Fournier's Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases

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 gangrene with concurrent multifocal necrotizing fasciitis: a systematic review and case report

PURPOSE

A patient presented to a regional surgical center with Fournier gangrene (FG) and concurrent multifocal necrotizing fasciitis (NF). Given the rarity, it was decided to undertake a systematic review to investigate the incidence and prevalence of FG with multifocal NF and consequently determine the treatment and approach to management of such presentation.

METHODS

Firstly, the report of the 56-year-old male patient is discussed regarding his surgical management. Secondly, a systematic review was undertaken according to PRISMA guidelines using MEDLINE, Scopus, and Embase databases. Searches used the following MeSH terms: ("fournier's gangrene") AND ((necrotising fasciitis) OR (necrotising soft tissue infection)). Once the search results were obtained, duplicate articles were removed. Titles, abstracts, and articles were reviewed by 2 authors.

RESULTS

The search strategy using the 3 databases revealed a total of 402 studies. Fifty-seven studies were removed due to duplication. A total of 345 records were screened via title and abstract, of which 115 were excluded. Two hundred and thirty studies were reviewed for eligibility. A total of all 230 studies were excluded; 169 were excluded as they included the incorrect patient population (patients suffered from FG or NF, but not both collectively), 60 studies were excluded due to incorrect study designs, and 1 report occurred in the wrong setting.

CONCLUSION

This highlights that while being a relatively known, uncommon infection both FG and NF are well documented separately within the literature. However, FG with concurrent multifocal NF has not been documented within the literature.

Two-Stage Penile Reconstruction after Paraffin Injection: A Case Report and a Systematic Review of the Literature

BACKGROUND

Penile injection of foreign materials is an obsolete practice often performed by non-medical personnel in order to enlarge penile size.

METHODS

A systematic review of the literature from 1956 to 2022 was conducted in accordance with the general guidelines recommended by the Primary Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We included full papers published from 1956 to 2022. We also described a case report of a 23 year old Bulgarian male affected by penile paraffinoma who underwent a 2-stages surgical technique.

RESULTS

A total of 152 cases have been reported, with a median age of 37.9 ranging from 18 to 64 years. Six different techniques have been described in the whole literature: bilateral scrotal flap, simple excision of the paraffinoma with primary closure, two-stage scrotum skin flap, medial prepuce-soprapubic advancement flap technique and penile reconstruction using split thickness skin graft (STSG) or full thickness skin graft (FTSG). An analysis of the distribution among early and late complications was then carried out.

CONCLUSION

In our experience, among the variety of surgical techniques described, a two-stage penile reconstruction using scrotal skin results in excellent cosmetic and functional outcomes, with a low rate of complications.

The Antimicrobial Resistance Index and Fournier Gangrene Severity Index of Patients Diagnosed with Fournier's Gangrene in a Tertiary Hospital in North Eastern Romania

Background: Although rare, Fournier's gangrene is a major urological emergency. We aimed to learn more about the pathogenesis of Fournier's gangrene and assess the antibiotic resistance patterns in individuals with this disease. Methods: We retrospectively evaluated the patients diagnosed with and treated for Fournier's gangrene in a Neamt county hospital and "CI Parhon" Clinical Hospital in Iasi, Romania between 1 January 2016 and 1 June 2022. Results: We included a total of 40 patients, all males; of these, 12.5% died. In our study, in the patients that died, the adverse prognostic factors were a higher body temperature (38.12 ± 0.68 vs. 38.94 ± 0.85 °C; p = 0.009), an elevated WBC (17.4 ± 5.46 vs. 25.23 ± 7.48; p = 0.003), obesity (14.28% vs. 60%; p = 0.04), and a significantly higher FGSI (4.17 ± 2.80 vs. 9.4 ± 3.2; p = 0.0002) as well as MAR index (0.37 ± 0.29 vs. 0.59 ± 0.24; p = 0.036). These patients were more likely to have liver affections than those in the group who survived, but the difference was not significant. The most frequently identified microorganism in the tissue secretions culture was E. coli (40%), followed by Klebsiella pneumoniae (30%) and Enterococcus (10%). The highest MAR index was encountered in Acinetobacter (1), in a patient that did not survive, followed by Pseudomonas (0.85) and Proteus (0.75). Conclusions: Fournier's gangrene remains a fatal condition, a highly resistant causative microorganism that is not always correlated with a poor prognosis.

Multidisciplinary Approach to the Diagnosis and Therapy of Mycosis Fungoides

Mycosis fungoides is the most common primary cutaneous T-cell lymphoma, characterized by skin-homing CD4+ T cells derivation, indolent course, and low-grade of malignancy. Mycosis fungoides's classic type typically onsets with cutaneous erythematous patches, plaque, and tumor. In WHO-EORTC classification, folliculotropic mycosis fungoides, pagetoid reticulosis, and granulomatous slack skin are recognized as distinct variants of mycosis fungoides, because of their clinical and histological features, behavior, and /or prognosis. Mycosis fungoides often shows diagnostic difficulties, due to its absence of specific features and lesional polymorphism. A patient's treatment requires staging. In about 10% of cases, mycosis fungoides can progress to lymph nodes and internal organs. Prognosis is poor at advanced stage and management needs a multidisciplinary team approach. Advanced stage disease including tumors, erythroderma, and nodal, visceral, or blood involvement needs skin directed therapy associated with systemic drugs. Skin directed therapy includes steroids, nitrogen mustard, bexarotene gel, phototherapy UVB, and photochemiotherapy, i.e., total skin electron radiotherapy. Systemic therapies include retinoids, bexarotene, interferon, histone deacetylase inhibitors, photopheresis, targeted immunotherapy, and cytotoxic chemotherapy. Complexity of mycosis fungoides associated with long-term chronic evolution and multiple therapy based on disease stage need a multidisciplinary team approach to be treated.

Hyperbaric oxygen therapy as adjuvant treatment for surgical site infections after male-to-female gender affirmation surgery: A ten-year experience

INTRODUCTION

Several urological conditions that share an impairment of tissue oxygenation can benefit from hyperbaric oxygen therapy (HBO), limited evidence is available on the impact of HBO in patients undergoing male-to-female (MtF) Gender Affirmation Surgery (GAS).

AIM

To evaluate the efficacy and safety of HBO as adjuvant treatment for surgical site infections in patients undergoing MtF GAS.

METHODS

This research was conducted as an observational retrospective study. Patients undergoing MtF GAS at the principal investigators' Institution from January 2009 to September 2019, with a discharge diagnosis of complicated superficial or deep wound infections, were included. All patients underwent standard management of wound infection. Subjects received HBO or not at the surgeon's discretion and were assigned to the HBO vs. non-HBO group accordingly. Complete wound healing rate (primary outcome), duration of antibiotic therapy, perineal drain time, bladder catheter time, and hospital stay were recorded. All adverse events that occurred during the study period were described.

RESULTS

A total of 156 patients underwent MtF GAS in the study period. Thirty-three patients were enrolled. Fifteen subjects belonged to the HBO group, the other 18 to the non-HBO group. No statistically significant differences were found between the two groups at baseline. Penile inversion vaginoplasty and intestinal vaginoplasty were performed in 9 (60%) and 6 (40%) patients of the HBO group. Only penile inversion vaginoplasty was performed in subjects of the non-HBO group. Complete wound healing was obtained in 15 patients (100%) of the HBO group and 17 patients (94.4%) of the non-HBO group (p = 0.35). Duration of antibiotic therapy, perineal drain time, bladder catheter time, and hospital stay were significantly lower in the HBO group (p<0.05).

CONCLUSION

Our preliminary data suggest a role of HBO as adjuvant treatment for surgical site infection in patients undergoing MtF GAS. Randomized controlled trials properly powered are needed to confirm our findings. This article is protected by copyright. All rights reserved.

Reconstruction of the Scrotum With Bilateral Gracilis Muscle Rotational Flaps in a Patient With Acute Myeloid Leukemia Complicated by Fournier’s Gangrene

We describe the case of a 43-year-old male diagnosed with acute myeloid leukemia complicated by Fournier’s gangrene. Multiple debridements led to the complete effacement of the scrotum, with 360 degrees of exposed testes and a narrow base of suspension. It was decided to reconstruct the scrotum using bilateral gracilis muscle rotational flaps, followed by split-thickness skin grafting from the thigh. The gracilis muscle as a donor flap allowed for the protection and support of the testes and suspensory tissue while achieving an aesthetically pleasing result that resembled the normal scrotum. We hope providers will consider this reconstructive method in future patients who present with similar extensive effacement of the scrotal tissue.

The role of C-reactive protein ratio in predicting mortality in patients with Fournier gangrene

Purpose

This study aimed to determine the C-reactive protein (CRP) ratio for the survival of patients with Fournier gangrene (FG).

Methods

Fifty-two patients with FG between January 2011 and September 2018 were retrospectively analyzed. Data on clinical presentation, Fournier Gangrene Severity Index (FGSI), CRP ratio, management, and outcome were analyzed. The CRP ratio was calculated as preoperative CRP/postoperative CRP value that measured 48 hours after surgical intervention. Possible alternative cutoff points for the FGSI and CRP were determined by receiver operating characteristic (ROC) analyses. The risk factors related to the prognosis were evaluated by univariate and multivariable logistic regression analyses.

Results

The mean CRP ratios were 6.7±6.6 in the survivor group and 1.2±0.8 in the non-survivor group (P=0.001). FGSI was significantly higher in the non-survivor group compared to survivor group (8.5±2.5 vs. 3.5±2.2, P=0.001). There was a negative correlation between FGSI and CRP ratio (r=-0.51). ROC analysis determined the cutoff value as 1.78 for CRP (sensitivity, 86%; specificity, 82%; AUC, 0.90) to predict death. The incidence of death for patients with CRP ratio of ≤1.78 increased 26.7 fold for those with CRP ratio of >1.78 (95% confidence interval [CI], 4.8-146.5; P=0.001). In the multivariable logistic regression model, CRP ratio (odds ratio [OR], 10.3; 95% CI, 1.5-72.2; P=0.019) and FGSI (OR, 17.8; 95% CI, 2.6-121.1; P=0.003) were independent risk factors for death.

Conclusion

The CRP ratio is a simple method to use to predict mortality in FG.