Fournier's Gangrene Does Not Spare Young Adults

Danijela Semenič, MD, PhD; Petra Kolar, MD

Disclosures

Wounds. 2018;30(7):E73-E76. 

In This Article

Case Report

A 30-year-old man without significant medical history presented to the outpatient clinic of the Department of Surgical Infections, University Medical Centre Ljubljana (Slovenia), complaining of swelling and pain in the gluteal area. The patient stated that he fell down the stairs 3 days prior. He mentioned he had a perianal abscess in that area in the previous medical history, but not on the day of inspection. He received antibiotics (clindamycin 600 mg every 8 hours and ciprofloxacin 500 mg every 12 hours) for 10 days and then was discharged home.

One day following discharge, he returned to the Emergency Services Department of the University Medical Centre Ljubljana with a high axillary temperature of 38°C and pain and swelling extending to the scrotum and pubic area (Figure 1). His blood pressure was 93/53 mm Hg and heart rate was 109 bpm. Clinical examination revealed swelling and redness of the skin in the inguinal, perianal, and scrotal areas with a 2-cm wound on the right side of the gluteus. Initial laboratory exam showed elevated levels of white blood cells (32.5 x 109/L [normal value 4.0–10.0 x 109/L]), C-reactive protein (362 mg/L [normal value < 5 mg/L]), and procalcitonin (24.83 μg/L [normal value < 0.5 μg/L]). Computed tomography (CT) scan showed fluid collection in the perineum and massive emphysema that extended posteriorly to the gluteal area. Fluid collection extended anteriorly to a massively edematous scrotum and testes. Signs of local inflammation were seen in the left groin area.

Figure 1.

Extended swelling of the scrotum and pubic area upon presentation to the emergency department.

The patient was urgently operated on the day of admission to the emergency department, and excessive fasciectomy and necrectomy were performed (Figures 2, 3, 4). Soft tissue samples were intraoperatively sent for pathohistological and microbiological examination. He suffered acute kidney failure before surgery. Intravenous imipenem/cilastatin 500 mg every 6 hours and intravenous clindamycin 600 mg every 8 hours were administered for the following 10 days. Two days after surgery, Esherichia coli, Bacteroides fragilis, Prevotella oralis, and Streptococcus anginosus were isolated from fascial tissue. Pathohistological changes confirmed necrotizing fasciitis. On postoperative day 3, an additional necrectomy was performed, and wounds were covered with an alginate dressing (Kendall; Medtronic, Minneapolis, MN) (Figure 5). Systemic inflammatory indicators decreased (white blood cells to 13 x 109/L, C-reactive protein to 46 mg/L, and procalcitonin to 0.1 μg/L) followed by delayed closure of the wound with sutures on postoperative day 12. Later, on postoperative day 13, the patient admitted he did not fall down the stairs but instead rode for 10 hours on a motorbike.

Figure 2.

Surgical revision.

Figure 3.

Initial emergent fasciectomy and necrectomy.

Figure 4.

Additional fasciectomy and necrectomy were performed 3 days post initial surgery.

Figure 5.

Wound dressing change with alginate dressing on postoperative day 3.

On postoperative day 16, he was afebrile with stable cardiopulmonary functioning and was discharged home from the hospital (Figure 6). The first follow-up visit was 2 weeks later to remove wound stitches; additional follow-up visits occurred monthly for the next 6 months. During this time, the patient did not have any functional or neurological deficits and he did not develop a relapse of the infection.

Figure 6.

Secondary closure with sutures upon discharge on postoperative day 16.

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