FOURNIER’S

GANGRENE
A FLESH EATING DISEASE

Author : Biru Diana-Madalina

Co-authors: Pricop Mariana, Pricop Daniela
Scientific Coordinator: Dr.Nutu Vlad
 Fournier’s Gangrene
Fournier’s gangrene is a rapidly
progressive fasciitis of the
perineum.
It was described in 1883 by Jean
Alfred Fournier, a French
venereologist .
Although most cases described
occur in diabetic men 50–70 years
old, Fournier gangrene also has
been described in women.
The rate of fascial necrosis has
been documented to be as rapid as
2–3 cm/h .
 Epidemiology of FG

The chart above shows the there has been an increase in the
number of cases reported in the literature over the last
decade.This probably is because of better recognition of this
condition and an increase in the reporting of this condition in
the medical literature.
 Clinical case study

P.G. is a 51-year-old man without any significant

pathology who presented himself to his primary care
doctor after 7 days of:

progressive pain
swelling in his genital region
low-grade fever
asthenia
 Differential diagnosis

Differential diagnosis for acute scrotal pain includes

testicular trauma
testicular torsion
acute epididymo-orchitis
Fournier’s gangrene.
 Clinical case study

There was no history of similar symptoms.

He denied recent trauma.
He had no nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, or
hematochezia.
He had dysuria.
Notably, he reported a 20 kg weight loss over the
last year.
 Physical examination

The patient was a mildly ill-appearing man in a

severe sepsis shock and with acute renal failure.
He was awake and alert.
His vital signs included:
 Physical examination
He was 1.67 cm tall and weighed 45 kg.
Head, eyes, ears, nose, and throat were normal.
Lungs were clear.
Heart was tachycardic with a normal s1 and s2 with
no murmurs or gallops and no rub.
Abdomen was nontender and distended with normal
bowel sounds and it revealed a palpable urinary
bladder size 40x20 cm.
His extremities had no edema, and pulses were
normal bilaterally.
 Genital examination

Diffuse erythema ,fluctuance, edema of his

scrotum,penis and perineal area, along with severe
tenderness, measuring almost 10 x 20 cm with the
development of a crepitus of the inflamed tissues.
There was a necrosis area measuring 4-5 cm in the
center involving a part of the scrotum but sparing the
penis. At compresion the necrotic area eliminated a
foul smelling, suggesting a microbial infection with
anaerobic.
His perirectal area was erythematous, but there was
no evidence of fissures, ulcerations, or crepitus .
 Fournier’s Gangrene
Clinical Signs
Patients have a sudden onset of perineal pain and
swelling.
Fever and leukocytosis.
Physical examination reveals
• pain,
• redness
• swelling of the perineal area.
Crepitus from the soft-tissue gas can be palpated.
 Digital rectal
examination
On the posterior side of the
rectum a necrosis area
within 2x2 cm which
eliminates gases with a fetid
odor and pus.
The posterior part of the anal
area revealed 4 warts which
leaded to the presumtion of
a condyloma acuminatum or
a anal cancer.A biopsy was
performed for diagnostic
purposes
 Fournier’s Gangrene
Aetiology
The bugs:
 Staphylococcus aureus
 Streptococci

 Enterococci

 Escherichia coli

 Peptostreptococcus

 Preveoella and Porphyromonas

 Klebsiella Pneumonie

 Bacteroides fragilis

 Clostridium
Como rbid r isk
factors
 Aetiology of FG

Anorectal or urogenital and perineal trauma,

including pelvic and perineal injury or pelvic
interventions are other causes of FG.
Investigations
Laboratory data
Laboratory data
 Evolution
2 2 29.0 30.0 31.0 2 3.04 4.04 7 8.04 9 11.04
7.0 8.0 3 3 3 .04 .04 .04
Gluc 3
307 3
248 442 360 245 150 170 139 94 191
ose 86
Na 134 135 130 134 133 136 137
K 4 4,8 3,9 4,9 2,9 3,3 3
,19
Cl 103 113 108 103 110 111 115
FA 228 149 240 185 220 163 330

Creat 4 3 3,02 2,62 2,22 2,46 1,93 2 1,82

inine ,99 ,98 ,11
Urea 114 105 94 79 67 80 81 61 36
 Evolution

27.03 28.03 29.03 30.03 2.04 3.04 4.04 8.04 11.04

Hb 9,1 8,2 8,4 7,9 6,3 7 7,95 8 7,2

Ht 26,2 23,1 23,7 23,2 18,4 20,7 23,1 23 21,9

Leu 35600 31600 26900 19500 26500 22000 18700 11900 10200

Tr 484000 485000 497000 520000 595000 516000 629000 492000 470000

 Diagnosis

PG’s. was diagnosed as having type 2

diabetes and Fournier’s Gangrene.
Pathological features
 Pathological features
Normal skin Early stage Advanced stage

Normal skin is held tightly by
proteins that make up the
connective tissue that keep the
dermis, epidermis and the muscle
tightly connected.
But when bacteria invades the
skin through open wounds and
punctures of the skin, they cause
devastating results by “eating”
the protein and the connective
tissue.
If left untreated the Bacteria will
continue eating and destroying the skin
and tissue beneath it until the muscle is
infected, when this happens there is no
hope of saving the person unless the
infected area is surgically removed to
keep the bacteria from spreading.
Pathological features

Photomicrograph showing presence of ulcerated epidermis. The dermis shows

presence of thrombosed blood vessel and bacterial colonies (H&E, X200)
 Pathogenesis

Thrombosis of subcutaneous and cutaneous blood vessels

produces gangrene, but the fascial necrosis is usually
more extensive than the visible gangrene suggests.
Classic findings are necrosis of the superficial and deep
fascial planes, fibrinoid coagulation of the nutrient
arterioles, polymorphonuclear cell infiltration, and
positive microorganism culture of involved tissues.
 Pathogenesis

The synergistic activity of aerobes and anaerobes lead to

the production of various exotoxins and enzymes like
collagenase, heparinase, hyaluronidase, streptokinase, and
streptodornase, which aid in tissue destruction and spread
of infection.
The platelet aggregation and complement fixation induced
by the aerobes and the heparinase and collagenase lead to
microvascular thrombosis and dermal necrosis. In addition
the phagocytic activity is impaired in the necrotic tissue,
aiding in further spread of the infection.
Paraclinical signs
Treatment-4 main
principles
 Treatment –
Resuscitation and
Antibiotics
The patient was hemodynamically stabilized.
Resuscitation with normal saline and broad-spectrum
antibiotics (ciprofloxacin,peniciline and
metronidazole) was commenced immediately.
A Foley catheter was used to drain urine and the
pacient eliminated 3500 ml of urine along with
hematuria at the end.
Treatment - Debridment

Consent for radical DEBRIDEMENT, as well as

possible colostomy.
Radical surgical excision of the entire necrotic tissue
Frequent wound dressings with hypertonic saline
His testicles were preserved and he required a
colostomy.
He received diabetes education and performed self-
monitoring of blood glucose four times a day. He was
treated with insulin. His diabetes was then managed
as an outpatient with no subsequent readmissions.
 Treatment - Debridment

After a week, the denuded area was

covered with healthy granulation tissue.
 Treatment – wound
dressing

Frequent wound dressings with hypertonic saline

 Treatment -
Reconstruction
The patient was sent to the Plastic Surgery Clinic for skin
grafing.
Split-thickness skin grafting (STSG) is a safe and easy
method to cover these raw areas. However, stabilizing the
grafts may be difficult due to free mobility of the testicles.
STSG can be done by using stamp-sized grafts or by the
mesh technique. Mesh skin grafting offers the advantage
of covering a large area with a small sheet of donor skin
but needs specialized equipment, i.e., mesh graft plate
and roller.
In our patient, we used stamp sized multiple skin grafts
to achieve maximum coverage of the denuded area of the
perineum and scrotum.
 Conclusions
Fournier's gangrene is an abrupt, rapidly progressive, gangrenous infection of the
external genitalia and perineum and a realy life threatning disease.
Prompt diagnosis and early surgical intervention is required for a better outcome of
these patients.
Resuscitation and corection of electrolyte disturbances is very important
Empiric broad spectrum antibiotics must be used
Urgent surgical debridment remains the cornerstone of the treatment
Fecal and urinary diversion might be necessary to avoid wound contamination or to
facilitate the treatment of underlying pathology or both
Continued medical care in the form of a multidisciplinary approach is necessary as
these patients may require reconstructive procedures in the future.
Proactive management of the diabetic and immunosuppressed patients with perineal
infections is of extreme importance to prevent the development of the condition in the
first instance as this condition in the presence of such comorbidities is associated with
high mortality.
Thank you!