From the Guidelines
Fournier gangrene is a severe and potentially life-threatening condition characterized by rapidly progressive necrotizing fasciitis of the perineal, genital, or perianal regions, requiring immediate recognition and treatment to reduce mortality rates, which can approach 20-50% despite treatment. The clinical findings of Fournier gangrene include severe pain, erythema, edema, skin discoloration, bullae, crepitus, and frank necrosis, as well as systemic manifestations such as fever, tachycardia, hypotension, and altered mental status as sepsis develops 1. Laboratory findings often show leukocytosis, elevated inflammatory markers, hyperglycemia, electrolyte abnormalities, and renal dysfunction 1. Risk factors for Fournier gangrene include diabetes mellitus, alcoholism, immunosuppression, and local trauma or infection 1.
The diagnosis of Fournier gangrene is mainly clinical, and a focused and detailed medical history as well as a complete physical examination, including a careful inspection of the perineum, is mandatory 1. Imaging studies, such as computed tomography or MRI, can help define the extent of the infection and suggest the need for bowel diversion 1. The Fournier’s Gangrene Severity Index (FGSI) is a useful tool for predicting outcome in patients with Fournier gangrene, with a score above 9 indicating a high risk of mortality 1.
Key Clinical Findings
- Severe pain that may seem disproportionate to initial physical findings
- Erythema and edema of the affected areas
- Skin discoloration, progressing from red to purple to black
- Bullae, crepitus, and frank necrosis
- Systemic manifestations, such as fever, tachycardia, hypotension, and altered mental status
- Laboratory findings, including leukocytosis, elevated inflammatory markers, hyperglycemia, electrolyte abnormalities, and renal dysfunction
Management
- Prompt and aggressive surgical debridement to halt the progression of the infection 1
- Broad-spectrum antibiotic therapy, with subsequent refinement according to culture results and clinical response 1
- Hemodynamic support and management of systemic complications 1
- Consideration for fecal diversion, either by colostomy or rectal diversion devices, in cases with fecal contamination 1
From the Research
Clinical Findings of Fournier Gangrene
- Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality 2
- The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum 2
- FG is a mixed infection of aerobic and anaerobic bacterial flora 2, 3
- The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death 2
Patient Profile
- FG has a strong association with male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder 2
- Patients with immunocompromise, including human immunodeficiency virus (HIV) and uncontrolled diabetes, are also at increased risk 4
- FG can also affect patients without risk factors 2
Diagnostic Findings
- Laboratory studies and imaging, including point-of-care ultrasound, conventional radiography, and computed tomography, are important diagnostic adjuncts 2
- Negative results cannot exclude diagnosis, and a high clinical level of suspicion is required for accurate diagnosis 2
- FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI) 4
Treatment and Management
- Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications 2
- Vacuum Assisted Closure (VAC) therapy can be effective in reducing the number of dressings and hospital length of stay 5, 3
- Hyperbaric oxygen therapy (HBOT) may also be used as an adjunctive therapy 5, 3