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Internal Medicine

Fournier’s gangrene (FG)

Fournier’s gangrene (FG) necrotic fascitis (dangerous and rapidly spreading infection of the fascial planes leading to necrosis of the subcutaneous tissues and overlying skin) of the perineum.

  • Older males usually involved
  • UROLOGICAL EMERGENCY

History

FG was first described by Baurienne in 1764 and is named after a French venereologist, Jean Alfred Fournier, following 5 cases he presented in clinical lectures in 1883.

390px-jean-alfred_fournier
Jean Alfred Fournier (1832–1914) was a French dermatologist who specialized in the study of venereal disease.

Aetiology

Risk factors:

  • Diabetes mellitus (M/significant risk factor 46% cases)
  • Alcoholism (~33% cases)
  • Immmunosuppression(chemotherapy, steroids, or malignancy) (~10% cases)

Clinical features

4 P’s:

  • Sudden pain in the scrotum (78%), prostration, pallor, and pyrexia (41%)

Other features:

  • Strong repulsive, fetid odour
  • Scrotal swelling and erythema
  • Purulence or wound discharge (60%)
  • Crepitation (presence of gas forming organisms)
  • Fluctulance

 

Case study:

nejmicm1609306_f1
Fournier’s Gangrene, Chih-Sheng Huang, M.D. | Huang, C.-S. (2017). Fournier’s Gangrene. New England Journal of Medicine, 376(12), 1158. https://doi.org/10.1056/NEJMicm1609306

A 46-year-old man with uncontrolled type 2 diabetes and alcoholic liver disease presented to the emergency department with painful swelling in the scrotum and perianal region. His temperature was 37.7°C, his pulse 130 beats per minute, and his blood pressure 97/61 mm Hg. The physical examination was notable for necrotic-appearing tissue in the scrotum and perineum, with areas of induration and crepitus (Panel A). Computed tomography revealed subcutaneous emphysema in the scrotum and perianal fascia, in addition to air in the pararectal fascia and rectal wall (Panel B, arrow). A diagnosis of Fournier’s gangrene, or necrotizing fasciitis of the perineum, was made. Fournier’s gangrene is a rare, life-threatening, fulminant infection. Elderly men and men with diabetes and chronic alcohol-use disorder are at increased risk. The patient underwent prompt laparoscopic-assisted abdominal perineal resection. Pathological analysis revealed multiple gas-filled pockets in necrotic tissue, with neutrophilic infiltration. In addition to surgery, the patient received fluid resuscitation and broad-spectrum antibiotics. Approximately 3 weeks after surgery, split-thickness skin grafting was performed for perineum reconstruction. The patient was discharged home with a permanent colostomy.

Management

Cornerstones of treatment of Fournier’s gangrene are urgent surgical debridement of all necrotic tissue + high doses of broad-spectrum antibiotics.

Broad spectrum antibiotics coverage:

  • Triple therapy (3rd generation cefalosporins/aminoglycosides + penicillin + metronidazole)
  • Carbapenems (Imipenem, meropenem, ertapenem) or piperaziline-tazobactam

Radical surgical debridement:

  • Multiple surgical debridement usually required
  • Debridement of deep fascia and muscle is not usually required as these areas are rarely involved similar to testes.
  • Debridement should be stopped when separation of the skin and the subcutaneous is not perform easily, because the cutaneous necrosis is not a good marker.
a-case-of-fourniers-gangrene-after-appendicectomy-incision-a-after-excision
Fournier’s gangrene after appendicectomy incision (a) After excision, demonstrating extent of fascial/skin involvement (b), After soft tissue cover with split thickness skin graft [STSG] | Global Surgery Fournier’s gangrene: A review of contemporary management priorities – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/A-case-of-Fourniers-gangrene-after-appendicectomy-incision-a-After-excision_fig3_325934139 [accessed 25 Jan, 2019]

Fecal diversion:

  • Colostomy:
    • Indications: Anal sphincter involvment, fecal incontinence, or continues fecal contamination of the wound’s margins
    • Advantage: Decrease in the number of germs in perineal region and improved wound healing
  • Flexi-weal fecal management system:
    • Silicone catheter designed to divert fecal matter in patients with diarrhea, local burns, or skin ulcers
isrn.surgery2012-942437.002
Flexi-Seal Fecal Management system | Mallikarjuna, M. N., Vijayakumar, A., Patil, V. S., & Shivswamy, B. S. (2012). Fournier’s Gangrene: Current Practices. ISRN Surgery, 2012, 942437. https://doi.org/10.5402/2012/942437

Urinary diversion:

  • Urinary catheterization (cystostomy in some cases):
    • Indications: Penile or urethral involvement though some cases may require may suffice in many

Hyperbaric oxygen therapy:

  • Inhibits and kill the anaerobic bacteria
  • Esp indicated in clostridial myonecrosis

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