Fournier Gangrene in a 70-Year-Old Man

A 70-year-old man was hospitalized after he fell and was unable to rise because of weakness. He denied dyspnea, chest pain, palpitations, vertigo, light-headedness, preceding aura, hematemesis, hematochezia, and melena. For the past year, the patient had had intermittent low-volume, watery diarrhea that had recently begun to occur daily; he had also lost 13.5 kg (30 lb) during the past 6 months. Shortly after he was admitted, scrotal edema, discoloration, bullae, and erythema of the upper left thigh developed (A).

Vital signs were normal. The abdomen was nontender and mildly distended; stool was black and guaiac-positive. Laboratory studies revealed hypochromic microcytic anemia; the hemoglobin level was 4.3 g/dL (normal range, 14 to 18 g/dL). Slow, chronic GI bleeding was suspected, and endoscopy was scheduled.

A scout film of the chest, abdomen, and pelvis revealed a prominent colon at the upper limits of normal, with elevationof the left hemidiaphragm, rightward displacement of the mediastinum, and abnormal gas in the region of the scrotum and perineum (B). A CT scan of the scrotum and perineum demonstrated the abnormal gas collections (C).

This constellation of findings was highly suggestive of Fournier gangrene secondary to a perforated obstructing colonic malignancy. An emergent surgical consultation led to local debridement and resection of a perforated rectal carcinoma and synchronous sigmoid carcinoma. Pathologic examination of surgical specimens confirmed the diagnosis.

CPT Edward Bergen, MC, USA; CPT Jonathan Brewer, USAF, MC; and LTC Ethan Emmons, MC, USA, of Fort Sam Houston, Tex, point out that a perforated colorectal carcinoma is an unusual cause of Fournier gangrene. Fournier disease--a rare form of type I necrotizing fasciitis that involves the male genitalia and perineum--usually results from urogenital surgery, trauma, or perirectal abscess.¹ Intra-abdominal causes are rare and are generally secondary to rupture of the appendix, rupture of the diverticula, or incarcerated hernia.² The presentation of anorectal causes is usually less typical, which contrib- utes to a delay in diagnosis and a worse prognosis.³

Given the mortality rate of 20% to 40%, early diagnosis and emergent surgical intervention are paramount to survival.⁴ When scrotal edema develops in patients with GI bleeding, a high index of suspicion for bowel perforation can ensure a rapid diagnosis and appropriate management.

This patient received broad-spectrum antibiotic therapy. After multiple debridements and continued supportive care, the patient was discharged. At follow-up, results of positron emission tomography revealed a residual rectal tumor but no evidence of metastasis. Adjuvant radiation therapy is planned.

References:

REFERENCES:

1. Dewire DM, Bergstein JM. Carcinoma of the sigmoid colon: an unusual cause of Fournier's gangrene. J Urol. 1992;147:711-712.

2. Gerber GS, Guss SP, Pielet RW. Fournier's gangrene secondary to intra-abdominal processes. Urology. 1994;44:779-782.

3. Spirnak JP, Resnick MI, Hampel N, Persky L. Fournier's gangrene: report of 20 patients. J Urol. 1984;131:289-291.

4. Flanigan RC, Kursh ED, McDougal WS, Persky L. Synergistic gangrene of the scrotum and penis secondary to colorectal disease. J Urol. 1978;119:69-371.