Distant subcutaneous spreading of Fournier’s gangrene: An unusual clinical identification by preoperative ultrasound study

Abstract

We present here the first case of successful management via preoperative ultrasonographic (US) study to detect a distant spreading of Fournier's gangrene (FG), which was happened in a 75-year-old man. US study showed the necrotizing infection in the periumbilical region distant 22 cm from the genital tract. A target incision of this periumbilical area and debridement of necrotic tissues was made. Computed tomography (CT) is superior to ultrasonography to confirm the diagnosis of FG and support in surgical management, but a CT evaluation in patients with FG may be limited by the frequent presence of concurrent acute renal failure or patient hemodynamic instability. Ultrasonography is an ideal technique for evaluating patients in bedside settings and can be routinely used in an emergency. KEY WORDS:Fournier's gangrene; Ultrasonography; Computed tomography. body temperature 38°C. His blood count showed: haemoglobin level, 11.3 g/dL, white blood cell count, 17.000/mm 3 , and platelet count, 185.000/mm 3 . C-reactive protein level was 13 mg/dL, glucose 280 mg/ dL and creatinine level was 1.4 mg/dL. Physical examination showed genital and perineal swelling, with erythema, edema and necrotic tissue over his scrotum with extension to the perineum ( Figure 1A); subcutaneous crepitation was also present. As part of the initial assessment, the patient received an US study that demonstrated marked thickening of the scrotal fascia with edema and high-amplitude echoes, as well as an area of subcutaneous gas in the periumbilical region was discovered distant 22 cm from the genital tract ( Figure 1B). However, a contrast-enhanced computed tomography (CT) was performed to differentiate areas of subcutaneous gas in the periumbilical and genital regions (Figure 2). These findings were compatible with Fournier gangrene. Immediate broad spectrum antibiotic administration were initiated. Although the initial vital signs were normal, he rapidly developed septic shock and was emergently taken to the operating room for aggressive surgical therapy including target incision on the periumbilical localization of infection and debridement of necrotic tissues until to be able to contain the progression of the gangrene. The patient was discharged after a flap reconstruction over the scrotum and 28 days of hospitalization. The clinical follow-up was 6 months and showed no signs of infectious or ischaemic complications.

Fournier’s gangrene: a modern analysis of predictors of outcomes

“…Early identification of patients at high risk for mortality allows rapid advancement of care and may provide survival benefit. While many institutions including our own use computed tomography (CT) scans to detect free air within the soft tissues, ultrasound has been reported to be of benefit for bedside detection of free air when CT is not readily available (10). The FGSI score is the most widely used prognostic tool in the management of FG.…”

Italian experiences in the management of andrological patients at the time of Coronavirus pandemic

“…In the first 50 days we had to intervene on two traumas of the genital tract that happened due to working activities. We listed criteria to plan andrological surgery in agreement with our experience, the Covid Task Force Unit in our hospital and published Guidelines on urological surgery (17)(18)(19)(20)(21). The andrological surgical activity included two orchiectomies for testicular cancer, one penile amputation with inguinal and ipsilateral pelvic lymph node dissection for penile cancer (Figure 4) and one surgery for severe gangrenous necrotizing fasciitis of the genitals in a 58-year male with diabetes, HIV and drugs addiction.…”