Fournier’s gangrene: a clinical presentation of necrotizing fasciitis after bone marrow transplantation

Abstract

Summary:Three patients with ANLL developed Fournier's gangrene as an early complication after allo-BMT (two cases) and auto-BMT (one case); two patients were in first CR, the third had resistant disease. Patients developed fever, perineal pain, swelling and blistering of the genital area. Pseudomonas aeruginosa was isolated from the lesions and patients received systemic antibiotic therapy, surgical debridement and medication with potassium permanganate solution. Two patients made a complete recovery although one died of sepsis. The third had progressive involvement of the abdominal wall and later died of leukemia. Early diagnosis of this disorder and prompt initiation of appropriate therapy can prevent progression of this acute necrotizing infection. Keywords: Fournier's gangrene; necrotizing fasciitis; bone marrow transplantation Fournier's gangrene (FG) is an acute severe necrotizing disease of the fascia, subcutaneous fat and skin caused by a combination of aerobic and anaerobic bacteria, and involves the lower parts of the genitourinary tract, anorectal soft tissue and genital skin. 1-5 Fournier's gangrene usually involves male genitalia, but it has also been described in females. 2,3 Schultz et al 6 suggest that Fournier's gangrene may be related to a form of localized vasculitis with histological evidence of hemorrhagic necrosis. A mortality rate of 30-50% has been reported; 2,3,6 predisposing factors include diabetes mellitus, perineal trauma or infection, chronic alcoholism, malignancies and an immunocompromised status. 3 Despite the severe immunodeficiency that occurs in patients who undergo bone marrow transplantation (BMT), 7 Fournier's gangrene has been described in only one case of autologous BMT (auto-BMT). 8 We report three further cases who developed FG in the early cytopenic post-transplant phase. Two had received an allogeneic BMT (allo-BMT); the third an auto-BMT; all were suffering from acute non-lymphocytic leukemia (ANLL). Case reports Case No. 1A 41-year-old male, with ANLL in first hematological complete remission (CR), underwent allo-BMT from an HLA identical sibling donor. Pre-transplant tests showed normal renal and hepatic function; chest X-ray revealed evidence of a previous right pleuritis; ECG and echocardiography were normal. Performance status was good and clinical examination was negative. Conditioning consisted of busulphan (BU) and cyclophosphamide (CY). The patient received 2 × 10 8 /kg donor bone marrow cells; take was documented on day +11 from transplant. On day +4, he complained of chills and fever Ͼ38°C; physical examination showed genital erythema, pain, swelling and crepitation. Broad-spectrum systemic antibiotic therapy was started; white blood cell (WBC) and platelets counts were respectively 0.5 × 10 9 /l and 0.1 × 10 9 /l. Cultures from the central venous catheter (CVC) were positive thereafter for Staphylococcus aureus. On day +10 the cutaneous genital lesions worsened with blistering and ulceration. The patient developed scrotal gangrene (Figure 1) involving the...

Fournier's gangrene and its emergency management

“…Factors that have been identified to negatively affect survival include age, primary anorectal source of infection, delay in treatment, and immunocompromised state. 35 There is as yet inconclusive evidence to suggest that diabetes 36 or number of surgical debridements adversely affects the prognosis.…”

Neuromuskuläre Komplikationen nach allogener Knochenmarktransplantation

“…Als Sonderformen dieser seltenen Komplikation nach KMT wurden Patienten mit eosinophiler Fasziitis [28] und mit erregerbedingter nekrotisierender Fasziitis [29] beschrieben.Während Einzelfallberichte von einer guten Wirkung von Steroiden ausgehen [51], zeigte eine Steroidtherapie in einer größeren retrospektiven Studie mit 14 Patienten nur bei der Hälfte der Patienten eine mäßige Besserung [24]. Auch bei dem hier vorgestellten Patienten kam es nur zu einer partiellen Besserungen auf eine Immunsuppression mit Steroiden.…”

Necrotizing Fasciitis is a Rare Complication after Bone Marrow Transplantation: A Case Report

“…Necrotizing fasciitis is uncommon and difficult to diagnose and it causes progressive morbidity until the infectious process is diagnosed and treated medically and surgically [8]. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable [9], but early diagnosis of this disorder and prompt initiation of appropriate therapy can prevent progression of this acute necrotizing infection [10,11] and reduce the severity, morbidity and mortality [12]. The mortality rates are still very high in necrotizing fasciitis due to the severe sepsis that necessitates other interventions to overcome sepsis-related mortality [8].…”