Severe Fournier’s gangrene in a patient with rectal cancer: case report and literature review

Abstract

BackgroundFournier’s gangrene in the setting of rectal cancer is rare. Treatment for Fournier’s gangrene associated with rectal cancer is more complex than other cases of Fournier’s gangrene. We report on a patient with severe Fournier’s gangrene in the setting of locally advanced rectal cancer who was treated with a combined modality therapy.Case presentationA 65-year-old man presented with general fatigue and anal pain. The medical and surgical histories were unremarkable. A black spot on the perineal skin surrounded by erythema was found on physical examination, suspicious for Fournier’s gangrene. Computed tomography scan showed a rectal tumor invading into the bladder (clinically T4bN2M0) and abscess formation with emphysema around the rectum. He was thus diagnosed with locally advanced rectal cancer and Fournier’s gangrene with a severity index score of 12 points. We created a diverting loop colostomy of the transverse colon and performed extensive debridement of the perineum and perianal area. Fifty days later, the patient underwent radical total pelvic exenteration with sacrectomy. In addition, reconstruction of the soft tissue defect was performed using the rectus muscle, the gluteus maximus muscle, and the femoral muscle. Histopathological findings of the specimen were as follows: the tumor was a moderately adenocarcinoma with invasion to the bladder and the prostate (T4b), metastases to four resected lymph nodes (N2), and lymphovascular invasion. There were no major postoperative complications, and the patient was discharged 108 days postoperatively.ConclusionsWe report a rare case of locally invasive rectal cancer associated with Fournier’s gangrene. This case highlights a usual cause of Fournier’s gangrene. Physicians should be cognizant not only of the more common condition but also of the rare presentations including those associated with rectal cancer.

Fournier’s Gangrene: Literature Review and Clinical Cases

“…The authors also note that the most frequent concomitant pathology was diabetes mellitus; the cause of the development of swelling was a perianal abscess. Yoshino et al [6] described the case of an anal fistula in a patient with type 2 diabetes mellitus, resulting in an abscess of pararectal tissue complicated by Fournier gangrene. Mosayebi et al [7] described Fournier gangrene in a newborn with acute myeloid leukemia.…”

Perforated Rectal Cancer Presenting as Fournier’s Gangrene in a Confused Older Patient

“…Attention to the history was essential, not only to the complaint of scrotal pain, but also the patient's preceding symptoms of changes in bowel habits and rectal bleeding supported a diagnosis of rectal malignancy. The combination of symptoms was thereby suggestive of local invasion resulting in Fournier's gangrene, as demonstrated in other reported cases [6]. Cross-sectional imaging is thus imperative in such scenarios to exclude other causes of local sepsis, such as pelvic abscess, and to allow for preoperative assessment whilst not delaying surgical debridement.…”

Pathology of Gangrene

“…Emergency surgery disclosed transmural gangrenous necrosis of the rectal wall with massive mixed bacterial infection, including E. coli. Occasionally, Fournier's gangrene has been complicated with rectal cancer [111,112].…”