Fournier’s gangrene: a surgical emergency

Excerpt

A 61-year-old man with acute promyelocytic lymphoma received remission induction therapy (RIT) with all-trans retinoic acid, idarubicin, and cytarabine. After RIT, he presented with a fever and groin pain despite receiving broad-spectrum antibiotics (meropenem, 2 g/day; and vancomycin, 2 g/day). Three weeks post-RIT, he developed shock vital status (blood pressure, 82/52 mmHg; heart rate, 92 beats/min; and body temperature, 37.8 °C) with rapidly progressive scrotal edema and erythema (Fig. 1a). Contrast-enhanced computed tomography showed extensive inflammation and air in the subcutaneous tissues around the scrotum and perineum. The diagnosis of Fournier’s gangrene was made. Surgical debridement was performed immediately (Fig. 1b). Intraoperative cultures were negative. Severe necrosis at the anus indicated the anus as the entry site of infection (Fig. 1b, arrow). We managed the lesion as an open wound with once-daily cleansing using saline solution and dressing changes with continuous antibiotics (meropenem, 2 g/day; vancomycin, 2 g/day; and clindamycin, 900 mg/day) for 28 days (Fig. 1c). Two months post-debridement, wound reconstruction and closure were performed using a right myocutaneous gracilis flap and split thickness skin grafts from the left femur (Fig. 1d). He recovered and was able to resume chemotherapy treatment. Fournier’s gangrene is a necrotizing fasciitis of the perineum caused by a mixed infection with aerobic/anaerobic bacteria. Antibiotic therapy alone is associated with a high mortality rate [1, 2]. Treatment consists of early and aggressive surgical exploration and the debridement of necrotic tissue, antibiotic therapy, and hemodynamic support as needed. This image series highlights the need for surgical intervention.

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