Fournier’s Gangrene as The Presenting Sign of an Undiagnosed Human Immunodeficiency Virus Infection

McKay, Thomas C.; Waters, W. Bedford

doi:10.1016/s0022-5347(17)32469-2

Cited by 35 publications

(13 citation statements)

References 12 publications

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“…4 Associated comorbidities include diabetes mellitus, alcohol use, or immunocompromise. 1,5,6 The infection commonly begins as cellulitis adjacent to the portal of entry with painful swelling and induration of the penis, scrotum, or perineum. Eschar, necrosis, crepitus, patchy areas of hypoesthesia, and foul odor may also be seen.…”

Section: Discussionmentioning

confidence: 99%

A Diabetic Male With a Suprapubic Mass and Painful Penis and Scrotum

Chun¹

2006

Infectious Diseases in Clinical Practice

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Fournier's gangrene is a life-threatening necrotizing synergistic fasciitis of the perineum, abdominal wall, and genitalia [Surg Clin North Am 2002;82:1213; Urol Clin North Am 1991;26:841]. We describe a case of a 66-year-old man whose atypical presentation posed a diagnostic and clinical challenge of such a urological emergency. Clinicians need to have a high index of suspicion for this disease in individuals with predisposing or associated conditions, given the risk for widespread extension and impact on patients' outcome. (Infect Dis Clin Pract 2006;14:65-67) CASE REPORTA 66-year-old African American male with a history of diabetes mellitus and peripheral vascular disease was admitted in December 2004 to a hospital emergency department with fever, chills, dysuria, and fluctuating blood sugars. He denied any penile discharge, unprotected intercourse, or costovertebral tenderness. He reported falling without loss of consciousness before arrival to the emergency department. Physical examination was unremarkable; there was no prostate tenderness. Values for standard laboratory tests revealed the following: white blood cell count 41 Â 1000/mm 3 , 70% neutrophils, 19% bands; urinalysis, 30 white blood cells per high-power field, negative nitrite, 2+ leukocyte esterase, moderate bacteria; sodium 133 mmol/L, potassium 3.3 mmol/L, bicarbonate 15 mmol/L, creatinine 1.1 mg/dL, lactate 2.9 mmol/L (range 0.5-2.2). No abnormalities were seen on chest radiograph and renal ultrasound.The patient was treated for a presumptive urinary infection with a fluoroquinolone. One day after discharge, the patient represented after awaking from sleep with a painful penis and scrotum and a weak interrupted urinary stream. Findings on physical examination revealed a nontoxic man with stable vital signs and a tender nonfluctuant suprapubic mass with scrotal, penile, and perineal edema. Laboratory analysis revealed white blood cell count 70.2 Â 1000/mm 3 , 86% neutrophils, 7% bands; sodium 132 mmol/L, potassium 4.0 mmol/L, bicarbonate 18 mmol/L, creatinine 0.7 mg/dL, lactate 0.7 mmol/L. Blood and urine cultures were negative. Computed tomography examination of the abdomen and pelvis demonstrated air in the subcutaneous tissue overlying the pelvis and perineum, along the fascial planes, extending halfway to the umbilicus (Fig. 1). These findings were suggestive of Fournier's gangrene.The patient was immediately taken to surgery for debridement of the perineum and corpora spongiosum. The patient was treated with intravenous imipenem and clindamycin. Wound Gram stain and culture revealed budding yeast that cultured out as Candida albicans; pathological tissue examination from the perineum revealed necrotic involvement of the skin and subcutaneous fat and fascia. Special stains for bacteria, acid-fast bacilli, and fungi were negative. The patient was taken to the operating room daily for repeated examination and debridement ultimately requiring a penectomy 21 days after initial debridement. Perineal wound vacuum cultures from 6 days after p...

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Section: Discussionmentioning

confidence: 99%

A Diabetic Male With a Suprapubic Mass and Painful Penis and Scrotum

Chun¹

2006

Infectious Diseases in Clinical Practice

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“…Diabetes mellitus, advancing age, malignancy and alcoholism are frequently reported as contributing factors. [1][2][3][4][5][6]8,[10][11][12] The first case of Fournier's gangrene associated with a hematological disease was described in 1983 by Patrizi et al They reported one case of acute promyelocytic leukemia treated by conventional chemotherapy. 11 Seven other patients with hematological malignancies have subsequently been reported; 8,12 they suffered from ANLL (three cases), ALL (two cases) and NHL (two cases).…”

Section: Discussionmentioning

confidence: 99%

“…Pseudomonas aeruginosa has been associated with Fournier's gangrene in some reports. 2,4,6,10 It was isolated in five out of seven patients with hematological malignancies. 8,11,12 In the majority of cases, Fournier's gangrene involves mixed bacterial flora: 3 the infection is caused by aerobic and anaerobic organisms with low or moderate virulence.…”

Section: Discussionmentioning

confidence: 99%

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

Martinelli

Alessandrino

Bernasconi

et al. 1998

Bone Marrow Transplant

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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...

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“…Complications of peri-anal sepsis include necrotizing fasciitis of the genital area, perineum, and peri-anal region (Fournier's gangrene), and there are several case reports involving patients with HIV. [2][3][4][5] The largest series of HIV peri-anal sepsis retrospectively reviewed 50 cases over a 10-year period.…”

Section: Necrotizing Peri-anal Infections In Patients With Hivmentioning

confidence: 99%

Acute Kidney Injury with Polyuria in a Patient with HIV

Silver¹,

Richardson²

2015

CJGIM

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SummaryWe describe the case of a 30-year-old man with HIV with an elevated creatinine and three litres per day of urine output. Using this patient as a framework, we review a diagnostic approach to acute kidney injury with polyuria. This case emphasizes the importance of a complete diagnostic evaluation of acute kidney injury. Without this approach, it would have been easy to attribute the patient's acute kidney injury to his HIV and necrotizing peri-anal infection, instead of the true lifethreatening cause. CaseA 30-year-old Caucasian man presented to hospital with fever and peri-anal abscesses. He suffered from chronic peri-anal fistulas and had previously undergone five fistulotomies. He also had a long-standing history of HIV treated with anti-retroviral therapy, but stopped his therapy six months previously. He had no history of opportunistic infections, and his most recent CD4 (T-cell) count taken two months prior to presentation was 460 cells/mm 3 . His CD4 count on admission to hospital was 77 cells/mm 3 . Abdominal imaging revealed intramuscular and fascial air throughout the right leg and pelvic muscles. There was loculated gas within the right mesorectum/presacral space. He was diagnosed with necrotizing fasciitis from a peri-rectal source and underwent a right above-knee amputation along with loop ileostomy. Cultures from the operating room later grew Streptococcus anginosis, and he was treated with appropriate antibiotics. He required several more debridements while in hospital and had a very slow convalescence. Onset of Acute Kidney InjuryWhile the patient recovered, routine blood work (complete blood cell count [CBC], electrolytes, and creatinine) was done on a weekly basis. Three months after his first surgery, his serum creatinine was noted to be 250 µmol/L from a baseline the previous week of 50 µmol/L. A nephrology consultation (which included the authors) was requested.Further history revealed that the patient was eating well with no significant gastrointestinal symptoms. His medication list included ritonavir, emtricitabine, tenofovir, atazanavir, metoprolol, cotrimoxazole prophylaxis, hydromorphone, and gabapentin. He had received no new nephrotoxic drugs such as non-steroidal anti-inflammatories or aminoglycosides. His last abdominal computed tomography (CT) scan, done three weeks earlier, reported normal-appearing kidneys.Physical examination revealed a heart rate of 80 beats per minute (BPM) and blood pressure 140/90. His jugular venous pressure was below the sternal angle when supine. His lungs were clear.

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Fournier’s Gangrene as The Presenting Sign of an Undiagnosed Human Immunodeficiency Virus Infection

Cited by 35 publications

References 12 publications

A Diabetic Male With a Suprapubic Mass and Painful Penis and Scrotum

A Diabetic Male With a Suprapubic Mass and Painful Penis and Scrotum

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

Acute Kidney Injury with Polyuria in a Patient with HIV

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