Fournier Gangrene

A 77-year-old African American man with type 2 diabetes mellitus and coronary artery disease presented to the emergency department with acute scrotal swelling and pain. His testicles were erythematous with focal areas of necrosis and associated tissue destruction. Similar skin changes were apparent in the lower abdominal and inguinal regions.

CT scans were obtained to rule out intra-abdominal involvement. Because of the patient's diabetes, intravenous—not oral—contrast was given. Indurated soft tissue was demonstrated in the left scrotum near the base of the penis, and superior medial displacement of the right testicle was also noted (A, arrow). An abscess in the left scrotum featured marked induration; inferior displacement of the left scrotum with a reactive hydrocele/pyocele was also noted (B, arrow). The CT findings helped confirm the diagnosis of Fournier gangrene.

This rare and dangerous condition was first described by Jean Alfred Fournier in 1883.¹ The polymicrobial necrotizing fasciitis of the genital, perianal, or perineal tissue may occur in either sex. A localized infection develops adjacent to a portal of entry and can progress rapidly; early diagnosis, surgical debridement, and antibiotic therapy are needed to prevent morbidity and mortality.^2,3

Predisposing conditions include diabetes mellitus, paraplegia, alcohol abuse, and malignancy. Many patients have an underlying urinary tract infection or colonic or perirectal disease, or they have undergone urologic instrumentation. Death is usually attributed to systemic illness, such as sepsis, coagulopathy, acute renal failure, diabetic ketoacidosis, or multiple organ failure.

Fournier gangrene usually begins insidiously with pruritus and discomfort of the external genitalia. Typically, patients wait a few days for symptoms to resolve before they seek medical care. Pain, which may be out of proportion to the early physical findings; swelling; erythema; and systemic symptoms, such as fever and chills, develop. Eventually, the pain may subside as the nerve tissue becomes necrotic.

The skin overlying the affected region can be normal, erythematous, cyanotic, bronzed, indurated, blistered, or frankly gangrenous. However, the skin's appearance often belies the degree of underlying disease. A feculent odor secondary to anaerobic bacteria also may be present.

Initial laboratory studies include a complete blood cell count; electrolyte, blood urea nitrogen, and creatinine levels; blood and urine cultures; and cultures of any open wound or abscess. Imaging studies may help confirm the diagnosis and determine the extent of the pathology. Imaging modalities can also be used to follow the disease course and response to treatment.

Based on evaluation of this patient's condition and the radiologic findings, it was determined that antibiotic therapy was futile. The testicles were removed to prevent further spread of the infection.