Fournier gangrene: Difference between revisions

Latest revision as of 21:12, 13 July 2023

Background

Scrotal anatomy

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

Early Fournier's Gangrene with classic spotted area of ecchymosis (right lower scrotum) and draining lesion (mid scrotum). Draining lesions are not always present initially and even small areas of ecchymosis should be considered highly concerning for Fournier's Gangrene.

Progression of Fournier's Gangrene to larger draining lesion.

Fournier's Gangrene

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

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

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

Authors:

[Shyam-1] 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.

[Concepts-2] 2.0 ^2.1 Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.

[3] 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

[1]

[2]

[3]

@@ Line 1: / Line 1: @@
 ==Background==
-*Polymicrobial necrotizing fasciitis of perineal, genital, or perianal anatomy
+[[File:Gray1144.png|thumb|Scrotal anatomy]]
-**Microthrombosis of small subcutaneous vessels leads to gangrene of overlying skin
+[[File:Figure 28 01 02.jpg|thumb|Scrotal anatomy]]
-*Risk Factors
+*Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area.
-**Diabetes mellitus
+**Mostly bacteria lower GI system - [[B. fragilis]] and [[E. coli]]
-**Hypertension
+**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>
-**Alcoholism
+*Mortality - often cited as 20-40%, but up to 80% in some studies<ref name="Concepts" />
-**Advanced age
-**Para/Quadriplegic
-*Under diagnosed in women<ref>Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.</ref>
-*Mortality
-**Most often 20-40%, but ranges from 4% to 80%<ref><ref>Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.</ref></ref>
+===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==
-*Benign infection or simple abscess that rapidly becomes virulent
+[[File:Thumbnail_IMG_9537.jpg|thumb|Early Fournier's Gangrene with classic spotted area of ecchymosis (right lower scrotum) and draining lesion (mid scrotum). Draining lesions are not always present initially and even small areas of ecchymosis should be considered highly concerning for Fournier's Gangrene.]]
-*Marked pain, swelling, crepitus, ecchymosis
+[[File:Fournier-Gangrene.png|thumb|Progression of Fournier's Gangrene to larger draining lesion.]]
+[[File:PMC3560168 JCAS-5-273-g004.png|thumb|Fournier's Gangrene]]
+*Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" />
+**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==
 {{Template:Testicular DDX}}
-==Labs==
+==Evaluation==
-*CBC
+===Work-up===
-*Electrolytes
+*CBC - very elevated leukocytosis
+*CMP - hyponatremia
+*ESR
 *CRP
+*Lactate
+*Type and Screen
+*Wound Culture
 *Blood Cultures
-*Type and Screen
+*CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology)
-*Culture from wound/pus
-*CT Abd/pel: typically to assess extent of disease process
+===Evaluation===
-*EKG (pre-op)
+*Clinical diagnosis, based on history and physical exam
-*Foley (pre-op)
+*LRINEC score here: [[Necrotizing fasciitis]]
-==Treatment==
+==Management==
-*[[Antibiotics]]
+*Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr<ref name="Shyam" />)
-**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)
-*Surgical debridement
+**[[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==
-*Urologic consultation, in addition to surgery consultation, is required if:
+*Admit to ICU
-**Periurethral abscess is inciting event
-**Infection has secondarily invaded the urinary tract and a suprapubic catheter is needed
 ==See Also==
@@ Line 52: / Line 65: @@
 [[Category:ID]]
-[[Category:GU]]
+[[Category:Urology]]