Fournier gangrene: Difference between revisions
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==Background== | ==Background== | ||
[[File:Gray1144.png|thumb|Scrotal anatomy]] | |||
[[File:Figure 28 01 02.jpg|thumb|Scrotal anatomy]] | |||
*Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area. | *Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area. | ||
**Mostly bacteria lower GI system - [[B. fragilis]] and [[E. coli]] | |||
**Obliterative endarteritis of subcutaneous arterioles leads to gangrene of overlying skin<ref name="Shyam">Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001.</ref> | **Obliterative endarteritis of subcutaneous arterioles leads to gangrene of overlying skin<ref name="Shyam">Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001.</ref> | ||
*Mortality - often cited as 20-40%, but up to 80% in some studies<ref name="Concepts" /> | *Mortality - often cited as 20-40%, but up to 80% in some studies<ref name="Concepts" /> | ||
===Risk Factors=== | |||
*[[Diabetes mellitus]] (most common) | |||
*[[Hypertension]] | |||
*[[Alcoholism]] | |||
*Advanced age | |||
*Para/Quadriplegic | |||
*Males>Females (10:1)<ref name="Shyam" />, (likely under-diagnosed in women<ref name="Concepts">Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.</ref>) | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Fournier-Gangrene.png|thumb|Fournier's Gangrene]] | |||
[[File:PMC3560168 JCAS-5-273-g004.png|thumb|ournier's Gangrene]] | |||
*Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" /> | *Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" /> | ||
**Gangrene develops over 2-7 days | **Gangrene develops over 2-7 days | ||
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*Fever | *Fever | ||
*Malodorous purulent drainage | *Malodorous purulent drainage | ||
*In late or severe cases, | *In late or severe cases, patient may present in septic shock | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Testicular DDX}} | {{Template:Testicular DDX}} | ||
== | ==Evaluation== | ||
===Work-up=== | ===Work-up=== | ||
*CBC | *CBC - very elevated leukocytosis | ||
*CMP | *CMP - hyponatremia | ||
*ESR | |||
*CRP | *CRP | ||
*Lactate | *Lactate | ||
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*CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology) | *CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology) | ||
== | ===Evaluation=== | ||
*Clinical diagnosis, based on history and physical exam | |||
*LRINEC score here: [[Necrotizing fasciitis]] | |||
==Management== | |||
*Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr<ref name="Shyam" />) | *Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr<ref name="Shyam" />) | ||
*[[Antibiotics]] - Must cover [[gram positive]], [[gram negative]], and [[anaerobes]] | *[[Antibiotics]] - Must cover [[gram positive]], [[gram negative]], and [[anaerobes]] | ||
**[[Vancomycin]] + ([[imipenem]] 1gm IV q24hr OR [[meropenem]] 500mg-1gm IV q8hr) | **[[Vancomycin]] + ([[imipenem]] 1gm IV q24hr '''OR''' [[meropenem]] 500mg-1gm IV q8hr '''OR''' [[piperacillin-tazobactam]] 3.375gm to 4.5gm IV q6h) +/- ([[clindamycin]] 600mg-900mg IV q8h '''OR''' [[metronidazole]] 1gm IV then 500mg IV q8h) | ||
*Aggressive supportive care, including fluid resuscitation (and [Vasopressors|pressors], if indicated) | **[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr and [[linezolid]] 600mg q12hr is an alternative regimen<ref>Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444</ref> | ||
*Aggressive supportive care, including fluid resuscitation (and [[Vasopressors|pressors]], if indicated) | |||
==Disposition== | ==Disposition== | ||
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[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Urology]] | ||
Revision as of 01:37, 9 February 2021
Background
- Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area.
- Mostly bacteria lower GI system - B. fragilis and E. coli
- Obliterative endarteritis of subcutaneous arterioles leads to gangrene of overlying skin[1]
- Mortality - often cited as 20-40%, but up to 80% in some studies[2]
Risk Factors
- Diabetes mellitus (most common)
- Hypertension
- Alcoholism
- Advanced age
- Para/Quadriplegic
- Males>Females (10:1)[1], (likely under-diagnosed in women[2])
Clinical Features
- Initial event is usually local trauma or extension of a UTI or perianal infection[1]
- Gangrene develops over 2-7 days
- Marked pain, localized swelling, crepitus, ecchymosis to genital or perineal area.
- Fever
- Malodorous purulent drainage
- In late or severe cases, patient may present in septic shock
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Evaluation
Work-up
- CBC - very elevated leukocytosis
- CMP - hyponatremia
- ESR
- CRP
- Lactate
- Type and Screen
- Wound Culture
- Blood Cultures
- CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology)
Evaluation
- Clinical diagnosis, based on history and physical exam
- LRINEC score here: Necrotizing fasciitis
Management
- Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr[1])
- Antibiotics - Must cover gram positive, gram negative, and anaerobes
- Vancomycin + (imipenem 1gm IV q24hr OR meropenem 500mg-1gm IV q8hr OR piperacillin-tazobactam 3.375gm to 4.5gm IV q6h) +/- (clindamycin 600mg-900mg IV q8h OR metronidazole 1gm IV then 500mg IV q8h)
- Piperacillin-Tazobactam 3.375-4.5g q6hr and linezolid 600mg q12hr is an alternative regimen[3]
- Aggressive supportive care, including fluid resuscitation (and pressors, if indicated)
Disposition
- Admit to ICU
See Also
References
- ↑ 1.0 1.1 1.2 1.3 Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001.
- ↑ 2.0 2.1 Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.
- ↑ Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444