ID Case ConferenceID Case Conference

Yvonne L. Ballard, MDYvonne L. Ballard, MD

26 March 200826 March 2008

CC: weakness/dizzinessCC: weakness/dizziness

44yo AAM with no known PMH 44yo AAM with no known PMH admitted 3/15 for a 2-week h/o blurry admitted 3/15 for a 2-week h/o blurry vision, weakness, dizziness, polyuria, vision, weakness, dizziness, polyuria, polydipsia, and SOB.polydipsia, and SOB.

On admission, found to be in DKAOn admission, found to be in DKA Also had leukocytosis and fever, but Also had leukocytosis and fever, but

denied localizing symptomsdenied localizing symptoms

History…History…

3 weeks ago, pt experienced hematuria 3 weeks ago, pt experienced hematuria that resolved spontaneouslythat resolved spontaneously

Reports history of recurrent abcesses, Reports history of recurrent abcesses, beginning 10 years ago (groin, axilla, beginning 10 years ago (groin, axilla, thigh)thigh)

Sexually active, monogamous with wifeSexually active, monogamous with wife No history of STDsNo history of STDs No history of HIVNo history of HIV

PMH:PMH:- HTNHTN- Diabetes Mellitus Diabetes Mellitus

(HgA1c = 12.3%)(HgA1c = 12.3%)- Large Subcut CystLarge Subcut Cyst

FamHx:FamHx:- Mom – healthyMom – healthy- Dad – DMDad – DM- ““my whole family has my whole family has

sugar”sugar”

Social Hx:Social Hx:- Lives in Moncure Lives in Moncure

with Momwith Mom- Married, wife lives in Married, wife lives in

Chapel HillChapel Hill- Construction workerConstruction worker- 1ppd smoker 1ppd smoker - Previously heavy Previously heavy

EtohEtoh- No illicits, No IVDANo illicits, No IVDA

History, cont…History, cont…

On the evening of admission, pt began to On the evening of admission, pt began to complain of right-sided groin pain that quickly complain of right-sided groin pain that quickly progressed overnightprogressed overnight

Also noted new onset of a large swelling in Also noted new onset of a large swelling in suprapubic areasuprapubic area

Worsened overnight, and began to have Worsened overnight, and began to have drainage from the scrotum the following daydrainage from the scrotum the following day

Denies testicular pain, urethral dischargeDenies testicular pain, urethral discharge No dysuria or pain with defecationNo dysuria or pain with defecation

Physical ExamPhysical Exam Temp 36.8, P 86, RR 14, BP 99/71, Pox 98% on RATemp 36.8, P 86, RR 14, BP 99/71, Pox 98% on RA Gen: WD, WN, NAD. Large cyst over right eyeGen: WD, WN, NAD. Large cyst over right eye HEENT: Peerla, Eomi, anicteric, conj pink. OP clear. HEENT: Peerla, Eomi, anicteric, conj pink. OP clear. Axilla: No LAD. Under right axilla, ~1cm area of induration Axilla: No LAD. Under right axilla, ~1cm area of induration

without fluctuance, erythema. Nontender.without fluctuance, erythema. Nontender. CV: RRR, Nrml S1S2, No m/g/rCV: RRR, Nrml S1S2, No m/g/r Pulm: CTA b/l, no w/w/rPulm: CTA b/l, no w/w/r Abd: Soft, ND, NT, NABS. No organomegalyAbd: Soft, ND, NT, NABS. No organomegaly GU: GU: Very firm indurated area superior to iliac crest, above the Very firm indurated area superior to iliac crest, above the

penis. No erythema or warmth. His penis appears normal, penis. No erythema or warmth. His penis appears normal, without lesion. No urethral drainage. The testicles are normal on without lesion. No urethral drainage. The testicles are normal on palpation, without mass or tenderness. In the middle of his palpation, without mass or tenderness. In the middle of his scrotum, he has an area of thickened skin, and central in that scrotum, he has an area of thickened skin, and central in that area is a small area of draining purulent yellow fluid. There are area is a small area of draining purulent yellow fluid. There are no abcesses palpated.no abcesses palpated.

Rectal: No masses, abcesses, or ulcers.Rectal: No masses, abcesses, or ulcers. Ext: No c/c/eExt: No c/c/e

Laboratory DataLaboratory Data

138

3.2

107

20

11

1.2142

15.519.5

299

8.6

3.2

2.1

6.7UA - 163 WBCs, 5 RBCs, 2+ LE, UA - 163 WBCs, 5 RBCs, 2+ LE, No Nitr, No blood. 4+ glu, 2+ ket. No Nitr, No blood. 4+ glu, 2+ ket.

CT Scan, 3/17:CT Scan, 3/17:

Repeat CT Scan, 3/18:Repeat CT Scan, 3/18:

Discussion…Discussion…

Fournier’s GangreneFournier’s Gangrene

HistoryHistory Reported by Bauriene in 1764Reported by Bauriene in 1764

- Affliction of King Herod the Great of Judaea (whom Affliction of King Herod the Great of Judaea (whom had DM)had DM)

Credited to Professor Jean-Alfred Fournier, a Credited to Professor Jean-Alfred Fournier, a Parisian Dermatologist and Venereologist, who Parisian Dermatologist and Venereologist, who described it in 1883described it in 1883

““Fulminant gangrene of the penis and scrotum”Fulminant gangrene of the penis and scrotum”- (1) sudden onset in a hitherto healthy young man(1) sudden onset in a hitherto healthy young man- (2) rapid progression to gangrene(2) rapid progression to gangrene- (3) absence of a definite cause(3) absence of a definite cause

Redefined in 1998: “an infective necrotizing Redefined in 1998: “an infective necrotizing fasciitis of the perineal, genital, or perianal fasciitis of the perineal, genital, or perianal regions”regions”

EtiologyEtiology Local Skin InfectionLocal Skin Infection Urinary Tract InfectionUrinary Tract Infection

- Renal AbcessesRenal Abcesses- Urethral StonesUrethral Stones- Urethral StricturesUrethral Strictures

Colorectal InfectionsColorectal Infections- Ruptured AppendicitisRuptured Appendicitis- Colonic CarcinomaColonic Carcinoma- DiverticulitisDiverticulitis

British Journal of Surgery 2000, 87, 718-728

J Microbiol Immunol Infect. 2007; 40:500-506

Comorbid and Predisposing Comorbid and Predisposing ConditionsConditions

Diabetes MellitusDiabetes Mellitus AlcoholismAlcoholism HTNHTN Chronic Liver Chronic Liver

DiseaseDisease HIVHIV MalignancyMalignancy Trauma/SurgeryTrauma/Surgery

Am Surg. 2002 Aug;68(8):709-13.

J Microbiol Immunol Infect. 2007; 40:500-506

BacteriologyBacteriology Classically a MIXED infectionClassically a MIXED infection Most common organisms:Most common organisms:

- Escherichia coliEscherichia coli- Bacteroides fragilisBacteroides fragilis- StreptococcusStreptococcus- StaphylococcusStaphylococcus- Enterococcus spp.Enterococcus spp.- Klebsiella pneumoniaeKlebsiella pneumoniae- CorynebacteriaCorynebacteria- ClostridiumClostridium- Proteus mirabilisProteus mirabilis

Synergistic RelationshipsSynergistic Relationships

J Microbiol Immunol Infect. 2007; 40:500-506

BacteriologyBacteriology

Increase in atypical organisms Increase in atypical organisms suggested in one studysuggested in one study- Shewanella putrefaciens, Vibrio vulnificus, Shewanella putrefaciens, Vibrio vulnificus,

Candida albicansCandida albicans- Decrease in anaerobic infections, as Decrease in anaerobic infections, as

evidenced by decrease in use of evidenced by decrease in use of hyperbaric oxygen chamber for treatment?hyperbaric oxygen chamber for treatment?

BJU Int. 2007 Dec;100(6):1218-20.

Clinical PresentationClinical Presentation

Early – swelling, erythema, tendernessEarly – swelling, erythema, tenderness Spreading – pain, fever, systemic toxicitySpreading – pain, fever, systemic toxicity Late – swelling and crepitus of the Late – swelling and crepitus of the

scrotum rapidly progresses, dark purple scrotum rapidly progresses, dark purple areas develop and progress to extensive areas develop and progress to extensive scrotal gangrenescrotal gangrene

Abdominal wall usually involved last…but Abdominal wall usually involved last…but accelerated spread in patients with accelerated spread in patients with DiabetesDiabetes

British Journal of Surgery 2000, 87, 718-728

Morbidity and MortalityMorbidity and Mortality Hospital stays from 2 to 278 daysHospital stays from 2 to 278 days ComplicationsComplications

- Resp failure, Renal failure, Shock, DKA, Resp failure, Renal failure, Shock, DKA, Pneumonia, Hepatic failure, DIC, UGIBPneumonia, Hepatic failure, DIC, UGIB

Mortality 0-45%Mortality 0-45% EARLY, aggressive treatment EARLY, aggressive treatment

associated with a reduced mortality rateassociated with a reduced mortality rate

Am Surg. 2002 Aug;68(8):709-13.

TreatmentTreatment

Broad-spectrum antibiotics – triple therapy Broad-spectrum antibiotics – triple therapy favored in most studiesfavored in most studies- Penicillins – StreptococciPenicillins – Streptococci- Metronidazole – AnaerobesMetronidazole – Anaerobes- 33rdrd gen. Cephalosporin (with/without Gent) gen. Cephalosporin (with/without Gent)

• Enteric organisms and staphylococciEnteric organisms and staphylococci

Surgical debridementSurgical debridement Unprocessed honeyUnprocessed honey Hyperbaric OxygenHyperbaric Oxygen

Hyperbaric OxygenHyperbaric Oxygen

Initially used for presumed clostridial Initially used for presumed clostridial infection when crepitus was observedinfection when crepitus was observed

Increases tissue oxygenation to a level Increases tissue oxygenation to a level that inhibits and kills anaerobesthat inhibits and kills anaerobes

Reduces systemic toxicityReduces systemic toxicity- Improvement in neutrophil functionImprovement in neutrophil function- Increased fibroblast proliferationIncreased fibroblast proliferation- Promotes angiogenesisPromotes angiogenesis

Hospital CourseHospital Course

Urology Consult – Bedside I&DUrology Consult – Bedside I&D Cultures: Beta-hemolytic Group B Cultures: Beta-hemolytic Group B

Streptococci and AnaerobesStreptococci and Anaerobes Treatment: Vanc, Zosyn, Clinda Treatment: Vanc, Zosyn, Clinda

Ceftriaxone and ClindamycinCeftriaxone and Clindamycin Fever resolved, continued drainageFever resolved, continued drainage Superior aspect - ? Hematoma?Superior aspect - ? Hematoma?

Have a Have a Great Day!!!Great Day!!!