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Fournier's gangrene

Etiology: - polymicrobial infection - Staphylococcus aureus - Streptococcus sp. - Klebsiella sp. - Escherichia coli - anaerobic bacteria - involvement of Clostridium sp. less common - risk factors include - immunodeficiency - diabetes mellitus - SGLT2 inhibitors (flozins) [3] - malnutrition - recent history of urinary catheterization or instrumentation - perineal surgery Epidemiology: - rare - incidence is increasing with an ageing population Pathology: - typically a type 1 necrotizing fasciitis - involvement can include perineum, scrotum, penis, anterior abdominal wall [4] - endotoxins cause tissue necrosis & severe cardiovascular impairment - subsequent inflammatory reaction by the host contributes to multi-organ failure - degree of internal necrosis is much greater than suggested by external signs Clinical manifestations: - painful swelling & erythema of the scrotum or perineum - testicular pain, perianal pain - signs of severe sepsis - small necrotic bulla with surrounding erythema & edema - crepitus on palpation & a foul-smelling exudate (prululent drainage) occurs with more advanced disease - in up to 40% of cases, the onset is insidious with undiagnosed pain Management: - broad spectrum intravenous antibiotics - coverage for gram-positive, gram-negative & anaerobic bacteria - adequate, repeated surgical debridement is necessary to save life - following resolution, reconstruction using skin grafts is required - prognosis: - with aggressive early surgical management, survival rates may be >70%

General

gangrene fasciitis urogenital disease

References

  1. Pais VM, Schwartz BF eMedicine: Fournier gangrene http://emedicine.medscape.com/article/2028899-overview
  2. Thwaini A, Khan A, Malik A et al Fournier's gangrene and its emergency management. Postgrad Med J. 2006 Aug; 82(970): 516-519. PMID: 16891442 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585703/
  3. Bersoff-Matcha SJ, Chamberlain C, Cao C et al Fournier Gangrene Associated With Sodium-Glucose Cotransporter-2 Inhibitors: A Review of Spontaneous Postmarketing Cases. Ann Intern Med. 2019. May 7 PMID: 31060053 https://annals.org/aim/article-abstract/2732837/fournier-gangrene-associated-sodium-glucose-cotransporter-2-inhibitors-review-spontaneous
  4. Voelzke BB, Hagedorn JC. Presentation and Diagnosis of Fournier Gangrene. Urology. 2018 Apr;114:8-13 PMID: 29146218 Review.
  5. NEJM Knowledge+ Endocrinology