Fournier gangrene: a rare case of necrotizing fasciitis of the entire right hemi-pelvis in a diabetic female

Fournier gangrene: a rare case of necrotizing fasciitis of the entire right hemi-pelvis in a... Fournier’s gangrene, a rare polymicrobial infection that affects the genitals and perineum, can present as an insidious onset to a rapid and fulminant course. Early recognition, diagnosis, initiation of broad-spectrum antibiotics and prompt surgical treatment remain the foundation of management. If treatment is not initiated aggressively, the patient will likely rapidly deteriorate, leading to organ failure and death. We present the case of a 58-year-old diabetic female presenting febrile, hypoxic, with severe respiratory distress and evidence of septic shock, found to have necrotizing fasciitis of the entire right hemi-pelvis. Despite rapid recognition, IV antibiotics and operative management, the patient went to the intensive-care unit on multiple pressors and died 24 h later. A 58-year-old female with a significant past medical history of of 436 mg/l, hemoglobin of 11.3 (g/dl), hyponatremia of 127, type 1 diabetes presented to the emergency department (ED) creatinine of 1.1 and glucose of 55 mg/dl. Computed tomog- via EMS for severe respiratory distress. The review of systems raphy abdomen/pelvis without contrast showed subcutaneous was limited secondary to the acuity of patient. Vitals on ED emphysema extending from the labia to the perineum back to arrival: 101.1°F, blood pressure of 86/52 mmHg, heart rate of the posterior right gluteus. Findings were consistent with nec- 116 beats/min, pulse oximetry of 77% on room air, respirations rotizing fasciitis involving the entire right hemi-pelvis (Fig. 2). 36 breaths/min and a weight of 68 kg. On physical exam she The patient was taken to the operating room by general sur- appeared ill, was in obvious distress, cyanotic, with mottled gery and obstetrics/gynecology for a partial left vulvectomy, upper and lower extremities and she was emergently intu- right vulvectomy, and excision of perineum, fat, fascia and bated. Cardiopulmonary exam demonstrated sinus tachycardia muscle. Multiple large fluid collections of malodorous purulent and course breath sounds bilaterally. Genital-urinary exam material were found. A total of 800 cm of tissue was removed. revealed an erythematous and indurated right labia, with no Anaerobic cultures grew Bacteroides fragilis, Clostridium ramosum evidence of crepitus. Sepsis protocol was followed and broad- and gram + cocci. spectrum antibiotics were initiated. Chest X-ray showed hazy opacities bilaterally consistent with a likely infectious etiology. DISCUSSION Subsequent pelvic X-ray showed extensive soft tissue subcuta- neous emphysema (Fig. 1). Laboratory values were significant Fournier’s gangrene, a polymicrobial necrotizing fasciitis, is a for a leukocytosis of 26.5, lactic acid of 4.2, C-reactive protein rare, life threatening, severe-flesh eating soft tissue infection Received: August 31, 2017. Revised: November 10, 2017. Accepted: November 18, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx094/4846369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Fournier gangrene 49 bacteria. Type 2 is generally caused by Streptococci and/or Staphylococci. Type 3 is caused by Vibrio species [3]. In our patient, anaerobic cultures grew B. fragilis, C. ramosum and gram + cocci. The synergistic effect of the polymicrobial bac- teria results in fulminate gangrene, multi-system organ failure and even death. Even with broad-spectrum antibiotics and wide excision debridement, the mortality rate is about 25% for necrotizing fasciitis in other regions of the body aside from the perineum, and up to 45% for Fournier’s gangrene. However, some reported studies include mortality rates approaching 75% when the infection extends cephalad into the pelvis and abdominal wall [4]. We present the case of a 58-year-old diabetic female not only diagnosed with Fournier’s gangrene but with a necrotizing fasciitis of the entire right hemi-pelvis. For the clinician, having a high index of clinical suspicion, prompt recognition, early antibiotics and immediate surgical consultation are of para- mount importance in potentially saving a life. Despite rapid recognition and maximal intervention, our patient continued to rapidly deteriorate. She went to the ICU on multiple pressors Figure 1: Pelvis (AP View): Extensive soft tissue subcutaneous emphysema and died 24 h later. involving the right hemi-pelvis. CONFLICT OF INTEREST STATEMENT None declared. FUNDING No financial support was received for this study. ETHICAL APPROVAL No approval is required. Figure 2: CT abdomen and pelvis without contrast: Subcutaneous emphysema CONSENT and extensive inflammatory stranding within the right ischiorectal fossa extending anteriorly and posteriorly involving the entire right perineum. The Consent could not be obtained from the patient. The patient was right-sided posterior subcutaneous air extends posteriorly and superior to the also estranged from her family and they were not contactable. level of the gluteus muscle. The right-sided anterior collection extends super- iorly and laterally to approximately the right ASIS. Additional pockets of air are appreciated within the left posterior rectal soft tissues and within the deep GUARANTOR fascial tissues within the right lower pelvis. G.T. is a guarantor of this study. affecting the genitals and perineum that carries with it a high- mortality rate. The incidence varies with multiple studies REFERENCES showing 1.6–3 cases per 100 000 people with a 10:1 male to female predominance [1]. This polymicrobial infection results 1. Sorensen M, Krieger J. Fournier’s gangrene: population based in a rapidly progressive infection with occasional extension epidemiology and outcomes. J Urol 2009;181:2120–6. into the abdominal wall. Most patients will have an underlying 2. Shukrym S, Ommen J. Necrotizing fasciitis—report of ten systemic disease process such as diabetes mellitus, alcoholism, cases and review of recent literature. J Med Life 2012;6:189–94. obesity, peripheral vascular disease, peri-anal disease, urethral 3. Smeets L, Bous A, Heymans O. Necrotizing fasciitis: a case stricture, local trauma and immunosuppression that increases report and review of literature. PubMed 2007;107:29–36. the susceptibility to this polymicrobial necrotizing fasciitis [2]. 4. Davis C, Necrotizing Fasciitis-Flesh Eating Disease. 2016. Necrotizing fasciitis is divided into three types: Type 1 is MedicineNet. http://www.medicinenet.com/necrotizing_fasciitis/ considered polymicrobial and caused by anaerobic and aerobic article.htm (16 October 2017, date last accessed). Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx094/4846369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Oxford Medical Case Reports Oxford University Press

Fournier gangrene: a rare case of necrotizing fasciitis of the entire right hemi-pelvis in a diabetic female

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Abstract

Fournier’s gangrene, a rare polymicrobial infection that affects the genitals and perineum, can present as an insidious onset to a rapid and fulminant course. Early recognition, diagnosis, initiation of broad-spectrum antibiotics and prompt surgical treatment remain the foundation of management. If treatment is not initiated aggressively, the patient will likely rapidly deteriorate, leading to organ failure and death. We present the case of a 58-year-old diabetic female presenting febrile, hypoxic, with severe respiratory distress and evidence of septic shock, found to have necrotizing fasciitis of the entire right hemi-pelvis. Despite rapid recognition, IV antibiotics and operative management, the patient went to the intensive-care unit on multiple pressors and died 24 h later. A 58-year-old female with a significant past medical history of of 436 mg/l, hemoglobin of 11.3 (g/dl), hyponatremia of 127, type 1 diabetes presented to the emergency department (ED) creatinine of 1.1 and glucose of 55 mg/dl. Computed tomog- via EMS for severe respiratory distress. The review of systems raphy abdomen/pelvis without contrast showed subcutaneous was limited secondary to the acuity of patient. Vitals on ED emphysema extending from the labia to the perineum back to arrival: 101.1°F, blood pressure of 86/52 mmHg, heart rate of the posterior right gluteus. Findings were consistent with nec- 116 beats/min, pulse oximetry of 77% on room air, respirations rotizing fasciitis involving the entire right hemi-pelvis (Fig. 2). 36 breaths/min and a weight of 68 kg. On physical exam she The patient was taken to the operating room by general sur- appeared ill, was in obvious distress, cyanotic, with mottled gery and obstetrics/gynecology for a partial left vulvectomy, upper and lower extremities and she was emergently intu- right vulvectomy, and excision of perineum, fat, fascia and bated. Cardiopulmonary exam demonstrated sinus tachycardia muscle. Multiple large fluid collections of malodorous purulent and course breath sounds bilaterally. Genital-urinary exam material were found. A total of 800 cm of tissue was removed. revealed an erythematous and indurated right labia, with no Anaerobic cultures grew Bacteroides fragilis, Clostridium ramosum evidence of crepitus. Sepsis protocol was followed and broad- and gram + cocci. spectrum antibiotics were initiated. Chest X-ray showed hazy opacities bilaterally consistent with a likely infectious etiology. DISCUSSION Subsequent pelvic X-ray showed extensive soft tissue subcuta- neous emphysema (Fig. 1). Laboratory values were significant Fournier’s gangrene, a polymicrobial necrotizing fasciitis, is a for a leukocytosis of 26.5, lactic acid of 4.2, C-reactive protein rare, life threatening, severe-flesh eating soft tissue infection Received: August 31, 2017. Revised: November 10, 2017. Accepted: November 18, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx094/4846369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Fournier gangrene 49 bacteria. Type 2 is generally caused by Streptococci and/or Staphylococci. Type 3 is caused by Vibrio species [3]. In our patient, anaerobic cultures grew B. fragilis, C. ramosum and gram + cocci. The synergistic effect of the polymicrobial bac- teria results in fulminate gangrene, multi-system organ failure and even death. Even with broad-spectrum antibiotics and wide excision debridement, the mortality rate is about 25% for necrotizing fasciitis in other regions of the body aside from the perineum, and up to 45% for Fournier’s gangrene. However, some reported studies include mortality rates approaching 75% when the infection extends cephalad into the pelvis and abdominal wall [4]. We present the case of a 58-year-old diabetic female not only diagnosed with Fournier’s gangrene but with a necrotizing fasciitis of the entire right hemi-pelvis. For the clinician, having a high index of clinical suspicion, prompt recognition, early antibiotics and immediate surgical consultation are of para- mount importance in potentially saving a life. Despite rapid recognition and maximal intervention, our patient continued to rapidly deteriorate. She went to the ICU on multiple pressors Figure 1: Pelvis (AP View): Extensive soft tissue subcutaneous emphysema and died 24 h later. involving the right hemi-pelvis. CONFLICT OF INTEREST STATEMENT None declared. FUNDING No financial support was received for this study. ETHICAL APPROVAL No approval is required. Figure 2: CT abdomen and pelvis without contrast: Subcutaneous emphysema CONSENT and extensive inflammatory stranding within the right ischiorectal fossa extending anteriorly and posteriorly involving the entire right perineum. The Consent could not be obtained from the patient. The patient was right-sided posterior subcutaneous air extends posteriorly and superior to the also estranged from her family and they were not contactable. level of the gluteus muscle. The right-sided anterior collection extends super- iorly and laterally to approximately the right ASIS. Additional pockets of air are appreciated within the left posterior rectal soft tissues and within the deep GUARANTOR fascial tissues within the right lower pelvis. G.T. is a guarantor of this study. affecting the genitals and perineum that carries with it a high- mortality rate. The incidence varies with multiple studies REFERENCES showing 1.6–3 cases per 100 000 people with a 10:1 male to female predominance [1]. This polymicrobial infection results 1. Sorensen M, Krieger J. Fournier’s gangrene: population based in a rapidly progressive infection with occasional extension epidemiology and outcomes. J Urol 2009;181:2120–6. into the abdominal wall. Most patients will have an underlying 2. Shukrym S, Ommen J. Necrotizing fasciitis—report of ten systemic disease process such as diabetes mellitus, alcoholism, cases and review of recent literature. J Med Life 2012;6:189–94. obesity, peripheral vascular disease, peri-anal disease, urethral 3. Smeets L, Bous A, Heymans O. Necrotizing fasciitis: a case stricture, local trauma and immunosuppression that increases report and review of literature. PubMed 2007;107:29–36. the susceptibility to this polymicrobial necrotizing fasciitis [2]. 4. Davis C, Necrotizing Fasciitis-Flesh Eating Disease. 2016. Necrotizing fasciitis is divided into three types: Type 1 is MedicineNet. http://www.medicinenet.com/necrotizing_fasciitis/ considered polymicrobial and caused by anaerobic and aerobic article.htm (16 October 2017, date last accessed). Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx094/4846369 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Oxford Medical Case ReportsOxford University Press

Published: Feb 1, 2018

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