A 5-year-old boy presented to the paediatric assessment ward with a 3-day history of fevers and a rash; a diagnosis of chicken pox was made and he was discharged home with paracetamol and ibuprofen.Two days later, he returned with pain, erythema and swelling of both his testicles. He was flushed and had a temperature of 37.9ºC and a pulse rate of 130 bpm. On physical examination, there were vesicular lesions all over his body, extensive erythema extending to his mid-thigh, and swelling of his scrotum with areas of purple discolouration. Laboratory tests showed a white blood cell count of 18,000/mm 3 (normal, 6000-12,500/mm 3 ) and a Creactive protein of 237 mg/l (normal, < 6 mg/l). Antibiotics were commenced (clindamycin and benzylpenicillin) and he was taken to theatre for debridement. The devitalised tissue including the whole of his scrotum was excised. His testicles and cord were not affected and were preserved. The dead tissue was sent for microscopy and Gram-stain.A second look in theatre the following day showed a small amount of necrotic tissue which was further debrided. He returned to the ward and the following day was constitutionally and clinically much improved. Blood culture and scrotal tissue confirmed Group A Streptococcus spp. and his antibiotics were continued for 10 days. Five days following his first debridement, a muscle flap and skin graft was performed by a plastic surgeon to repair the defect.
DiscussionFournier's gangrene is a necrotising fasciitis of the perineum which can rapidly spread to the skin of the entire scrotum and penis (1-2 cm/h). The process begins with focal skin infection and spreads along the fascial plane where inflammation, ischaemia, and necrosis result. This process was first described in 1883, by the French venereologist Jean Alfred Fournier. He described a series of five young men with progressive gangrene of the penis and scrotum, without apparent cause.
1,2Despite knowledge spanning over two centuries, mortality remains high and averages 20-30%.
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