Perianal tuberculosis presenting as a Fournier's gangrene.

Key Clinical Message: In the setting of Fournier's gangrene, atypical clinical manifestations and complications in an immunocompetent patient warrant consideration of perineal tuberculosis as a potential underlying cause. Abstract: Tuberculosis cutis orificialis is a rare form of extrapulmonary tuberculosis that affects the perianal region. Fournier's gangrene is an aggressive necrotizing fasciitis that primarily involves the perianal area and external genitalia. A previously healthy 38-year-old man presented with a left perianal abscess. His condition deteriorated, leading to septic shock and multiorgan dysfunction syndrome. A CT scan displayed extensive necrotizing fasciitis. Treatment included broad-spectrum antibiotics, numerous surgical perineal debridements, a transverse loop colostomy, and hyperbaric oxygen therapy. We believe the patient had pre-existing asymptomatic, non-diagnosed perianal tuberculosis, and a subsequent bacterial superinfection resulted in a perineal local abscess that progressed to severe Fournier's gangrene. The diagnosis of tuberculosis was confirmed through positive cultures and molecular identification in perineal biopsies. The patient experienced a complex clinical course with complications such as myocardial necrosis, acute respiratory distress syndrome, rhabdomyolysis with severe critical illness polyneuromyopathy and internal jugular thrombosis. Fournier's gangrene resulted in air dissection throughout the perineal fasciae, extending to the abdominal wall muscles resulting in an infected extraperitoneal spontaneous hematoma, probably caused by therapeutic anticoagulation. An extraperitoneal surgical drainage was performed. This case emphasizes the complexities in diagnosing and managing both perianal tuberculosis and Fournier's gangrene.

Case literature analysis of Fournier's gangrene caused by sodium-glucose protein-2 inhibitors.

Objective: To analyze the clinical characteristics and correlation of Fournier's gangrene induced by sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors, providing references for safe clinical drug use. Methods: The CNKI, WanFang, and PubMed databases were searched, and relevant documents were collected and statistically analyzed. The basic information of patients, drug use information, adverse reactions and outcomes were extracted and analyzed. Results: A total of 12 patients (8 males and 4 females) were included, with an average age of 55.6 years (ranging from 34 to 72 years). SGLT-2 inhibitors associated with Fournier's gangrene include empagliflozin (5 cases), dapagliflozin (5 cases), and canagliflozin (2 cases). Among them, 10 cases reported the time of first medication, ranging from 1 month to 6 years for the occurrence of adverse reactions. The most common concomitant drug was metformin (7 cases). Adverse reactions mainly manifested as redness, swelling and pain in the buttocks, perineum, perianal, scrotum and other positions, accompanied by an increased white blood cell count. Following surgery and antibiotic treatment, all patients showed improved. Conclusion: Fournier's gangrene induced by SGLT-2 inhibitors is rare. If patients using SGLT-2 inhibitors are suspected of having Fournier's gangrene, it is recommended to discontinue the drugs immediately and initiate active treatment to ensure clinical safety.

A rare case of Fournier's gangrene developing from colon perforation in an infant: A case report.

Fournier's gangrene, a rare and life-threatening soft tissue infection affecting the genitalia and perineum, results from various microorganisms. This rapidly progressing necrotizing fasciitis yields higher mortality and morbidity rates. We report a case of a 1-month-old male infant with Fournier's gangrene due to perforation transverse colon complicated with septic shock and pneumonia also accompanied by patent processus vaginalis. Radiological findings of pneumonia and pneumoperitoneum were exhibited. Early diagnosis and management are demanded to mitigate life-threatening and improve the prognosis. The patient underwent incision drainage, peritoneal lavage, exploratory laparotomy, colostomy, necrotomy debridement, and patent processus vaginalis ligation after hemodynamic status stabilization.

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.

Role of diverting colostomy and reconstruction in managing Fournier's gangrene-a narrative review.

OBJECTIVE: To examine the role of bowel diversion and reconstructive surgeries in managing Fournier's gangrene (FG) to facilitate multidisciplinary collaboration between urologists, colorectal and plastic surgery teams. METHODS: A review of the literature was conducted using the databases Medline, Embase, PubMed in June 2023. The review included studies that evaluated the outcomes of FG following reconstructive surgeries or diverting colostomies. RESULTS: The existing evidence suggests that bowel diversion and colostomy formation could reduce the need for further debridement, shorten the time to wound healing, and facilitate skin graft or flap uptake in patients with FG. Additionally, the psychological impact of a stoma was shown not to be a major concern for patients. However, stoma carries a risk of perioperative complications and therefore may prolong the length of hospital stay. In reviewing the evidence for reconstruction in FG, large and deep defects seem to benefit from skin grafts or flaps. Noticeably, burial of testicles in thigh pockets has grown out of favour due to concerns regarding the thermoregulation of the testicles and the psychological impact on patients. CONCLUSION: The use of bowel diversion and reconstructive surgeries in managing FG is case dependent. Therefore, it is important to have close discussions with colorectal and plastic surgery teams when managing FG.

Fournier's gangrene in a female: A case report.

Fournier's gangrene is characterized by an acute necrotic infection. The infection can occur in all parts of the body including the scrotum, penis, or perineum, and is a rare condition that is primarily reported in men and seldom in women. Existing literature suggests that it might be underreported, possibly leading to overlooked cases. Risk factors include diabetes, chronic illness, and trauma. This case involves a 52-year-old female with a 10-year medical history of diabetes mellitus, multiple healed skin lesions all over the body, and dermatitis. The presentation was a perianal swelling, which progressed into an extensive necrotizing soft tissue infection of the perineum, making a diagnosis of Fournier's gangrene. She underwent wide local debridement and was managed with antibiotics in a timely manner. The patient's clinical course and subsequent follow-up were uneventful. Uncontrolled diabetes and dermatitis significantly increase the risk of Fournier's gangrene; therefore, it should be suspected in women with such comorbid conditions. This case highlights the need for increased awareness and vigilance regarding this condition among women.

A case of successful treatment of Fournier's gangrene through conservative management and elective debridement.

Introduction: Fournier's gangrene refers to a necrotizing fasciitis that mainly affects the perineal region and a condition that requires immediate debridement. This case involved elective debridement of Fournier's gangrene after the general condition was improved through antibiotic treatment instead of requesting an emergency debridement. Case presentation: The patient was an 85-year-old man with a performance status of 4 admitted to a nursing home. He was transferred by ambulance with a fever. Blood tests showed a markedly elevated inflammatory response, and computed tomography revealed widespread aerodermectasia around the right testis to the lower abdomen. The patient was diagnosed with Fournier's gangrene. However, his family declined emergency surgical debridement. The patient's general condition was improved with antibiotics, and debridement was eventually performed. After 52 days of hospitalization, the patient was transferred to another hospital. Conclusion: This study describes the successful treatment of Fournier's gangrene through conservative treatment followed by elective debridement.

[Acute genital diseases]. / Akute Genitalerkrankungen.

Acute genital diseases can occur at any age and are characterized by complaints of various kinds of the external genitalia. Pain, swelling, and redness of the scrotum, adjacent groin region, and immediate surroundings are the leading symptoms, the severity of which may vary. In addition, peritonitic symptoms such as nausea, vomiting, and circulatory sensations may be present and are comparable to symptoms of an acute abdomen. The term "acute scrotum" encompasses various clinical entities, where scrotal symptoms are predominant and represent a urological emergency situation. Immediate and comprehensive diagnostics are necessary to ensure timely management in case of necessary surgical intervention.

Reported outcome measures in necrotising soft tissue infections: a systematic review.

Introduction: There are inconsistencies in outcome reporting for patients with necrotising soft tissue infections (NSTI). The aim of this study was to evaluate reported outcome measures in NSTI literature that could inform a core outcome set (COS) such as could be used in a study of hyperbaric oxygen in this indication. Methods: A systematic review of all NSTI literature identified from Cochrane, Ovid MEDLINE and Scopus databases as well as grey literature sources OpenGrey and the New York Academy of Medicine databases which met inclusion criteria and were published between 2010 and 2020 was performed. Studies were included if they reported on > 5 cases and presented clinical endpoints, patient related outcomes, or resource utilisation in NSTI patients. Studies did not have to include intervention. Two independent researchers then extracted reported outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory. An attempt was made to identify trends in outcome measures over time and by study design. Results: Three hundred and seventy-five studies were identified and included a total of 311 outcome measures. Forty eight percent (150/311) of outcome measures were reported by two or more studies. The four most frequently reported outcome measures were mortality without time specified, length of hospital stay, amputation performed, and number of debridements, reported in 298 (79.5%), 260 (69.3%), 156 (41.6%) and 151 (40.3%) studies respectively. Mortality outcomes were reported in 23 different ways. Randomised controlled trials (RCTs) were more likely to report 28-day mortality or 90-day mortality. The second most frequent amputation related outcome was level of amputation, reported in 7.5% (28/375) of studies. The most commonly reported patient-centred outcome was the SF-36 which was reported in 1.6% (6/375) of all studies and in 2/10 RCTs. Conclusions: There was wide variance in outcome measures in NSTI studies, further highlighting the need for a COS.

Fournier's gangrene: a review of predictive scoring systems and practical guide for patient management.

This article aims to provide a practical guide for patient management and an overview of the predictive scorings for Fournier's gangrene (FG) that are available to aid clinicians. A literature was performed reviewing currently used scoring systems for FG and presenting a practical guide for its management based on the available evidence. There are four specific scoring systems available for the assessment of FG although few other non-specific and generic tools also exist. These specific tools include Laboratory Risk Indicator for Necrotizing Fasciitis, Fournier's Gangrene Severity Index, Uludag Fournier's Gangrene Severity Index, and Simplified Fournier's Gangrene Severity Index and help calculate expected mortality. Our proposed algorithm covers primary assessment, resuscitative interventions, initial investigations, urgent care, post-operative care, and long-term follow-up. The management of the FG patient can be divided into initial resuscitation, surgical debridement, ongoing ward management with antibiotic therapy, wound reconstruction, and long-term follow-up. Each facet of care is vital and requires multidisciplinary team expertise for optimal outcomes. Whilst mortality continues to improve, it remains significant, reflecting the severe and life-threatening nature of FG. More research is certainly needed into how this care is individualised, and to ensure that long-term outcomes in FG include quality of life measures after discharge.

Fournier's gangrene: a review of predictive scoring systems and practical guide for patient management The management of Fourniers gangrene can be divided into initial resuscitation, surgical debridement, ongoing ward management with antibiotic therapy, wound reconstruction, and long-term follow-up. Each facet of care is vital and requires multidisciplinary team expertise for optimal outcomes. More research is certainly needed into how this care is individualised, and to ensure that long-term outcomes in FG includes quality of life measures after discharge.

Post catheterization Fournier's gangrene involving the entire anterior urethra: case report.

INTRODUCTION AND IMPORTANCE: Fournier's gangrene is necrotizing fasciitis involving the penis, scrotum, or perineal region. This is to report necrosis of the entire anterior urethra by necrotizing infection even though the involvement of the urethra by Fournier's is a very rare presentation. A high index of suspicion is important for early intervention. The main Mode of treatment for Fournier's gangrene is debridement. CASE PRESENTATION: This is a case report for a 58-year-old male patient who presented with penile and scrotal swelling after he was catheterized with NG tube for acute urinary retention. The physical finding shows swollen scrotum with ulcerated necrotic glans penis anteriorly. Laboratory result shows leukocytosis and urine analysis is positive for urinary tract infection and ultrasound shows bladder diverticula with normal prostate volume. He underwent debridement up to the level of membranous urethra and suprapubic catheterization was done. He was treated with antibiotics and wound care and finally, the wound closed. Post-operative cystourethrography was done 9 months later and we offered staged urethroplasty but he decided for permanent SPC. DISCUSSION: Fournier's gangrene is a fatal rapidly spreading infection that occurs in the perineal area. Involvement of urethra by necrotizing infection following catheterization is very rare presentation and diagnosis is mostly clinical. Once it is diagnosed the management is surgical debridement. CONCLUSION: Fournier's gangrene with urethral involvement is a very rare presentation and a high index of suspicion is important for early diagnosis and management. Following the standard procedural steps of catheterization is important to avoid this complication.

Fournier's gangrene revealing an acute arterial occlusion: A case report.

INTRODUCTION AND IMPORTANCE: Fournier gangrene (FG) is a rare form of necrotizing fasciitis that affects both the deep and superficial layers of the perineal genital region. When left untreated, Fournier gangrene can rapidly advance, leading to substantial morbidity and mortality. Herein, we present a case of Fournier's gangrene, which revealed acute arterial occlusion. To the best of our knowledge, few cases of Fournier's gangrene secondary to arterial occlusion have been reported. CASE PRESENTATION: We report the case of a 37-year-old man with no known medical history who presented with fever and painful swelling of the scrotum. Physical examination revealed a large black spot on the scrotum surrounded by erythema, suggestive of Fournier's gangrene. We performed an extended debridement of the scrotal area. Three days later, the patient complained of severe pain in the left foot accompanied by numbness. Lower limb computed tomographic angiography (CTA) revealed multiple arterial occlusions. Thrombectomy and anticoagulation therapy were crucial in managing the vascular thrombosis and preventing the further extension of the gangrene. CLINICAL DISCUSSION: This case underscores the importance of recognizing diverse etiologies of Fournier's gangrene, including vascular involvement, and emphasizes the need for a multidisciplinary approach. Early identification, aggressive surgical debridement, and broad-spectrum antibiotics remain the cornerstone of management, with the added consideration of anticoagulation in cases involving vascular thrombosis. CONCLUSION: FG is a rare yet potentially life-threatening condition. Its multifaceted etiologies, including vascular factors, underscore the complexity of its presentation and challenges for timely diagnosis. The recognition of vascular involvement as a potential etiology of FG warrants further in-depth exploration.

Fournier's gangrene due to rectal cancer: A case report.

Fournier's gangrene (FG) is an extremely rare necrotizing fasciitis that is insidious, rapidly spreading and life-threatening. FGs due to rectal cancer occur rarely and there is a lack of clinical reference. In the present study, a severe FG due to rectal cancer perforation was described and the features of this rare disease were summarized with a literature review. A 57-year-old man was admitted because of rectal cancer-induced FG. The patient was misdiagnosed with extensive perianal abscess until the intraoperative biopsy confirmed that rectal cancer was the culprit. Incision, debridement and drainage were carried out to reduce infectious burdens. After that, the patient was transferred to Peking University People's Hospital for the subsequent therapy. Empirical broad-spectrum antibiotic therapy was used at the initial stage. Diversional transverse loop colostomy was performed to control infection and resume oral feeding. After four rounds of vacuum-assisted closure (VAC) therapy, radical resection and wound closure were accomplished. The scrotal defect was repaired by a skin flap. Pathological results indicated a moderately differentiated adenocarcinoma with perforation. The patient was discharged from the hospital on postoperative day 15 without any post-operative complications. No signs of recurrence were observed during a 22-month follow-up. In the setting of rectal cancer-induced FGs, the liquid resuscitation, broad-spectrum antibiotic therapy, and prompt debridement are the cornerstones of the initial management. Diversional colostomy and VAC therapy were effective in the management of severe infection and large wounds. The present case report also provided a clinical reference for the implementation of staged surgeries and the perioperative multidisciplinary management of FGs.

Role of SFGSI, microbial culture and qSOFA as predictive factors in determining the survival rate in Fournier Gangrene patient.

OBJECTIVES: To examine the simplified Fournier Gangrene Severe Index Score (SFGSI) and the number of species in culture findings for predicting death in Fournier Gangrene (FG) patients in terms of their predictive power. METHODS: From January 2017 to July 2022, the medical records of individuals undergoing emergency surgery for FG were obtained. A total of 80 patients were examined for clinical data such as age, gender, laboratory parameters, etiology, isolated bacteria, and mortality rate. RESULTS: We identified a statistically significant mean difference between SFGSI (p<0.0001) and quickSOFA (qSOFA) scores (p=0.002) in determining the survival rate of FG patients. The sensitivity and specificity of the SFGSI score in predicting mortality were 90.1% and 88.3% respectively, whereas the sensitivity and specificity of the qSOFA score were 88.2% and 86.2%. E. Coli comprised 56.2% of the bacteria, followed by S. Haemolyticus, S. Aureus, P. Aeruginosa, and K. Pneumoniae. On the basis of bacterial culture results, P. Aeruginosa had the highest fatality rate (100%) followed by S. Aureus (75%), S. Haemolyticus (30%), and E. Coli (20%), in that order. CONCLUSION: The survival rate of FG patients can be predicted using the sensitivity and specificity of the SFGSI and qSOFA scores together. P. Aeruginosa-infected patients have the greatest mortality rate (100%) compared to the other groups.

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.

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.

Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction.

This review delves into reconstructive methods for scrotal defects arising from conditions like Fournier's gangrene, cancer, trauma, or hidradenitis suppurativa. The unique anatomy of the scrotum, vital for thermoregulation and spermatogenic function, necessitates reconstruction with thin and pliable tissue. When the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. However, for larger defects, some type of transplantation surgery is required. Various options are explored, including testicular transposition, tissue expanders, split-thickness skin grafts, local flaps, and free flaps, each with merits and demerits based on factors like tissue availability, defect size, and patient specifics. Also, physicians should consider how testicular transposition, despite its simplicity, often yields unsatisfactory outcomes and impairs spermatogenesis. This review underscores the individuality of aesthetic standards for scrotal reconstruction, urging surgeons to tailor techniques to patient needs, health, and defect size. Detailed preoperative counseling is crucial to inform patients about outcomes and limitations. Ongoing research focuses on advancing techniques, not only anatomically but also in enhancing post-reconstruction quality of life, emphasizing the commitment to continuous improvement in scrotal reconstruction.

A rare case of an extra-oral plasmablastic lymphoma presenting through a scrotal abscess in a 42-year-old man.

Plasmablastic lymphoma (PBL) is a rare lymphoid neoplasm frequently presenting in the oral cavity. It is an aggressive type of non-Hodgkin's lymphoma that shares pathological features with plasma cell myeloma. In addition to human immunodeficiency virus (HIV), it is also associated with Epstein-Bar virus (EBV) and immunosuppression in HIV-negative patients, for example, post transplantation. Extra-oral PBL is rare and only a few case reports involving the testis have been described. Here we describe the first reported case of PBL presenting with a scrotal abscess (not involving the testes) in a patient newly diagnosed with HIV. This case highlights the rare presentation of a rare disease, the difficulties in establishing a diagnosis and the importance of a timely multidisciplinary approach to its management.

Reconstruction of penile skin loss by superficial circumflex iliac perforator (SCIP) pedicled flap after Fournier's gangrene.

INTRODUCTION: Fournier's gangrene is a serious pathology with a high mortality rate. Treatment requires a large debridement of necrotized tissues, conducing to a skin loss, requiring a reconstruction, which may involve different surgical techniques, depending on the context as well as the size and location of the skin loss. The most common covering technique uses split-thickness skin grafting, which however presents a risk of contracture. CASE: Our 63 years old patient presented a Fournier's gangrene, leading to pubic and circular penile skin defects after multiple debridements. We decided to practice a right superficial circumflex iliac perforator (SCIP) pedicled flap to reconstruct the penile skin sheath. The flap was rotated 180 degrees and rolled around the penis. DISCUSSION: The inguinal pedicle flap is described for penile reconstruction, the SCIP flap for perineal reconstruction, and even bilateral SCIP flaps for performing phalloplasty, but SCIP pedicled flap is not already described for isolated penile skin sheath reconstruction. Skin loss in our patient was not extensive, permitting us to perform this surgical technique. To go further, note the possibility of carrying out this reconstruction by a super-thin SCIP flap, as a pure skin graft flap. CONCLUSION: The SCIP pedicled flap seems us to be a safe technique for penile skin reconstruction and a good alternative to the usual skin grafts, especially regarding the lower risk of contracture, and low donor-site morbidity.