Abdom Imaging 19:471-474 (1994)
Abdominal 9 Springer-VerlagNewYorkInc. 1994
Fournier's Gangrene: CT Findings M. A. Amendola, 1 J. Casillas, 1 R. Joseph, 1 R. Antun, 2 0 . Galindez 3 1Department of Radiology, University of Miami/Jackson Memorial Medical Center, P.O. Box 016960 (R-109), Miami, FL 33101, USA 2Department of Urology, University of Miami/Jackson Memorial Medical Center, 1611 N.W. 12th Avenue, Miami, FL 33101, USA 3Department of Medicine, University of Miami/Jackson Memorial Medical Center, 1611 N.W. 12th Avenue, Miami, FL 33101, USA Received: 25 October 1993/Accepted after revision: 4 November 1993
Abstract. F o u r n i e r ' s g a n g r e n e is an u n c o m m o n gasf o r m i n g i n f e c t i o n o f the s c r o t u m w h i c h i f not r e c o g n i z e d e a r l y and treated a p p r o p r i a t e l y m a y b e fatal. In three patients r e c e n t l y s e e n at o u r institution, c o m p u t e d t o m o g r a p h y ( C T ) w a s i n s t r u m e n t a l in e s t a b l i s h i n g the c o r r e c t d i a g n o s i s and d e t e r m i n i n g the e x t e n t o f the inf e c t i o u s p r o c e s s p r i o r to surgery. T h e i m a g i n g findings at C T and its d i f f e r e n t i a l d i a g n o s i s are illustrated. A b r i e f r e v i e w o f the current t h e o r i e s o f p a t h o g e n e s i s o f this i n t e r e s t i n g entity is p r e s e n t e d .
all three patients CT was able to delineate the extension of the gasforming infection, helping to direct the planning for surgical debridement and management (Figs. 1 and 2).
Case R e p o r t
Materials and Methods
A 45-year-old man with no significant past medical history except for chronic alcoholism presented to the emergency room with severe pain in the right lower quadrant and genital area of 2 days' duration. He also complained of fever, chills, and burning on urination. Physical exam was only remarkable for signs of dehydration, mild right lower quadrant pain without rebound, and a tender 1.5-cm mass where the scrotal sac meets the perineal body. He had a leukocytosis of 15,400 WBC. The patient was admitted and hydrated because he was volumedepleted and was started on intravenous ciprofloxin. During the next 24 h the scrotal pain became worse. The patient developed a fever of 103~ The scrotum, which originally was normal in appearance, had become markedly swollen, erythematous, and tender. The patient was switched to ampicillin, gentamycin, and flagyl. An ultrasound of the scrotum (Fig. 1A) revealed bilateral peritesticular fluid with intact testicles and epidydimus and thickening of the scrotal skin. Multiple focal areas of high-amplitude echoes with posterior acoustic shadowing were noted in the scrotal subcutaneous tissue suspicious for gas formation. This was confirmed on a subsequent retrograde urethrogram that failed to disclose a urethral fistula or contrast extravasation. A C T scan was obtained for preoperative evaluation of the extent of the abnormality, showing extensive soft tissue gas surrounding both testicles and extending from the scrotum into the perineum along the insertions of the ischiocavernosus and bulbocavernosus muscles but without further extension into the perirectal area or into the true pelvis (Fig. 1B and C). The patient was immediately taken to the operating room where extensive debridement of the devitalized tissues was carried out. Gram stain revealed many gram-negative rods and many gram-positive cocci. Cultures yielded heavy growth of Streptoccocus viridans, yeast and light growth of Escherichia eoli, and Corynebacterium species. The patient improved rapidly and eventually was discharged 3 weeks later with excellent cosmetic result.
The medical records and imaging studies of three patients with Fournier's gangrene diagnosed in the last 2 years in our institution were reviewed. Clinical data and outcome are summarized in Table 1. In
Discussion
Correspondence to: M. A. Amendola
In 1883, F o u r n i e r d e s c r i b e d five patients w i t h g a n g r e n e o f the p e n i s and s c r o t u m , a s y n d r o m e that since has
Key words: Scrotum, gangrene--Scrotum,
CT.
F o u r n i e r ' s g a n g r e n e is a r a p i d l y p r o g r e s s i v e and p o t e n tially lethal n e c r o t i z i n g i n f e c t i o n o f the p e r i n e u m and m a l e g e n i t a l i a [1]. Patients p r e s e n t w i t h scrotal p a i n and s w e l l i n g . U s u a l l y the first i m a g i n g s t u d y o b t a i n e d is an u l t r a s o u n d o f the s c r o t u m . T h e p l a i n r a d i o g r a p h i c and u l t r a s o u n d findings o f F o u r n i e r ' s g a n g r e n e h a v e b e e n d o c u m e n t e d in the literature [ 2 - 4 ] . H o w e v e r , e x c e p t for a r e c e n t c a s e report, the c o m p u t e d t o m o g r a p h i c ( C T ) findings and d i f f e r e n t i a l d i a g n o s i s o f this i m p o r t a n t dise a s e e n t i t y h a v e not b e e n f u l l y d e s c r i b e d [5], W e rec e n t l y h a d the o p p o r t u n i t y to s t u d y t h r e e p a t i e n t s w i t h F o u r n i e r ' s g a n g r e n e w i t h C T o f the pelvis. C T w a s h i g h l y u s e f u l to e v a l u a t e the fult e x t e n t o f i n f e c t i o u s p r o c e s s b e f o r e s u r g i c a l e x c i s i o n and d r a i n a g e .
M. A. Amendola et al.: Foumier's Gangrene
472 Table 1. Clinical data and outcomeof patients with Foumier's gangrene Patient
Age (yr)
Generalcondition at presentation
Etiology
Associated conditions
Site
Cultures
Days in hospital
Outcome
1
45
Fair
Idiopathic
Alcoholism
Scrotum Penis Perineum
E. coli S. viridans
21
Recovered
Scrotum Penis
E. coli Enterobacter S. aureus
14
Died
20
Recovered
2
59
Very ill
Idiopathic
3
66
Ill
Ischiorectal abscess
RupturedAAAa Diffuse peritonitis Small bowel perforation Paraplegia Urethral catheter (acute urinary retention)
Yeast Corynebacteriumsp.
Enterococcus Scrotum E. coli Penis Lactobacillus P e r i n e u m Yeast
a AAA, abdominal aortic aneurysm
borne his name [1]. In his original description, Fournier emphasized (1) the abrupt onset in young healthy males, (2) the rapid progression to gangrene, and (3) the absence of an obvious predisposing condition. Since then, more than 400 cases have been reported in the literature and it has become evident that Foumier's gangrene can be seen at all ages ranging from newborns after circumcision to debilitated elderly patients [6, 7]. In most patients a recognizable focus of primary infection can be found either from a urogenital source or from a colorectal origin, usually a perirectal or ischiorectal fossa abscess [8, 9]. Underlying urological abnormalities have included urethral strictures, urinary extravasation, chronic urinary tract infection, recent urological instrumentation, neurogenic bladder, and epididymitis [10-17]. Trauma, insect bites, bums, and circumcision have been reported as causative agents in children [18]. The onset is not always fulminating and can be insidious in debilitated patients with diabetes mellitus or peripheral vascular disease. Alcoholics and patients with poor personal hygiene are also at risk, and Fournier's gangrene has recently been described complicating aggressive therapy for hematologic malignancy [19]. In the pre-antibiotic area the disease was commonly fatal, but more recently mortality rates have ranged from 11% [10] to 50% [12]. Despite the use of broad-spectrum antibiotics and aggressive surgical debridement, the mortality rate was 45% in a report of 20 patients seen between 1974 and 1984 in a major university hospital [20]. It also causes considerable morbidity and leads to prolonged periods of hospitalization. Pathologically, there is soft tissue necrosis including cellulitis, myositis, and fasciitis, which are clinically indistinguishable. There may be subcutaneous vessel thrombosis with endarteritis and gangrene of the overlying dermal and epidermal tissues [6]. It has been pos-
tulated that Foumier's gangrene can arise by either of two mechanisms [20]. If the source of the infection is in the lower urinary tract, the periurethral glands become involved with subsequent spread to the corpus spongiosum. The infection may be temporarily contained by the tough fibrous tunica albuginea of the corpus. Buck's fascia is the next obstacle, but only rarely is purulent material limited by this layer [21]. After penetrating Buck's fascia the process spreads rapidly, following the dartos fascia along the penis and scrotum and Colles' fascia. Once Colles' scrotal fascia is penetrated the infection can spread into the ischiorectal space in the perineum, to the buttocks, thighs, or upwards in the abdominal wall under Scarpa's fascia. If the source of the infection is perirectal in origin, it can penetrate Colles' fascia and involve the penis and scrotum by direct extension along the above-mentioned fascial planes. There is some evidence indicating that Colles' fascia is not a continuous layer but rather a condensation of fibrous tissue with instertices that may allow spread of a perirectal process to involve the scrotum and penis [22]. Typically, the bacteriology of Fournier's gangrene is a combination of aerobic and anaerobic bacteria, which by synergistic effect results in extensive tissue necrosis requiring wide excision and drainage for adequate treatment [21]. The most common organisms are Staphylococcus aureus, Streptococci, Escherichia coli, and Bacterioides species as seen in other forms of necrotizing fasciitis. Clostridium welchii has been rarely
described as a causative agent [18]. Crepitus indicating the presence of insoluble subcutaneous gases, such as hydrogen and nitrogen, is a common but not constant finding [23]. The radiologic differential diagnosis of Fournier's gangrene includes gas-containing scrotal abscess (Fig. 3), scrotal hernia with gas-containing bowel (Fig. 3), emphysema of the scrotum resulting from colonic per-
M. A. Amendola et al.: Fournier's Gangrene
Fig. 1. Case 1. A Ultrasound of the scrotum: transverse view demonstrates bilateral peritesticular fluid and discrete areas of high-amplitude echoes with posterior acoustic shadowing consistent with gas in the soft tissues of the scrotum. B Pelvic CT scan shows gas bubbles around both testicles. C The bubbly gas/fluid collection extends into the anterior perineum along the insertion of the bulbocavemosus muscles. The process does not involve the perianal soft tissues.
Fig. 2. Case 3. CT scans at three different levels demonstrate gasforming infection extending from bilateral ischiorectal fossa abscesses (A) into the scrotum (C) alongside the urethra (B) in a 67-year-old paraplegic man. Note Foley catheter in the urethra displaced to the right of the midline by the collection in (B). The catheter had been recently placed for treatment of acute urinary retention; however, it was believed by the surgeons that the scrotal infection was secondary to extension from the perirectal abscess in this patient.
473
foration secondary to sigmoid diverticulitis or colonoscopy, retroperitoneal perforation of duodenal ulcer, extension of subcutaneous emphysema from pulmonary barotrauma in mechanically ventilated patients, and air leaking and dissection from faulty chest tube positioning [24-27]. In the older literature most reported cases of scrotal pneumatocele were described after use of artificial pneumoperitoneum in the treatment of pulmonary tuberculosis [24]. Although scrotal air or gas can be demonstrated on standard radiographs and strongly suspected on ultrasound examinations, CT is clearly superior because of its high contrast resolution and its cross-sectional display of muscles, fat, vessels, and bony structures. CT is ideally suited for investigation of
474
Fig. 3. Gas-forming abscess in the left scrotum (arrow) and herniated bowel containing oral contrast and gas (curved arrow) in the right scrotal sac is clearly depicted and differentiated by CT in a 56-yearold man presenting with an acute abdomen.
s u b c u t a n e o u s e m p h y s e m a and n e c r o t i z i n g fasciitis w h e r e the i n f e c t i o n i n v o l v e s the s u b c u t a n e o u s soft tissues, i n c l u d i n g the superficial and d e e p f a s c i a and diff e r e n t i a t e it f r o m gas g a n g r e n e w h e r e the gas lies w i t h i n the m u s c l e s [28, 29]. C T has b e e n e s t a b l i s h e d as the m o d a l i t y o f c h o i c e for d e t e c t i n g and e v a l u a t i n g p e r i n e a l abscesses especially when associated with extraluminal gas f o r m a t i o n [30]. In m a n y p a t i e n t s C T m a y h e l p to d e f i n e the c a u s e and a n a t o m i c p a t h w a y s o f s p r e a d in cases of extraabdominal extension of gastrointestinal tract p e r f o r a t i o n s to the e x t e r n a l genitalia, b u t t o c k s , hips, and l o w e r e x t r e m i t i e s [31, 32].
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