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Table of Contents
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 104-106

Ultrasound in the diagnosis of Fournier's gangrene


1 Department of Emergency Medicine, Ohio Health, Ohio State University, Columbus, OH, USA
2 Department of Surgery, Ohio State University, Columbus, OH, USA

Date of Web Publication16-Jun-2012

Correspondence Address:
David P Bahner
756 Prior Hall, 376 W. 10th Avenue, Columbus OH 43210
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.97276

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   Abstract 

Fournier's gangrene (FG) is a life-threatening, rapidly progressive necrotizing infection. If not recognized and treated early, it is associated with high morbidity and mortality. The classic physical exam findings of crepitus are seen in approximately two-thirds of patients during the early stages of FG. Focused bedside sonography performed in cases of suspected gangrene represents an excellent adjunct in confirming the presence of subcutaneous gas and other signs of necrotizing infection. We present an illustrative case of a patient with FG who was evaluated with focused bedside ultrasonography.

Keywords: Bedside diagnosis, Fournier′s, ultrasound


How to cite this article:
Kube E, Stawicki SP, Bahner DP. Ultrasound in the diagnosis of Fournier's gangrene. Int J Crit Illn Inj Sci 2012;2:104-6

How to cite this URL:
Kube E, Stawicki SP, Bahner DP. Ultrasound in the diagnosis of Fournier's gangrene. Int J Crit Illn Inj Sci [serial online] 2012 [cited 2019 Mar 23];2:104-6. Available from: http://www.ijciis.org/text.asp?2012/2/2/104/97276


   Introduction Top


Fournier's gangrene (FG) is a life-threatening, rapidly progressive necrotizing infection of the perineal, perianal, and genital regions. [1] The mortality of FG ranges between 7.5% and 88%, depending on patient risks, comorbidities, and severity of presentation, with most reports citing 20-40% mortality. [2],[3] Prompt diagnosis is essential in order to facilitate immediate operative debridement because the sequential progression of tissue necrosis can reach 2-3 cm per hour. [4] Consequently, diagnostic and therapeutic delays have been shown to increase morbidity, extent and number of surgical intervention(s), as well as mortality. [5] Although clinical examination in conjunction with confirmatory imaging (usually computed tomography) constitute the traditional diagnostic approach to FG, [6] increasing number of clinical reports advocate the use of focused bedside sonography as an adjunctive imaging method in the setting of suspected FG. [5],[7],[8],[9]


   Case Report Top


A middle-aged man with a history of metastatic adenocarcinoma of the colon presented to the Emergency Department complaining of vomiting, severe testicular pain, and scrotal edema. His vital signs on arrival showed a blood pressure of 78/45 mmHg, a heart rate of 124 beats/min, and a temperature of 97.6 F. Initial laboratory evaluation featured an elevated serum lactate of 3.5 mg/dL, leukocytosis (white blood cell count 14,900), and acute renal failure (creatinine 3.14 mg/dL). His physical exam revealed acute edema and erythema of the scrotum, with crepitus and exquisite tenderness to palpation extending from the left scrotum to the left lower abdominal wall.

Immediate intravenous fluid resuscitation and broad-spectrum antibiotic administration were initiated. Emergency surgery and urology services were promptly consulted. Following initial IV hydration, his blood pressure improved to 100/62 mmHg, with a heart rate of 106/min. Bedsides, ultrasonography was performed to evaluate gas in the subcutaneous tissue of the scrotum and lower abdominal wall. The ultrasound showed small foci of gas within the tissues of the scrotum, with posterior acoustic shadowing [Figure 1]. Concurrently, the patient underwent computed tomography of the pelvis and scrotum, which showed foci of subcutaneous air [Figure 2]. Given these findings, the patient was immediately taken to the operating room with general and urological surgery services where he underwent extensive debridement of necrotic tissue of his scrotum and abdominal wall.
Figure 1: Scrotal ultrasound with subcutaneous gas bubbles and associated hyperechoic shadowing

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Figure 2: CT scan transverse showing subcutaneous air tracking from the left scrotum into the abdominal wall

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The patient recovered well postoperatively. His initial hospital care took place in the surgical intensive care unit, mainly due to the need for conscious sedation during serial wound-dressing changes and initial hemodynamic resuscitation related to underlying infection/sepsis. Following the acute phase of his wound care, he underwent subsequent split-thickness skin grafting of the scrotum at approximately 2 weeks postadmission. He was discharged from the hospital 20 days after the initial presentation.


   Discussion Top


Physical exam findings of FG include scrotal edema and tenderness. However, these findings can be present with other processes such as epididymitis or cellulitis. The hallmark of necrotizing infections is gas production by the bacterial organisms, which can sometimes (but not always) be appreciated on physical exam. In fact, estimates are that crepitus may not be detectable in as many as one-third of patients with the diagnosis of necrotizing infection. [10] This may be especially relevant at the early infection stage when surgical intervention is least extensive.

In addition to the physical exam, there are several diagnostic studies that can be used to evaluate necrotizing infections. Plain radiography of the pelvis may reveal subcutaneous emphysema in the involved tissue planes. Computed tomography (CT) may demonstrate adipose "stranding", fascial thickening, as well as trace amounts of subcutneous gas. CT scan may also help in delineating the etiology of any associated and/or underlying infection, such as a perirectal abscess or other abdominal/pelvic processes. [11] Imaging evaluation in patients with FG may be limited by the frequent presence of concurrent acute renal failure (thus precluding the use of intravenous contrast material) or patient hemodynamic instability making transport to the imaging department unsafe [Figure 3]. Ultrasound constitutes an excellent minimally invasive alternative in such situations because it allows for bedside evaluation for any associated scrotal pathology or soft tissue collection/abscess, and has been shown to identify subcutneous gas, even prior to the overt development of crepitus on physical exam. [5] The characteristic ultrasonographic features of necrotizing infections include the presence of gas in the tissue, which will be bright (hyperechoic) with hyperechoic shadowing distally. The ultrasound may also show evidence of scrotal skin thickening and peritesticular fluid. [8]
Figure 3: CT scan showing subcutaneous air tracking from the left scrotum into the abdominal wall

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   Conclusion Top


This report highlights a case in which focused bedside ultrasonography was used in a critically ill patient to help delineate the etiology of his illness and expedite appropriate treatment. The diagnosis of FG is certainly a lot easier to make in the setting of advanced disease, when the patient has crepitus on exam, but these findings may only be seen in 19-64% of cases on early presentation. [5] It is in these cases where one needs to maintain a high index of suspicion for necrotizing infection and consider further diagnostic evaluation to determine the etiology. Multiple imaging modalities may be used [6],[12] and it is up to the provider to balance time constraints, comfort with bedside diagnostics, and the role of imaging in their management of the emergent conditions at hand. Ultrasound can easily be used at the bedside to evaluate for subcutaneous gas as well as other possible etiologies associated with similar clinical presentation, including testicular, scrotal, and soft tissue pathology.

 
   References Top

1.Jiménez-Pacheco A, Arrabal-Polo MÁ, Arias-Santiago S, Arrabal-Martín M, Nogueras-Ocaña M, Zuluaga-Gómeza A. Fournier Gangrene: Description of 37 cases and analysis of associated health care costs. Actas Dermosifiliogr 2012;103:29-35.  Back to cited text no. 1
    
2.Sorensen MD, Krieger JN, Rivara FP, Broghammer JA, Klein MB, Mack CD, et al. Fournier's Gangrene: Population based epidemiology and outcomes. J Urol 2009;181:2120-6.  Back to cited text no. 2
    
3.Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier's gangrene: An analysis of 80 patients and a novel scoring system. Tech Coloproctol 2010;14:217-23.  Back to cited text no. 3
    
4.Paty R, Smith AD. Gangrene and Fournier's gangrene. Urol Clin North Am 1992;19:149-62.  Back to cited text no. 4
    
5.Kane CJ, Nash P, McAninch JW. Ultrasonographic appearance of necrotizing gangrene aid in early diagnosis. Urology 1996;48:142-4.  Back to cited text no. 5
    
6.You JS, Chung YE, Cho KS, Kim SW, Park I. The emergency computed tomography as important modality for early diagnosis of Fournier gangrene. Am J Emerg Med 2010;29:959.e1-2.  Back to cited text no. 6
    
7.Abascal García JM, González Filgueira P, Suárez Hevia MA, Fernández Mariño B, Izquierdo Osorio P, Abascal García R. Ultrasonographic diagnosis of Fournier's gangrene. Arch Esp Urol 1995;48:637-9.  Back to cited text no. 7
    
8.Morrison D, Blaivas M, Lyon M. Emergency diagnosis of Fournier's gangrene with bedside ultrasound. Am J Emerg Med 2005;23:544-7.  Back to cited text no. 8
    
9.Dogra VS, Smeltzer JS, Poblette J. Sonographic diagnosis of Fournier's gangrene. J Clin Ultrasound 1994;22:571-2.  Back to cited text no. 9
    
10.Carroll PR, Cattolica EV, Turzan CW, McAninch JW. Necrotizing soft-tissue infections of the perineum and genitalia. Etiology and early reconstruction. West J Med 1986;144:174-8.  Back to cited text no. 10
    
11.Uppot RN, Levy HM, Patel PH. Case 54: Fournier gangrene. Radiology 2003;226:115-7.  Back to cited text no. 11
    
12.Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging. Radiographics 2008;28:519-28.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Modern sonology and the bedside practitioner: evolution of ultrasound from curious novelty to essential clinical tool
S. P. Stawicki,D. P. Bahner
European Journal of Trauma and Emergency Surgery. 2014;
[Pubmed] | [DOI]



 

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