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OBJECTIVES: To identify effective factors in the survival of patients with Fournier's gangrene and to determine the accuracy of the Fournier's gangrene severity index score. METHODS: In our clinic, 25 patients with Fournier's gangrene were treated between 1995 and 2000. Data were collected about medical history, symptoms, physical examination findings, admission and final laboratory tests, timing and extent of surgical debridement, and antibiotic therapy used. RESULTS: The results were evaluated in two groups: those who died (n = 6) and those who survived (n = 19). No statistically significant difference was found between the age of the survivors and those who died. The admission and final laboratory parameters that correlated statistically significantly with outcome included urea, creatinine, bicarbonate, sodium, potassium, total protein, albumin, leukocyte count, hematocrit, lactate dehydrogenase, and alkaline phosphatase. The greater mean extent of body surface area involved among patients who died was significantly different statistically from that of those who survived (5.4% and 2.1%, P < or =0.0001). The mean Fournier's gangrene severity index score (FGSIS) for survivors was 3.0 +/- 1.8 compared with 12 +/- 2.4 for nonsurvivors. Regression analysis demonstrated a strong correlation between the Fournier's gangrene severity index score and the death rate (P < or =0.0001). CONCLUSIONS: Patients' metabolic status and the extent of disease at presentation is an important factor in the prognosis of Fournier's gangrene. We suggest the clinical use of FGSIS, which is simple and objective when evaluating therapeutic options and predicting outcome.
Cutaneous and subcutaneous gangrene are serious sequelae of secondary or tertiary hyperparathyroidism which may accompany chronic renal failure. Based on analysis of the present typical case and a retrospective survey of similar cases in the literature, we propose the term 'uraemic gangrene syndrome' for this association. These skin lesions in chronic renal failure patients represent the most serious clinical manifestation of calciphylaxis, a condition originally described by Selye. The appearance of early skin lesions should be regarded as an indication for subtotal parathyroidectomy. The association of cutaneous gangrene with vascular calcification was first described by Bryandt and White in 1989, and was termed by these authors as 'gangrenous calcification'. A total of 80 cases of this rare complication of chronic renal disease had been reported up to early 1994. A retrospective review of these reports has strongly suggested a close interrelationship between renal failure, secondary hyperparathyroidism, vascular calcification and cutaneous gangrene. The present report concerns a characteristic case to draw attention to this syndrome which is accompanied by serious, predominantly cutaneous, changes.
After reporting a case of synergistic gas gangrene of the retroperitoneum spreading to the thigh, revealing a carcinoma of the descending colon, the authors review the symptomatology and management of synergistic gas gangrene defined as a gas gangrene due to anaerobic non clostridial bacilli, and aerobic flora and emphasize the exceptional nature of its association with a carcinoma of the colon.
A 65-year-old Japanese male, who was treated for Fournier's gangrene, developed an enlarged erythema over the right thigh and right lower quadrant. The area was surgically debrided, and he was given antibiotics. However, he complained of abdominal swelling with a metallic bowel sound, pain, and vomiting and was then treated for paralytic ileus. Although his symptoms initially improved, he complained again of the same symptoms and underwent surgery for mechanical ileus occurring at the site of a surgical scar from an appendectomy 43 years earlier. This is a very rare case of Fournier's gangrene which caused mechanical ileus of the small intestine and adherence to a peritoneal scare after paralytic ileus due to inflammation of the abdominal fascia following scrotal gangrene.
Fournier's gangrene is an aggressive disease affecting the perineum. Clearly, it can no longer by considered idiopathic in its origin, as most infection can be localized to a cutaneous, urethral, or rectal source. It presents in a broad age range and can have an indolent onset, thus requiring a high index of suspicion. It may be fulminant and progressive in the case of immunocompromise and underlying debilitating illnesses. Despite aggressive antibiotic therapy and debridement, it is associated with a high mortality rate. This rate has been higher in older patients, those with a rectal focus, and diabetics. Hyperbaric oxygen therapy has shown some promise in shortening hospital stays, increasing wound healing, and decreasing the gangrenous spread when used in conjunction with surgical debridement and antibiotics. New reconstructive efforts, such as medial thigh myocutaneous flaps, have improved the cosmetic aftermath of the extensive debridement. Fournier's gangrene remains a true urologic emergency, which mandates aggressive initial care by means of early recognition, early hemodynamic stabilization, and the institution of parenteral broad-spectrum antibiotics. This is followed by multiple debridements and in some cases urinary or rectal diversion. The concomitant use of hyperbaric oxygen therapy in selected cases followed by meticulous reconstructive surgery and salvage has further reduced the mortality rate and improved the cosmetic outcome.
The microbiologic and therapeutic aspects of polymicrobial genital gangrene (Fournier's gangrene) studied in nine patients are presented. Seven patients had both aerobic and anaerobic bacteria isolated from the site of infection; four had Bacteroides and two, Clostridia. Broad-spectrum penicillins such as ticarcillin, mezlocillin, and piperacillin, or combined clindamycin and gentamicin therapy were used. One patient died of fulminating infection and eight patients were cured of their infections. Anaerobic bacteria and appropriate antibiotic therapy should be considered in all patients with genital gangrene.
OBJECTIVE: To evaluate effective factors in the survival of patients with Fournier's gangrene (FG) and to determine the validity of the Fournier's Gangrene Severity Index (FGSI), which was designed for determining disease severity in these patients. METHODS: The study included 20 men with a median age of 63.5 yr treated for FG between July 2002 and June 2005. The data were evaluated about medical history, symptoms, physical examination findings, vital signs, admission and final laboratory tests, timing and extent of surgical debridement, and antibiotic treatment used. All the patients had radical surgical debridement. The FGSI, which was developed to assign a numerical score that describes the acuity of the disease, was used in our study. This index presents patients' vital signs (temperature, heart and respiratory rates) and metabolic parameters (sodium, potassium, creatinine, and bicarbonate levels, hematocrit, white blood cell count) and computes a score relating to the severity of the disease at that time. The data were assessed according to whether the patient survived or died. RESULTS: Of the evaluated 20 patients, 6 died (30%) and 14 survived (70%). The difference in age between survivors (median age, 60.0 yr) and those who died (median age, 64.5 yr) was not significant (p = 0.321). The median extent of the body surface area involved in the necrotizing process in patients who survived and did not survive was 2.3% and 4.8%, respectively (p = 0.001). Except for the albumin and alkaline phosphatase levels, no significant differences were found between survivors and who those died in the other admission laboratory parameters. The median admission FGSI scores for survivors and nonsurvivors were 2.0+/-2.2 and 4.0+/-3.7, respectively (p = 0.331). CONCLUSIONS: The FGSI score did not predict the disease severity and the patient's survival. Metabolic parameters, predisposing factors, and extent of the disease seemed to be important risk factors for predicting FG severity and whether or not a patient survived.
Clostridium perfringens gas gangrene is a fulminant infection, and radical amputation remains the single best treatment. It has been hypothesized that rapid tissue destruction is related to tissue hypoxia secondary to toxin-induced vascular obstruction, and previous studies demonstrated that phospholipase C (PLC) caused a rapid and irreversible decrease in skeletal muscle blood flow that paralleled the formation of intravascular aggregates of activated platelets, fibrin, and leukocytes. In this study, flow cytometry demonstrated that PLC stimulated platelet/neutrophil aggregation in a gpIIbIIIa-dependent fashion. Pretreatment of animals with heparin or depletion of leukocytes reduced blood-flow deficits, and aggregate formation caused by PLC. It is concluded that fulminant tissue destruction in gas gangrene results from profound attenuation of blood flow caused by PLC-induced, gpIIbIIIa-mediated formation of heterotypic platelet/polymorphonuclear leukocyte aggregates. Therapeutic strategies that target gpIIbIIIa may prevent vascular occlusion, maintain tissue viability, and provide an alternative to radical amputation for patients with this infection.
The authors describe a case of Fournier's gangrene in a young man affected with acute promyelocytic leukemia. They emphasize the rarity of this disease especially in a patient affected with leukemia. Pseudomonas aeruginosa with the same strict antibiotic sensitivity has been found in cutaneous lesions and in several blood cultures. The Fournier's gangrene etiology is discussed.
Ischaemic cutaneous gangrene is described in a 44-year-old female patient. It was found to be attributable to metastatic calcinosis following secondary hyperparathyroidism. Recovery was obtained by means of subtotal parathyroidectomy combined with local treatment. The designation "uremic gangrene syndrome" is recommended for this characteristic syndrome.
Four cases of acute gangrenous inflammation of the male genitals are discussed, after a brief review of the literature, with reference to the authors' own experience. In addition to dermal and fascial necrosis the disease causes severe sepsis and shock. Characteristics include rapid progression, occasionally in a matter of hours, and high rate of mortality. Attention is called to the importance of early surgical intervention and to the difficulties in combatting the septic shock.
OBJECTIVES: Fournier's gangrene (FG) is a rare but life-threatening disease. Although antibiotics and aggressive debridement have been broadly accepted as the standard treatment, the mortality rate remains high. We conducted a retrospective study to analyze the outcome and identify the risk factors and prognostic indicators. METHODS: We retrospectively reviewed the medical records of 25 patients diagnosed with FG between July 1993 and August 2003. Data collected included age, predisposing factors, treatment modalities, length of hospital stay, surgical debridement times, and outcome. The FG severity index was used to predict outcome. Univariate analysis of the different prognostic factors was performed using t test and Fisher's exact probability test. RESULTS: All patients were male, 60% were diabetic, and the mean age was 55.8 years. The mean hospital stay was 20 days and the mortality rate was 32%. The mean age of 53.8+/-18.3 (SD) years in the survival group (n=17) was significantly lower than the 59.9+/-10.2 years (n=8) of the non-survival group (p<0.05). Non-survival group patients had lower serum hematocrit (mean 28.9, p=0.019) and albumin (mean 1.93, p=0.024) levels. In our series, the mean FG severity index for survivors was 4.41+/-2.45 (range 2-9) compared to 12.75+/-2.82 (range 9-18) for those who died (t test, p<0.0001). CONCLUSION: The survival rate of younger patients with FG was higher. We agree that a FG severity index cutoff value of 9 is an excellent predictor of outcome.
Three successfully managed cases of Fournier's gangrene, all with diabetes, are reported. A simple bacteriological classification is offered and the importance of diabetes mellitus as a predisposing factor is stressed.
Four cases of perineoscrotal gangrene are reported herein. All were immune-suppressed and three were diabetics. Its primary focus was in the GU tract or intestine. Culture was positive for Gram-negative aerobes and anaerobes. Early aggressive surgery and adjuvant antibiotic therapy achieved an excellent survival rate.
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