A 56-year-old man who has type 2 diabetes presents with feverof 3 to 4 days’ duration, scrotal swelling, and a feculent odor. He has nohistory of trauma or serious illness; however, his glucose level has not beenwell controlled during the past several weeks.
THE CASE:A 56-year-old man who has type 2 diabetes presents with feverof 3 to 4 days' duration, scrotal swelling, and a feculent odor. He has nohistory of trauma or serious illness; however, his glucose level has not been well controlled during the past several weeks.
What is the likely cause of the patient's symptoms?
This patient hasFournier gangrene, an aggressive,synergistic fasciitis of the perineum.It was originally described byFournier in 1883 as an idiopathic,rapidly progressive necrotizing fasciitisof the penis and scrotum. Sincethat time, more than 800 cases havebeen reported; most of these have adefinitive cause--ie, a urologic, colorectal,or cutaneous source. The diseaseaffects male and female patientsfrom infancy to old age. Mortality remainselevated despite antibiotictherapy and aggressive debridement.The presentation varies considerablyand a high index of suspicion is required,especially in such vulnerablepatients as those with alcoholism ordiabetes and those who are debilitatedor immunocompromised.
When a single organism is involved,it generally is of low to moderatevirulence; however, usually a combinationof aerobic and anaerobic bacteria is involved. The most commonlycultured organisms include Escherichia coli, Bacteroides species, and staphylococci.Suspect clostridial involvement in infections of colorectal origin if myonecrosisis present.
Regardless of the cause, the initial event is the establishment of a local infectionadjacent to a portal of entry. Subsequent spread of the inflammatoryprocess and local infection extend to the deep fascial planes; this results in tissuenecrosis from local ischemia and the synergistic effects of various bacteria.
Begin antibiotic treatment with triple broad-spectrum coverage immediately.One possible regimen is penicillin (to cover gram-positive organisms andClostridium perfringens), an aminoglycoside or third-generation cephalosporin(to cover gram-negative organisms), and metronidazole or clindamycin (tocover anaerobes). Surgical debridement is also warranted. Local wound careand hyperbaric oxygen therapy (although the latter modality is controversial)may limit the extent of tissue destruction; current reconstructive techniquesoffer improved cosmetic results.
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