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This refers to the letter to editor ’Necrotizing Fascitis’ published in Medical Journal Armed Forces India . We would like to share our experience in successfully managing a case of Fournier's gangrene in our hospital.
A 67 year old ex-serviceman, neglected by his grown up children was brought to this hospital with history of weakness of right side of his body-10 days and swelling of penoscrotal region with foul smelling discharge - 3 days. He was unable to walk and passed stools and urine in bed. Examination revealed a frail old man who had foul smell emanating from him. He had tachycardia with normal blood pressure. Temperature on admission was 99.4°F. Pallor was present. He had right sided hemiparesis. Local examination revealed an edematous scrotum with edema extending on to the penis. There were multiple superficial ulcers. Urine and faeces contaminated the scrotum and perineal region. Skin over the 2/3 of the scrotum was gangrenous and had bullous vesicles. Crepitus was present over the scrotum and penis. He was managed as a case of Fournier's gangrene.
Investigations revealed haemoglobin of 8.6 gm% with mild leucocytosis. Blood sugar fasting and post prandial were 232 mg% and 330 mg% respectively. Blood cultures and pus cultures were sterile. Screening test for HIV was negative.
He was managed with IV fluids, broad-spectrum antibiotics (3rd generation cephalosporins, amino glycosides and metronidazole). Repeated extensive surgical debridement was undertaken which left the testes uncovered. Indwelling Foley's catheter was used for urinary diversion. Injection plain insulin (8 units) after each meal was used to control blood sugar. With these measures, the patient gradually improved. The infection subsided and penoscrotal wound became healthy. Secondary suturing was undertaken after about four weeks. He was discharged from hospital after 6 weeks and has remained well thereafter.
Fournier's gangrene is a rapidly progressive genital infection that is urological emergency. It was originally described in five healthy men by the French venereologist AJ Fournier in late 1880's. It is an uncommon disease with mortality as high as 60% in some series . Extensive surgical debridement, broad-spectrum antibiotics, and control of diabetes mellitus with nutritional support help in a favourable outcome. The elderly diabetic who is socially neglected, nutritionally depleted and has an immunocompromised status is most vulnerable to this life threatening disease. Test for HIV should be done in all cases, as Fournier's gangrene may be a presenting feature of an undiagnosed HIV infection .