Aug 22, 2003 6:46pm

Subject: quinolone induced Fournier gangrene (R rated graphic description)

http://www.medscape.com/viewarticle/458852_3

Case Report

A 74-year-old man presented to the urology clinic with a 10-day history of fever accompanied by scrotal swelling and pain. He had been undergoing treatment from his primary care physician with an oral fluoroquinolone for presumed epididymo-orchitis. His medical history was significant for poorly controlled diabetes and severe peripheral vascular disease that had necessitated bilateral above-knee amputations. Physical examination revealed a hemodynamically stable patient with a tender discolored scrotum and swelling extending into the suprapubic area with palpable crepitus throughout. A clinical diagnosis of Fournier gangrene was made, and emergent debridement was undertaken.

The initial incision into the scrotum yielded watery pus with a fungal odor. Approximately 350 mL of pus was aspirated from the wound. Extensive debridement of the scrotum and base of the penis was performed, exposing necrosis of the scrotum that tracked into the inguinal and suprapubic area. The right testicle was absent; the left testicle did not appear to be grossly infected and was spared. The skin over the suprapubic area appeared viable and was not excised.

A suprapubic tube was placed, and the wound was packed with a sterile dressing. Gram stain of the wound fluid demonstrated yeast, and intravenous therapy with a third-generation cephalosporin and fluconazole was begun pending results of final wound cultures. A second debridement procedure was performed 48 hours later.

Aerobic and anaerobic cultures of material obtained from the primary debridement demonstrated only Candida albicans; blood cultures were negative. Pathologic examination of the debrided tissue showed acute suppurative inflammation (Figure). Daily whirlpool therapy was initiated, as were wet-to-dry dressing changes. The patient was discharged from the hospital on postoperative day 4, with arrangements made for outpatient wound care.

Discussion

Fournier gangrene is somewhat of a misnomer for this disease, because true myonecrosis is uncommon. Nonetheless, this does not detract from the seriousness of the illness, because the infection tends to follow the distribution of Scarpa fascia, thereby allowing for extension as far cephalad as the clavicles and as far caudad as the fascia lata. Although the disease was classically described in patients with periurethral abscess, more contemporary presentations occur in the diabetic or immunocompromised host.[2,3]Modern interventions have greatly improved the prognosis for patients with Fournier gangrene, but the disease still is capable of producing grave morbidity, because large areas of tissue debridement may be required for disease control. Dahm and associates[4] reported a 20% mortality rate in their contemporary case series, with depth of invasion, extent of infection, and treatment with hyperbaric oxygen observed as the most important prognostic variables.

It should be noted, however, that the use of hyperbaric oxygen is a controversial treatment for patients with Fournier gangrene, although it may be a useful adjunct to debridement and antibiotic therapy in severe circumstances.The extensive tissue infarction and destruction seen in Fournier gangrene is usually the result of anaerobic bacterial infection. In many cases, this infection may begin as a primary infection with less virulent organisms, with anaerobic infection occurring as a secondary phenomenon. Thus, initial antibiotic therapy should consist of broad-spectrum coverage that includes agents active against anaerobes. Because of the rarity of fungal infection in this scenario, antifungal agents are probably not required in most cases.

Because our patient's solitary testicle appeared viable at surgery, we believe that the most likely scenario to explain his clinical course was a misdiagnosed scrotal abscess that was managed with a broad-spectrum antibiotic, resulting in selection for yeast. Thus, we cannot rule out the possibility that a bacterial infection had been the initial inciting event. Nevertheless, in this patient, fungal sepsis did not develop, and he did not require extensive hospitalization, perhaps emphasizing the importance of early recognition and intervention in the management of all types of Fournier gangrene.