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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 53-55

Fournier's gangrene and perianal abscess: Is there a common denominator?


1 Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication30-Jan-2017

Correspondence Address:
Ajibola Emmanuel Jeje
Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, PMB 12003, Idiaraba, Surulere, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-6859.199166

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  Abstract 

Fourniers gangrene is a genital catastrophe with significant morbidity and mortality. We present a 57 year old patient with fournier's gangrene and perianal abscess. He had serial debridements with daily bedside dressing and secondary closure of the scrotal defect. Further evaluation during the course of treatment revealed diabetes mellitus. We conclude that aggressive multidisciplinary treatment will improve outcome and that the existence of fournier's gangrene coexisting perianal abscess could alert the clinician to the possibility of underlying diabetes mellitus - A common denominator.

Keywords: Diabetes mellitus, Fournier's gangrene, perianal abscess


How to cite this article:
Jeje AE, Mofikoya BO, Oliyide AE. Fournier's gangrene and perianal abscess: Is there a common denominator?. J Clin Sci 2017;14:53-5

How to cite this URL:
Jeje AE, Mofikoya BO, Oliyide AE. Fournier's gangrene and perianal abscess: Is there a common denominator?. J Clin Sci [serial online] 2017 [cited 2019 Sep 22];14:53-5. Available from: http://www.jcsjournal.org/text.asp?2017/14/1/53/199166


  Introduction Top


Fournier's gangrene (FG) is an acute, rapidly progressive, potentially fatal, and infective necrotizing fasciitis affecting the external genitalia, perineal, or perianal region.[1] It was first reported as an acute idiopathic gangrene of the scrotum in the young male by Professor Jean Alfred Fournier (1832–1914). However, understanding of the disease has changed with increasing elucidation on the epidemiology, causative organisms, and pathogenesis.

Predisposing factors include diabetes mellitus (DM), immunosuppression either from diseases or medications and malignancy.[2],[3] Anorectal and urogenital trauma are thought to provide a portal of entry for the introduction of bacteria that initiate the infectious process. It is usually polymicrobial with the presence of both aerobic and anaerobic bacteria which act synergistically.

The mainstay of management is an aggressive surgical debridement with concurrent hemodynamic stabilization and use of broad-spectrum antibiotics. The resultant extensive skin and soft tissue loss is associated with exposure of the testes. Reconstruction of scrotal/perianal defects, therefore, pose a surgical challenge.

Even though FG has been discussed in several reports, there are few from Nigeria, especially with perianal abscess and the importance of a common risk factor. We present a case of FG following a perianal abscess in a diabetic, which was successfully managed with secondary closure of the resultant scrotal defect.


  Case Report Top


Mr. B. O. is a 57-year-old male trader admitted on account of 8 days history of a perianal boil and 5 days history of progressive scrotal swelling. There was spontaneous eruption of the boil with foul-smelling purulent discharge and progressive dark discoloration of scrotal skin with ulceration.

There was no prior history of trauma, retroviral disease, or diabetes; however, random blood sugar was 558 mg/dl on presentation.

On examination, he was an acutely ill looking middle-aged man with a temperature of 37.6°C, pale, and pulse rate was 96 bpm with a blood pressure of 126/70 mmHg.

Perianal examination revealed a buried circumcised phallus (on account of edema) with a normally sited external urethral meatus with penoscrotal swelling and a necrotic patch measuring 15 cm by 15 cm, not tender, firm in consistency with a discharging perianal sinus [Figure 1].
Figure 1: Necrotic scrotal skin with right perianal abscess

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A diagnosis of FG with perianal abscess in a newly diagnosed diabetic patient was made.

Full blood count revealed a packed cell volume 28%, white blood cell count 8,600/mm 3, platelets was 298,000/mm 3 with an erythrocyte sedimentation rate of 81 mm/h. He was retroviral negative on screening. Serum electrolyte estimation revealed hyponatremia of 128 mol/L and other parameters were normal.

FG severity index (FGSI) score was calculated to be eight.

The patient had aggressive fluid and insulin administration. He subsequently had extensive surgical debridement [Figure 2] within 48 h of admission. Tissue cultures were obtained for the isolation of the responsible microorganisms. The necrotic skin in the scrotum was excised, and the perianal abscess fully drained. Preoperative antibiotic treatment with broad-spectrum antibiotics combinations was initiated and later adjusted to the culture sensitivity of the microbial isolates. The patient received ceftriaxone, metronidazole, and gentamicin but was later changed to meropenem. Insulin dose was further adjusted to optimize glycemic control.
Figure 2: Initial debridement

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He subsequently had two more surgical debridements. Local wound care was done with moist gauze dressings using EUSOL and normal saline and was changed twice daily until healthy granulation tissue was observed. Healthy granulation tissue was present by 2 weeks after the initial debridement, with a ragged irregular 10 cm × 8 cm anteroinferior scrotal defect and exposure of both testes [Figure 3] necessitating secondary closure by mobilization of the scrotal skin. The perianal wound was left to heal by secondary intention.
Figure 3: Following multiple debridements

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The patient was discharged on the 21st postoperative day and followed up with satisfactory outcome [Figure 4].
Figure 4: Final appearance at discharge

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  Discussion Top


FG is a rare but fulminant form of necrotizing fasciitis involving the genitals, perineal, and perianal regions. Other names include necrotizing cellulitis, periurethral phlegmon, phagedena, streptococcal scrotal gangrene, and idiopathic scrotal gangrene. It is characterized by polymicrobial aerobic and anaerobic infection with subsequent vascular thrombosis and tissue necrosis aggravated by poor host defenses.

The most frequent concomitant diseases are DM present between 32% and 66% of cases), as was present in our patient, alcoholism and cancer, among other immunosuppressive diseases.[4] DM, in particular, represents an apparent associated factor due to the defective phagocytosis, the increased incidence of urinary tract infections as a result of functional urinary tract obstructions from diabetic neuropathy and disease of the small vessels.[3] In fact, one study reported FG as the presenting feature of DM.[5] This was also the case as regards our patient.

FG is characterized by high mortality rates, ranging from 15% to 50% and is an acute surgical and urological emergency.[6] Initially, FG was considered to be idiopathic, but nowadays, the most common initial ports of entry are thought to be local trauma or extension of a urinary tract or perianal infection. Anorectal sources of infection include ischiorectal, perianal, and intersphincteric abscesses; our patient was noted to have a perianal boil which served as the source of FG. A report by Irekpita et al.,[7] in Irrua, documented four FG cases out of 17 over 10 years with perianal abscess (postdrainage) and another three cases with DM but none with the two risk factors. Furthermore, in an earlier published work, the most common comorbidity in anorectal sepsis in Lagos was DM.[8]

The FGSI is a clinical predictive score useful in helping to predict outcome. It is a numerical score obtained from a combination of physiological and biochemical hospital admission parameters that include temperature, heart rate, respiration rate, sodium, potassium, creatinine, leukocytes, hematocrit, and bicarbonate. A FGSI score >9 is associated with a 75% death rate while FGSI score of <9 is associated with 78% survival. Futhermore, Kabay et al.[9] predicted that FGSI score of >10.5 is associated with 96% death and a score of <10.5 is associated with 96% survival. Our patient had FGSI of eight which portended good prognosis.

Standard therapy is characterized by early aggressive serial debridement, intravenous wide-spectrum antibiotics, and topical wound care agents, followed by some form of durable wound coverage. Testicular coverage is often prioritized over scrotal cosmesis due to the comorbidities typically seen in this patient population. Various options for wound coverage and reconstruction include primary closure, secondary closure, skin grafting, and use of various flaps, which may be sensate. Our index patient had secondary closure 14 days post the initial debridement.

Although the number of patients with FG has decreased due to advances in medicine, the mortality is still high. In patients presenting with sepsis, DM, and late admissions to the hospital mortality rates were found to be highest.[2] Hospitalization for this disease is extremely long with a reported average of 6 weeks.[10] Our patient was discharged after 3 weeks of admission having been jointly managed by urologist/physician/plastic surgeon.


  Conclusion Top


FG is a fulminant condition with a high morbidity and mortality. The clinician should be reminded that DM is a common risk factor for both perianal abscess and FG. Therefore, an aggressive multidisciplinary management is mandatory. Skin loss is quite incapacitating and distressing to the patient. Early debridement and wound coverage are mandatory to allow patients to return to normal life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol 1998;81:347-55.  Back to cited text no. 1
    
2.
Czymek R, Hildebrand P, Kleemann M, Roblick U, Hoffmann M, Jungbluth T, et al. New insights into the epidemiology and etiology of Fournier's gangrene: A review of 33 patients. Infection 2009;37:306-12.  Back to cited text no. 2
    
3.
Nisbet AA, Thompson IM. Impact of diabetes mellitus on the presentation and outcomes of Fournier's gangrene. Urology 2002;60:775-9.  Back to cited text no. 3
    
4.
Verma S, Sayana A, Kala S, Rai S. Evaluation of the utility of the Fournier's gangrene severity index in the management of Fournier's gangrene in North India: A Multicentre Retrospective Study. J Cutan Aesthet Surg 2012;5:273-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Slater DN, Smith GT, Mundy K. Diabetes mellitus with ketoacidosis presenting as Fournier's gangrene. J R Soc Med 1982;75:530-2.  Back to cited text no. 5
    
6.
Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ, Davies BJ. Validation of the Fournier's gangrene severity index in a large contemporary series. J Urol 2008;180:944-8.  Back to cited text no. 6
    
7.
Irekpita E, Salami TA, Dongo AE, Eze KC. Fournier's gangrene: Irrua teaching hospital, Nigeria, experience. Sudan J Dermatol 2008;6:34-42.  Back to cited text no. 7
    
8.
Jeje EA, Mofikoya BO, Osunkoya SA, Olajide TG, Osinowo AO. Clinical and proctosigmoidoscopic findings in patients with anorectal sepsis in a private health facility in Lagos, Nigeria. Nig Q J Hosp Med 2012;22:14-7.  Back to cited text no. 8
    
9.
Kabay S, Yucel M, Yaylak F, Algin MC, Hacioglu A, Kabay B, et al. The clinical features of Fournier's gangrene and the predictivity of the Fournier's gangrene severity index on the outcomes. Int Urol Nephrol 2008;40:997-1004.  Back to cited text no. 9
    
10.
Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of Fournier's gangrene. J Urol 2005;173:1975-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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