Fournier's gangrene or necrotizing fasciitis of the perineal, perianal or genital regions is a challenging situation in the field of surgical infections. Tissue ischemia is the main pathogenetic factor and it is usually characterized by rapidly progressing myonecrosis and/or necrotizing fasciitis, leading to thrombotic occlusion of small subcutaneous vessels and development of gangrene. It is usually caused by polymicrobial infection, both aerobic and anaerobic bacteria [1
]. The most commonly isolated microbe is Escherichia coli
- as in our patient - followed by Streptococcus, Staphylococcus
species, Enterobacter cloacae, Enterococcus faecalis
and Klebsiella pneumonia
]. Although broad-spectrum antibiotic prophylaxis is used and modern operating techniques are performed, the mortality rate is still high reaching 14.7% in non-diabetic and 33% in diabetic patients [3
A Fournier's Gangrene Severity Index (FGSI) was created by Laor et al.
in 1995 by modifying the acute physiology and chronic health evaluation (APACHE) II severity score [4
]. In the FGSI, nine parameters are measured and the degree of deviation from normal is graded from 0 to 4. Parameters examined include temperature, heart rate, respiratory rate, serum sodium, potassium, creatinine and bicarbonate levels, hematocrit and leukocyte count. Regression analysis among different studies has shown a strong correlation between the FGSI score and the death rate.
In a recent study by Fajdic et al.
including seven male patients with mean age 61 years ranging from 57 up to 66 years, it was shown that diabetes mellitus, urethrostenosis, hemorrhoids, anal fissure and abscesses might be strongly correlated with Fournier's gangrene [5
]. According to a study by Unalp et al.,
Fournier's Gangrene Severity Index (FGSI) > 9, diabetes mellitus and sepsis on admission were found to be factors for an unfavorable prognosis [6
]. Chronic renal failure, hepatic failure, prosthetic penile implants, AIDS, malignancy and obesity were also important risk factors. Fournier's gangrene has been described in immunosuppressed patients following liver, renal or even cord blood stem cell transplantation [4
]. We should note that Fournier's gangrene may represent the sole sign of underlying malignancy, as was reported in a Romanian study where such a case was the unique sign of a lower rectal adenocarcinoma [7
Fournier's gangrene may still have an idiopathic origin that usually leads to a refractory situation [8
]. It should be mentioned that our patient was a 65-year-old man with diabetes and anemia and with benign polyps of the sigmoid colon.
Fajdic et al.
suggested that treatment has the potential to be successful when it is started at the onset of the disease and is aggressive, such as with necrectomy and broad antibiotic protection [5
]. The therapeutic role of locally 100% oxygen in daily doses is also discussed [10
]. Hyperbaric oxygen therapy may be a useful adjunct, but it is not a substitute for surgery and, consequently, it must not be allowed to delay the surgical debridement of an invasive soft tissue infection. Reconstruction of defects can also be offered by using local skin flaps [11
]. Colostomy, urinary diversion or orchiectomy have also been suggested but have only been used for extensive and complicated cases [12