, likely facilitated by the previously repaired left inguinal hernia. Surgical management necessitated debridement, multiple washouts, and ileostomy. Follow-up evaluations revealed previously undiagnosed Crohn's disease with fistula-in-ano as the inciting factor.

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 Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy

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.

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.

Fournier's gangrene mimicking an acute epididymitis

Fournier's gangrene is a urologic emergency secondary to a necrotizing soft tissue infection. Fournier's gangrene is characterized by severe pain and features of Fournier's gangrene may include edema, blisters and bullae, crepitus, subcutaneous gas, and systemic symptoms. Risk factors include male gender, alcohol abuse, immunocompromised state, uncontrolled diabetes mellitus, obesity, and malignancy. The diagnosis is made clinically but is often supported by radiography, ultrasound, computed tomography, and magnetic resonance imaging. Treatment consists of emergent hospitalization and surgery to debride the necrotic tissues. Morbidity and mortality for Fournier's gangrene are very high if left untreated. Early surgical intervention is key to the successful treatment of Fournier's gangrene. This case report presents a case of Fournier's gangrene mimicking acute epididymitis and highlights the importance of a thorough physical examination with high clinical suspicion for Fournier's gangrene.

Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Cellulitis and abscess are a common reason for presentation to the emergency department, although there are several nuances to the care of these patients.

OBJECTIVE

The purpose of this narrative review article was to provide a summary of the background, pathophysiology, diagnosis, and management of cellulitis and abscesses with a focus on emergency clinicians.

DISCUSSION

The most common bacteria causing cellulitis are Staphylococcus aureus, Streptococcus pyogenes, and other β-hemolytic streptococci, and methicillin-resistant S. aureus is most common in abscesses. The history and physical examination are helpful in differentiating cellulitis and abscess in many cases, and point-of-care ultrasound can be a useful tool in unclear cases. Treatment for cellulitis typically involves a penicillin or cephalosporin, and treatment of abscesses is incision and drainage. Loop drainage is preferred over the traditional incision and drainage technique, and adjunctive antibiotics can be considered. Most patients can be managed as outpatient.

CONCLUSIONS

It is essential for emergency physicians to be aware of the current evidence regarding the diagnosis and management of patients with cellulitis and abscess.

Fournier's Gangrene Diagnosis and Treatment: A Systematic Review

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.