Fournier’s Gangrene (FG) is a rare polymicrobial necrotizing fasciitis of the perineum and groin; most often seen in male diabetics and alcoholics.  It is associated with a poor prognosis as it can lead to sepsis, multiorgan failure and death.  Additional risk factors include immunosuppression, liver disease, and chronic corticosteroid use.¹

Clinical presentation – The infection will often begin as cellulitis near the site of injury, progressing to readily apparent edema and intense pain.  As the infection continues, the cellulitis gives way to necrotic patches of skin and subcutaneous tissues following the facial planes.  Without aggressive treatment this can quickly progress to sepsis and ultimately death.¹

Pathophysiology – The initial insult is typically some sort of urogenital injury which leads to an obliterative endarteritis, necrosis and eventual microorganism infiltration.  The most common microorganisms enterobacteriaceae, anaerobic microbes, and Bacillus fragilis. The polymicrobial nature of these wounds leads to complications with adequate antimicrobial coverage.²

Diagnosis – Diagnosis is primarily clinical, although imaging and wound culture are important adjuvants in patient care, in particular when monitoring the spread of disease.

Differential – There are many possible differential diagnoses for FG, including; simple cellulitis, strangulated hernia, scrotal abscess, warfarin necrosis, pyoderma gangrenosum, and streptococcal necrotizing fasciitis to name a few.¹

Treatment – Aggressive surgical debridement and broad spectrum antibiotic therapy are the mainstays of therapy, with early debridement being the most important factor.¹  A 2007 study also indicated that hyperbaric therapy in septic patients correlated with a higher likelihood of survival, 100% (7/7) vs 22.22% (4/18).(Hung)   A scoring system was developed by Laor et al to quantify the severity of the infection and likely prognosis.  This scoring system, which considers heart and respiratory rate, temperature, serum sodium and potassium, serum creatinine, hematocrit, leukocytes, and serum bicarbonate is a useful tool for prognostic outcomes.   A score of over 9 is associated with a 75% mortality risk while a score of less than 9 was associated with a 78% likelihood of survival.³

References:

• Thwaini, A; Khan, A; Malik, A; Cherian, J; Shergill, I; Mammen, K. Fournier’s gangrene and its emergency management. Postgrad Medical Journal. 2006;82:516–519. doi: 10.1136/pgmj.2005.042069.
• Hung M-C, et al., The role of hyperbaric oxygen therapy in treating extensive Fournier’s gangrene, Urological Science (2015), http://dx.doi.org/10.1016/j.urols.2015.06.294
• Verma S, Sayana A, Kala S, Rai S. Evaluation of the Utility of the Fournier’s Gangrene Severity Index in the Management of Fournier’s Gangrene in North India: A Multicentre Retrospective Study.Journal of Cutaneous and Aesthetic Surgery. 2012;5(4):273-276. doi:10.4103/0974-2077.104916.

Contributing author Jaclyn Stacy, MS3 Campbell University College of Osteopathic Medicine