Fournier's gangrene in neonates and infants

A rare case of Fournier's gangrene developing from colon perforation in an infant: A case report

Fournier's gangrene, a rare and life-threatening soft tissue infection affecting the genitalia and perineum, results from various microorganisms. This rapidly progressing necrotizing fasciitis yields higher mortality and morbidity rates. We report a case of a 1-month-old male infant with Fournier's gangrene due to perforation transverse colon complicated with septic shock and pneumonia also accompanied by patent processus vaginalis. Radiological findings of pneumonia and pneumoperitoneum were exhibited. Early diagnosis and management are demanded to mitigate life-threatening and improve the prognosis. The patient underwent incision drainage, peritoneal lavage, exploratory laparotomy, colostomy, necrotomy debridement, and patent processus vaginalis ligation after hemodynamic status stabilization.

Fournier gangrene in an infant, complicated with severe sepsis and liver dysfunction: A case report

BACKGROUND

Fournier gangrene is a rare, life-threatening infection characterized by necrotizing fasciitis in the perineal, genital and/or lower abdominal regions. Despite its rarity, the unfavorable prognosis associated with this disease is dependent on the timing of medical care.

CASE SUMMARY

A 3-month-old boy was admitted to our pediatric intensive care unit in critical condition after a 5-day history of fever and scrotal erythema with breaching skin lesions and swelling. Despite ambulatory antibiotic treatment, the child's clinical condition deteriorated. At the time of admission, the child had necrotizing scrotal fasciitis that had spread to the abdomen. Following reanimation, the surgeon decided on an immediate intervention to rule out testicular torsion and to debride the affected area. Despite optimal antibiotic and supportive therapy, the patient developed severe sepsis with liver dysfunction, making treatment more challenging.

CONCLUSION

Recognizing Fournier gangrene, prompt referral to pediatric surgery, and appropriate antibiotic coverage are critical for avoiding sepsis and multiorgan dysfunction.

Progress in Multidisciplinary Treatment of Fournier's Gangrene

Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.

Fournier's gangrene in an eight-day-old male neonate, a case report

INTRODUCTION AND IMPORTANCE

Fournier's gangrene is necrotizing fasciitis of the scrotum and perineal area. It is a polymicrobial infection of perianal origin characterized by rapid necrotizing spread along fascial planes to abdominal wall and flank area. The very rare nature of this illness in neonates makes it important to take a lesson in subsequent management of similar cases.

CASE PRESENTATION

An eight days old male neonate come with compliant of high-grade intermittent fever, scrotal swelling, crying during urination and irritability of 3 days duration. Objectively he has temperature of 38.8 degree Celsius, pulse rate of 172 and blackish ulcerated scrotum with minimal puss discharge. Blood work showed leukocytosis and scrotal ultrasound ruled out other pathology.

CLINICAL DISCUSSION

Identifiable causes constitute about 80% of the cases. Culture from the puss in our case showed polymicrobial cause. Mortality is mainly due severe sepsis, coagulopathy and renal failure. Medical management include optimization of cardiorespiratory status with cautious resuscitation, respiratory support and inotropic support with severe cases. Prompt surgical debridement, incision and drainage help reduce ongoing infection and systemic toxicity.

CONCLUSION

The poor hygiene and immature immune response are the likely predisposing factors. Medical management with broad spectrum antibiotics and surgical debridement are cornerstones for good recovery.

Neonatal Fournier's gangrene; pattern and predisposing factors in a tertiary health facility in Southern Nigeria

Fournier's gangrene (FG), a necrotizing fasciitis of the genital and perineal region, is a serious and debilitating multi-infective pathological condition. More commonly seen in adults, its occurrence in neonates is uncommon. We share our experience with neonatal FG (NFG), highlighting potential factors which may predispose neonates to it.Ours is a five year retrospective review of cases of NFG in our service. Data obtained included health facility of birth, mode of delivery, symptoms and duration, investigation results, treatment and outcome. Sixteen neonates were included, comprising 13 males (M:F  =  4.3:1). Fourteen were delivered outside our centre; breech vaginal delivery, hot water massaging and application of native concoctions were common. All were treated with antibiotics and wound debridement, but five (37.5%) died.NFG is not that rare in our service. Early recognition is imperative to reduce mortality. Neonates delivered by breech vaginally may be particularly at risk.

Fatal infections in andrology. Atypical clinical presentation of a Fournier's disease

BACKGROUND

Fournier disease (FD) is a worrisome infection of genital area caused by a polimicrobial infection and characterized by a rapid progression to necrosis. Scrotum, perineum and lower abdomen represent the primary sites of origin. Clinical presentation and laboratory strongly suggest FD, but if not precociously diagnosed, it may quickly evolve into septic syndrome and patient's death.

CASE REPORT

A 62 years old Caucasian male presented for fever and penile gross oedema recently occurred. No history of previous urinary tract infection, hematuria or genital trauma was referred. He did not complain any storage or voiding low urinary tract symptom (LUTS); no foci of infection in genitoperineal area was observed nor urethral discharge. The ultrasound (US) revealed a disomogeneous broad thickening of subcutaneous tissues with increased vascularity on Color-Doppler. When the penis was manipulated in order to reduce oedema, retract foreskin and evaluate the glans, clinical parametres rapidly worsened and the patient developed a septic shock with blood pressure falling down, dyspnoea and tachyarrhythmia, and he was fastly sent to Intensive Care Unit where it has been hemodynamically stabilized and subjected to antibiotic therapy. Considering the clinical absence of gangrene's foci, we opted for a conservative treatment by maintaining bladder catheter and drug therapy.

Fournier's gangrene during ACTH therapy

Fournier's gangrene is an infectious necrotizing fasciitis of the perineal, genital, or perianal regions and is uncommon in children. Adrenocorticotropic hormone (ACTH) is effective for the treatment of infantile spasms; however, suppression of immune function is one of the major adverse effects of this approach. We encountered a 2-month-old boy with infantile spasms that had been treated with ACTH and had developed complicating Fournier's gangrene. Strangulation of a right inguinal hernia was observed after ACTH treatment. Although surgical repair was successful and no intestinal injuries were detected, swelling and discoloration of the right scrotum developed in association with pyrexia and a severe inflammatory response. A scrotal incision revealed pus with a putrid smell. The patient was subsequently diagnosed with Fournier's gangrene complicated by septic shock and disseminated intravascular coagulation. Extensive debridement and intensive care was performed. Enterobactor aerogenes, methicillin-resistant Staphylococcus aureus, and Enterococcus faecalis were isolated from the pus. Meropenem, teicoplanin, and clindamycin were administered to control the bacterial infection. The patient was discharged from the intensive care unit without any obvious neurological sequelae. Suppression of immune function associated with ACTH therapy may have been related to the development of Fournier's gangrene in this case.

Fournier gangrene with extensive necrosis of urethra and bladder mucosa: A rare occurrence in a patient with advanced prostate cancer

Fournier gangrene (FG) is polymicrobial necrotizing infection of subcutaneous tissues and deep fascia, commonly involving the perineum, external genitalia, anterior abdominal wall and medial aspect of thighs. Urethral pathology, although often the inciting factor for FG, extensive involvement with urethral necrosis is very rare. This is the first report in English literature, describing complete sloughing of the bulbar urethra with ischemic necrosis of the bladder mucosa from FG. Such extensive disease is associated with high mortality, despite higher antibiotics, through debridement and intensive care. Urethral involvement needs extensive debridement and temporary or permanent urinary diversion.

Neonatal necrotizing fasciitis of the scrotum caused by Streptococcus agalactiae

We herein describe the case of a 27-day-old male infant who was brought to the emergency room for intermittent crying, and swelling of the left scrotum. Based on the clinical findings, necrotizing fasciitis was suspected, and surgical intervention was successfully completed within a few hours of admission. Streptococcus agalactiae type Ia was cultured from the drained abscess, and was considered the causative pathogen. To our knowledge, this is the first report of neonatal necrotizing fasciitis caused by S. agalactiae. Prompt diagnosis and immediate surgical debridement are crucial in the initial management of this disease.

Fournier's Gangrene as Seen in University of Maiduguri Teaching Hospital

Background. Fournier's gangrene is uncommon but increasingly being seen over the last two decades probably due to increasing socioeconomic problems including an upsurge in HIV infection especially in the tropics. Patients and Methods. The study retrospectively reviewed all patients with Fournier's gangrene managed in UMTH between January 2007 and December 2012. Results. Thirty-eight males aged 2 weeks to 80 years (mean 37.82) were reviewed, with most aged 30-39 years (13 (34.21%)). Clinical features were scrotal pain and swelling, 36 (94.74%), fever, 19 (50.00%), and discharging scrotal wound, 19 (50.00%). The predisposing conditions were UTI secondary to obstructive uropathy in 11 (28.95%), perianal suppuration, and HIV, in 8 (21.05%) patients each. Wound biopsy culture revealed mixed organisms in 27 (71.05%). Twenty-six (68.42%) had blood transfusions. Thirty-seven (97.37%) patients had wound debridement. Twenty (52.63%) had flap rotation for skin cover. There were 6 (15.79%) mortalities, of which 4 (10.53%) were HIV positive, 1 (2.63%) was diabetic, and 1 (2.63%) was both diabetic and HIV positive. Conclusion. Fournier's gangrene is a fulminant synergistic necrotising fasciitis of the perineum and genitalia with poor prognosis especially when associated with HIV and diabetes, requiringprompt and aggressive management for good outcome.

Fournier's gangrene

Fournier's gangrene (FG) is a synergistic polymicrobial gangrenous infection of the perineum, scrotum and penis which is characterised by obliterative endarteritis of the subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-threatening disease, and despite therapeutic advances in recent years, the mortality rate is 3%-67%, with an incidence of 1:7500-1:750,000. Anorectal, genitourinary and cutaneous sources of infection are the most common causes of FG, with diabetes mellitus being the most common risk factor. The clinical condition presents evolution from 2 to 7 days and is characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. Current imaging techniques for initial evaluation of the disease include radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful in uncertain diagnosis and when clinical findings are ambiguous. Treatment of FG is based on a multimodal approach which includes intensive fluid resuscitation to stabilise the patient and correction of electrolyte imbalance, if any. This is followed by extensive debridements and resections in order to remove all necrotic and infected tissue, wide spectrum antibiotics and reconstructive surgery, whenever required. However, despite all the advances in treatment today, FG remains a surgical emergency, hence, early recognition with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and urgent surgical debridement are the mainstay of treatment.

Surgical aspects of bacterial infection in African children

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.

Fournier's gangrene: a dreadful disease

BACKGROUND

Although there is much consensus, certain controversies still exist regarding the pathology of Fournier's gangrene. The purpose of this study was to determine the prevalence of the disease in the catchment area of the three teaching hospitals, to identify the systemic predisposing factors and local aetiological factors, and to assess the recommended role of aggressive surgical debridement as a part of treatment.

MATERIALS AND METHODS

This prospective study was conducted in the surgical departments of three tertiary care hospitals of the Khyber Medical University, Peshawar, Pakistan, from 1 January 2002 to 30 June 2007. Detailed history and examination of all patients were carried out to reach the diagnosis of Fournier's gangrene. After initial resuscitation, patients were treated aggressively, including surgical debridement.

RESULTS

Sixty patients were studied in the study period. The male to female ratio was 5:1. The age range was 20-75 years with mean 47+17.4 (SD) years. The socioeconomic status of patients was poor (the average income was less than $50 per week) in 36 (60%) and 24 (40%) were middle class (the average income being $50-100 per week). Thirty-nine patients (65%) presented in the hot humid months of the year. Extent of the disease was scrotum in 18 patients (30%), perineum in 30 (50%) and abdominal wall in 12 (20%). Systemic predisposing factors identified in our study were diabetes mellitus in 20 (33.33%) patients, chronic alcohol abuse in two (3.33%) and long-standing steroid therapy in four (6.67%) while in 34 patients (56.67%) no cause was identified. The local aetiological origin of Fournier's gangrene was urogenital in 14 (23.33%) patients, anorectal in 10 (16.67%) and cutaneous in 8 (13.33%) and no local pathologies could be identified in 28 (46.67%) patients. The mean time interval between first symptom and initial treatment was 2.5 days with a range of 1-7 days. Number of debridement sessions per patient was 2-6 (mean, 3.15). Mean hospital stay was 31+7 (SD) with a range of 10-50 days. Morbidity was 80%. Four patients (6.67%) died. Three of these patients presented to hospital 5-6 days too late.

CONCLUSION

Fournier's gangrene is not an uncommon disease in South Asia. Systemic predisposition such as diabetes mellitus, long-standing steroid therapy, chronic alcoholism and even the hot humid season can contribute to this dreadful disease. Local causes in the form of urogenital, anorectal and cutaneous disorders may trigger this disease in some patients. Early recognition of disease and aggressive surgical debridement are the main treatments.

Fournier's gangrene in childhood: a report of 3 infant patients

Fournier's gangrene is uncommon in pediatric age group, and little is known about the disease in the newborn period and infancy. Three patients, aged 10 days, 14, and 17 months, with Fournier's gangrene, were treated in our hospital. The predisposing factors were prematurity, a diaper rash, and varicella infection, respectively. Especially, prematurity and diaper rash are rare predisposing factors in the pediatric population; therefore, high index of suspicion, prompt diagnosis, conservative surgery, and multidisciplinary approach are the mainstays of management in children with Fournier's gangrene.

[Extensive Fournier gangrene. A dermatologic emergency]

Fournier gangrene is a necrotizing fasciitis of the perineal and genital region, which almost exclusively affects men. The cause is a polymicrobial infection associated with superficial trauma, urological diseases and operations, as well as colorectal diseases. Diabetes mellitus, alcoholism, immunosuppression and other severe illnesses are frequent co-factors. Immediate administration of systemic broad-spectrum antibiotic therapy with coverage of both gram-positive and gram-negative bacteria combined with surgical debridement and intensive medical care can lower the high mortality rate of this condition.