Fournier gangrene

Fournier gangrene is a necrotizing infection involving the soft tissues of the male genitalia. It was first described in 1764 by Baurienne and given its eponymous name after Jean-Alfred Fournier in 1883 presented a case of perineal gangrene in an otherwise healthy young man.While only 600 cases of Fournier gangrene have been reported in the world literature since 1996, it is a common and serious disease in Africa. In Maputo Central Hospital alone, between 12 and 16 cases are admitted every year and treated with a 20% mortality. The typical patient is an elderly male in his sixth or seventh decade with co-morbid diseases.While considered to affect males only, a similar condition may occasionally affect the female genitalia.     

Gas gangrene disclosing colonic cancer. Role of synergistic gangrene

After reporting a case of synergistic gas gangrene of the retroperitoneum spreading to the thigh, revealing a carcinoma of the descending colon, the authors review the symptomatology and management of synergistic gas gangrene defined as a gas gangrene due to anaerobic non clostridial bacilli, and aerobic flora and emphasize the exceptional nature of its association with a carcinoma of the colon.     

Symmetrical peripheral gangrene

Symmetrical peripheral gangrene (SPG), seen in a wide variety of medical conditions presents as symmetrical gangrene of two or more extremities without large vessel obstruction or vasculitis. Fingers, and toes (rarely nose, ear lobes or genitilia) are affected. It may manifest unpredictably in conditions associated with sepsis, low output states, vasospastic conditions, myeloproliferative disorders or in hyperviscosity syndrome. It carries a high mortality rate with a very high frequency of multiple limb amputations in survivors. Disseminated intravascular coagulation (DIC) is seen in majority of cases of SPG. A more or less stereotyped clinical picture of SPG in spite of ever widening aetiological spectrum is suggestive of DIC as the final common pathway of its pathogenesis. Early recognition of acrocyanosis, quick reversal of DIC, effective management of the underlying condition, haemodynamic stabilization and (perhaps) anticoagulation with low dose heparin (300-500 iu/hour) may be helpful in arresting the progression of pre-gangrenous changes to frank gangrene. Vasopressors such as dopamine should be used judiciously in the presence of DIC. Development of acrocyanosis and increase in serum lactate levels may be indicative of impending SPG and the imperative need to treat DIC as well as the underlying condition.     

Symmetrical peripheral gangrene.

Two cases of symmetrical peripheral gangrene associated with intracardiac lesions are described. One had a secondary deposit from a uterine leiomyosarcoma in the wall of the right ventricle, the other had a free ball thrombus in the right atrium; there were no valvular lesions in either case. The published reports of this type of gangrene indicate that it may result from (1) va sospastic conditions, (2) small vessel obstruction, or (3) conditions producing a very low cardiac output. The two patients reported are unusual examples of the last.     

Fournier's gangrene complicating ulcerative pancolitis

Fournier gangrene is a very rare and a rapidly progressing, polymicrobial necrotizing faciitis or myonecrosis of the perineal, perianal and genital regions, with a high mortality rate. Infection is associated with superficial traum, urological and colorectal diseases and operations. The most commonly found bacteria are Escherichia coli followed by Bacteroides and streptococcal species. Diabetes mellitus, alcoholism, and immunosuppression are perpetuating co-factors.Fournier's gangrene complicating inflammatory bowel disease has been reported in three patients so far, two with Crohn's disease.A 78-year-old man diagnosed with ulcerative pancolitis was referred for fever, and painful perianal and scrotal swelling after perianal surgery for a horseshoe-type perianal abscess. Since bowel disease diagnosis, patient was on mesalazine and achieved long-term remission. Perianal abscess occurred suddenly one week before perianal surgery without any evidence of pre-existing fistula or other abnormalities. Physical examination showed extensive edema and crepitus of perineum and genitalia and patient had symptoms of significant toxicity.The diagnosis of Fournier's gangrene was made and patient underwent emergency surgery with extensive surgical debridement of the scrotal and perianal area and Hartman procedure with a diverting colostomy. In addition, patient started on therapy with mesalazine 3gr, methylprednisolone 16 mg, parenteral nutrition and broad spectrum of antibiotics. Two days after the first operation the patient needed a second operation for perianal debridement. On the fourth day, blood cultures showed E. coli. Patient had an uneventful recovery and was discharged after 34 days of hospitalization. On follow up, disease review is scheduled and colostomy closure is planned.     

Diabetes mellitus and Fournier's gangrene

A case is described in which Fournier's gangrene was the presenting feature of diabetes mellitus and in which extensive subcutaneous emphysema prevented the use of spinal anaesthesia for debridement. In the literature four cases have been reported in which Fournier's gangrene was the presenting feature in patients with diabetic ketoacidosis. Diabetes may predispose to a form of Fournier's gangrene in which subcutaneous gas formation is marked, though subcutaneous emphysema to the degree described in this case has not previously been reported in this condition. Diabetes mellitus and subcutaneous emphysema must be sought in patients with Fournier's gangrene as both may have a profound influence on management.     

Prognostic factors in intestinal gangrene

103 patients with intestinal gangrene were treated over a ten-year period in Ile-Ife, Nigeria. The various causes of the intestinal gangrene were herniae (63%), intussusception (20%), adhesions (12%), volvulus (3%) and mesenteric vascular occlusion (2%). The presence of pre-operative shock, purulent and faeculent peritonitis, intra-peritoneal perforation of bowel and involvement of long bowel segments in the gangrene process; constitutes the important prognostic factors. The presence of a pre-operative febrile response also influences the course of the disease while the age and sex of the patient, the duration of symptoms and the portion of bowel involved showed no relationship with the ultimate outcome. It is recommended that the patients with the ominous prognostic factors constitute a high risk group and should be given intensive care to ensure survival.     

Fournier's gangrene after genital piercing

A fulminant case of streptococcal toxic shock syndrome is described. Early surgery was life saving, and the antibiotic regimen should include clindamycin. The value of secondary measures is discussed. High dose intravenous immunoglobulin (IVIG) has shown promising effects in recent publications. Hyperbaric oxygen (HBO) treatment is under evaluation. Piercing of mucosal surfaces might be associated with severe infections.