Fournier’s gangrene

Fournier’s gangrene is the most common type of necrotizing fasciitis.

·         Most commonly found in patients who are immunocompromised (ie.diabetic, HIV)

·         Typically is spread from sources including, urinary (recent instrumentation, extravasation of infected urine), deep anal-rectal abscesses and spread of superficial local infection

·         It may present with pain, fever or other signs of sepsis

Exam findings:

·         May range from erythema, edema, warmth and tenderness of the scrotum, penis and low abdominal wall to blistering/sloughing of skin and frank necrosis of visible tissue

·         Crepitus, a sign of gas in the tissue, may or may not be present, but is often a late finding

·         Pain out of proportion to the examination findings should raise concern for deeper infection than just the superficial skin

The differential should include:

·         Epidiymoochitis  (can present with an erythematous, edematous and tender scrotum, although this process is more likely to be unilateral and certainly should not present with signs of gangrene or local cellulitic spread)

·         Scrotal cellulitis (likely the closest diagnosis) -Simple cellulitis, is a superficial process which should not affect the deeper tissues.

Imaging:

·         XR  and ultrasound- both of which can detect air in the tissues

·         CT which may detect early changes in muscle and deep tissues.

Definitive treatment includes:

·         Debridement of infected tissue

·         Antibiotics should have broad coverage for Gram-positive, Gram-negative and anaerobic organisms

Harwood Nuss

Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions