JRSSEM 2021, Vol. 01, No. 5, 492 – 501
E-ISSN: 2807 - 6311, P-ISSN: 2807 - 6494
DOI : 10.36418/jrssem.v1i5.55
DIAGNOSIS AND TREATMENT OF FOURNIER GANGRENE
IN SECONDARY HOSPITAL; A REPORT OF TWO CASES
David Reiner Hutajulu 1
Hafizh Fanani Rizkyansyah 2*
1, 2, General Practitioner at Sultan Imanuddin General Hospital, Indonesia
*Correspondence: hafizh.fanani@gmail.com
Submitted: 7 December 2021, Revised: 11 December 2021, Accepted: 14 December 2021
Abstract. Fournier Gangrene (FG) is a specific form of necrotizing fasciitis that localized on genital
and perianal, although it is rare but it is progressively fast and potentially fatal. The incidence of FG
is 1.6 cases per 100,000 males, with a case fatality rate of 7.5%. Proper diagnosis and management
are very important to avoid serious complications. Early debridement, broad-spectrum antibiotics
and immediate supportive therapy, can reduce mortality. The objective is reporting two cases of
FG who were admitted to a secondary hospital and what is the best management based on our
setting. The method is qualitative observational study. The material collected through direct
interview and from medical record. The best management for our setting was rapid diagnosis and
followed by prompt debridement.
Keywords: gangrene fournier; diagnosis; treatment.
David Reiner Hutajulu , Hafizh Fanani Rizkyansyah | 493
DOI :
INTRODUCTION
Fournier's gangrene is a specific form of
necrotizing fasciitis, localized to the
external genital organs, perianal,
accompanied by arterial thrombosis, which
causes gangrene of the skin and
subcutaneous tissue, with manifestations of
severe sepsis, to organ failure multiple
(Chennamsetty et al., 2015). predisposing
factors for this disease are age, diabetes
mellitus, hypertension,
immunosuppression, chronic renal failure,
alcoholism, obesity, cachexia, pulmonary
disease, and systemic disorders (Hsu et al.,
2014).
Fournier's gangrene represents <0.02%
of hospitalized patients. Stay in hospital.
The incidence of FG is 1.6 cases per 100,000
men and the case fatality is 7.5% in
America. 1972 The highest mortality
reported in one study was 88%. Fournier
gangrene is an emergency in the field of
diagnosis and treatment urology (Sorensen
& Krieger, 2016). fast, precise and
aggressive important for bagus.5results
Debridement immediate are essential to
ensure a good result for delayed
intervention is done, give a prognosis that
buruk.6 The objective of this work was
reported two cases of Fournier gangrene
treated in secondary hospital setting and
find the best approach management.
MATERIALS AND METHODS
This case report method is an
observational study with retrospective
approach. Two cases are our sample and
population that came to Sultan Imanuddin
General Hospital, a secondary hospital. The
material collected through direct interviews
and medical records then discussed
qualitatively with recent literature
RESULTS AND DISCUSSION
Case Presentation
First Case
A 70-year-old male, with a history of
previous urinary tract infection and
unknown diabetes, came to the emergency
department with complaints of swelling of
the testicles within 3 days after being
treated with traditional oil, initially pain was
felt in the testicles for 6 days. Before
coming to the ED, fever for 7 days. From
physical examination, vital signs 120/60,
pulse 98, s 36.5 degrees Celsius, rr20 spo2
99%, BMI 17.6 GCS 15. Gangrene in the
right scrotum and abscess in the right
scrotum, there is crepitus and tenderness
to the touch. Rectal examination was within
normal limits. From the laboratory
examination, it was found that leukocytes
in the urine were macroscopic and full
leukocytes were evenly distributed in the
urine sediment. The patient was diagnosed
with a scrotal abscess with suspicion of
Fournier's gangrene. From routine
hematology Hemoglobin 11.2g/dl,
Leukocytes 20,800/ul, Hematocrit 35.1%,
Platelets 313,000, from the leukocyte count,
neutrophils 78%, lymphocytes 13%, urea 30
mg/dl, creatinine 0.5 mg/dl, and random
blood sugar 261 mg/dl, with a Neutrophil-
Lymphocyte Ratio (NLR) of 6.3, and a
Platelet-Lymphocyte Ratio (PLR) of 115.75.
He was given maintenance crystalloid fluid
therapy, injection of Cefotaxime 1 g twice a
494 | Diagnosis and Treatment of Fournier Gangrene In Secondary Hospital; A Report of Two Cases
day, Metronidazole 500 mg 3 times a day,
and the patient was immediately debrided.
An abscess of about 10 cc was found, tissue
was necrotic and the right testicle was
necrotic, so a right orchiectomy was
decided. The antibiotic injection was
continued, the wound was treated with
0.9% Nacl, and blood sugar control was
carried out using fast-acting insulin and
basal insulin. The patient went home with
good wound healing results after 7 days of
treatment.
Second Case
A 50-year-old man with a previous
history of type 2 diabetes, Consultant of
Internal Medicine with scrotal abscess. The
patient entered the emergency room with
the initial complaint that a lump appeared
near the anus, without pain for ± six days
of SMRS. After two days, the lump
disappeared, and a lump appeared in the
right pubic pouch area. Within ± four days,
the pubic pouch enlarges and is followed
by pain. CHAPTER and BAK within normal
limits. Nausea (-), fever (-), vomiting (-).
From inspection, the scrotum is enlarged,
tissue necrosis, pus, tenderness, and
crepitus are seen. Physical examination
revealed vital signs, BP 95/60, HR 112, RR
20, SpO2 96%, temperature 36.5 degrees
Celsius, BMI 24.2, GCS 15. Rectal
examination showed a lump at 6 o'clock.
Diagnosed with hyperglycemia suspicious
of Diabetic Ketoacidosis, with Orchitis, and
Internal Hemorrhoids. The patient received
one-liter crystalloid resuscitation fluid
therapy, injection of Cefotaxime 1 g/12
hours, Metronidazole 500 mg/8 hours inj,
and 12 IU fast-acting insulin sc. From
laboratory tests, it was found. Hemoglobin
13.3 g/dl, Leukocytes 15.300/ul, Platelets
317.000, Hematocrit 37.7%,. From the
leukocyte count, it was found that
Basophils 0, Eosinophils 1, Neutrophils rods
10, Neutrophil segment 71, lymphocytes
12, monocytes 6, Blood glucose at 594
mg/dl, Urea 37, Cr 1.7, SGOT 54, SGPT 45.
Urinalysis examination showed protein
(Albumin) +3, Glucose +3 Leukocytes
negative, Blood negative, Bacteria +1. NLR
scores 6.75 and PLR 172.65. After being
examined by a surgeon, it diagnosed
Fournier's gangrene. A cito debridement
was performed, gangrene was found in the
fascia, it detected a feculent odor, a
fasciotomy, and a right orchidectomy were
decided. After one week of treatment, the
wound healed, and the patient was allowed
to go home.
In Both cases prompt diagnosis and
debridement were the best management in
our secondary hospital setting.
Fournier's gangrene (FG) is a specific
form of necrotizing fasciitis, localized to the
external genital organs, perianal,
accompanied by arterial thrombosis, which
causes gangrene of the skin and
subcutaneous tissue, with manifestations of
severe intoxication, up to multiple organ
failure.1 Fournier's gangrene is a rare and
often fulminant disease. This condition was
first described as a disease of young adults
of unknown cause by Fournier in 1888
(Chalya et al., 2015).
Fournier's gangrene represents
<0.02% of hospitalized patients. The
incidence is 1.6 cases per 100,000 men and
the case fatality is 7.5% in America. The
literature reports a mortality rate of 20-
40%, with some studies reporting mortality
David Reiner Hutajulu , Hafizh Fanani Rizkyansyah | 495
as high as 88% (Sorensen & Krieger, 2016).
A Case Series in an Australian tertiary
hospital reported a FG incidence of 15
cases out of 250,000 with a mortality rate of
7 per cent during 2012-2017 (Heijkoop et
al., 2019). Meanwhile, the incidence in
Polish hospitals was 13 cases per 450,000
patients and all were male during 1995-
2013.9 A retrospective study in Tanzania for
the period 2006-2014 found 84 cases with
a male to female ratio of 41:1 (Chalya et al.,
2015).
Studies on the incidence of Fournier
Gangrene in Indonesia have not been
found. The reported predisposing factors
are age, diabetes mellitus, hypertension,
immunosuppression, chronic renal failure,
alcoholism, obesity, cachexia, pulmonary
disease, and systemic disorders (Hsu et al.,
2014). The most common predisposing
factor in Fournier's gangrene is diabetes
mellitus. Chemotaxis, phagocytosis, and
cellular respiration are impaired in diabetic
patients. This leads to an increased
susceptibility to infection (Oymacı et al.,
2014). The predisposition in both of our
cases was also diabetes mellitus, which is
thought to increase susceptibility to
Fournier's gangrene. As a predisposing
factor, diabetes is present in 32% to 66% of
cases of Fournier's gangrene. Notably, the
patient profiles tended to be younger and
wound cultures revealed distinct bacterial
colonies. Patients with uncontrolled
diabetes will have a poorer prognosis
requiring more aggressive wound care and
extensive debridement (Singh et al., 2016).
In another study Diabetes mellitus was
the most frequent comorbid (64%)
(Yilmazlar et al., 2017). It is explained in the
case of one with diabetes who are not
known to occur in old age (70 years) with
blood sugar randomized 261 mg / dl, while
in the second case occurs relatively young
(50 years old) with a blood sugar
randomized 596 mg / dl. It seems that
random blood sugar can indicate the
severity of the case at the time of
presentation.
In the first case the portal entry FG
probably started from the urogenital tract
due to a history of urinary tract infection,
while in the second case it started from a
perianal abscess. Although it cannot be
ascertained because there was no fistula
between the scrotum and urogenital in the
first case, and no digestive tract fistula was
found in the second case.
In a study by (Bilgiç et al., 2020),
infections of perianal origin (58%) were the
most common cause of FG, followed by
pressure ulcers (12%) and Bartholin's
abscess (10%).12 In line with this, (Morais et
al., 2017) The suspected etiologic factors
for Fournier's gangrene are: perianal
abscess (26.3%); urinary tract infection
(21%); Genital infection, trauma and
surgical wound account in 1 each case.5
Another study also stated that the most
common etiologic origins were perianal
abscess (41.6%), rectal tumor (16.6%),
Bartholin's abscess (8.3%), vulvar abscess
(8.3%).13 The cultures were monomicrobial
in 20% of patients and polymicrobial in
76%. Escherichia coli was the most
frequently identified microorganism (72%),
followed by Enterococcus sp. (62%) and
Acinetobacter baumannii (30%) (Yilmazlar
et al., 2017). The causative agent of
infection in both cases could not be
496 | Diagnosis and Treatment of Fournier Gangrene In Secondary Hospital; A Report of Two Cases
determined because bacterial cultures were
not performed.
Clinical presentation in both cases was
pain for 6 days in the first case, and pain for
4 days in the second case. Scrotal swelling
that lasted about 3 days in the first case,
and 4 days in the second case. Scrotal
swelling, fever and pain are the most
common symptoms of FG, symptoms
usually lasting from 2 days to more than a
week (Wroblewska et al., 2014). Although
initially described as sudden in onset, this
condition more often has a slow onset.
Symptoms of pruritus, pain and general
discomfort tend to worsen 3-5 days before
hospital admission (Singh et al., 2016).
One study showed that the clinical
characteristics of Fournier's gangrene in
elderly patients (>65 years) did not differ
from those of younger patients, and that
elderly patients did not experience more
severe clinical findings. However, the
percentage of elderly patients who
experience shock is quite significant, and
the majority of patients who eventually die
are also in shock at presentation (Hsu et al.,
2014). In both cases there was gangrene,
pus and crepitus. Physical examination may
reveal purulent discharge, crepitus, and
patches of necrotic tissue with surrounding
edema (Singh et al., 2016). Crepitation is a
common sign of this disease in the
presence of gas-forming anaerobic
microorganisms. The degree of internal
necrosis is often much greater than
external clinical signs indicate (Wroblewska
et al., 2014). In a subacute process, the
patient may experience generalized
symptoms such as fever and fatigue. Signs
such as skin erythema with ill-defined
margins and swelling may be found
(Matilsky et al., 2014).
Early diagnosis and management of FG
is important to avoid serious complications
of this disease. A high degree of suspicion
is required for early diagnosis (El-Shazly et
al., 2016). In the first case a scrotal abscess
was diagnosed with a suspicion of
Fournier's gangrene from the clinical
presentation. Whereas in the second case
the diagnosis of hyperglycemia and orchitis
was made because of the patient's
presentation in shock and suspicion of
diabetic ketoacidosis.
The diagnosis of FG is mainly based on
the clinical findings of fluctuation, crepitus,
local tenderness and sores on the genitalia
and perineum, an atypical clinical
presentation found on the genitals,
especially in older or advanced patients,
may lead to misdiagnosis (Chennamsetty et
al., 2015). In most cases, imaging is not
required. Under no circumstances should
surgery be significantly delayed for any
imaging. However, imaging modalities can
be useful in cases when the presentation is
atypical or when there is concern about the
true extent of the disease (Yim et al., 2016).
In the case report of (Matilsky et al.,
2014) with a clinical presentation such as
scrotal cellulitis, ultrasound examination
was performed, and fluid and gas were
found in the scrotum. Cool scrotal skin is
evidenced by hypoechoic tissue over the
testes, whereas heterogeneous hypoechoic
appearance with irregular borders shows
tissue edema, fluid and gas. Ultrasound has
a sensitivity of 88.2% and a specificity of
93.3% for diagnosing suspected
necrotizing fasciitis and a sensitivity of
David Reiner Hutajulu , Hafizh Fanani Rizkyansyah | 497
100% for detecting soft tissue air in
cadaveric studies (Matilsky et al., 2014).
Ultrasound is also useful in
differentiating necrotizing soft-tissue
infections from other scrotal pathologies.
In this context, ultrasound is superior to
radiography (Singh et al., 2016).
Meanwhile, the case of Fournier's gangrene
presented by Miyamoto et al. used the
LLINEC score and MRI for the initial
diagnosis of Fournier's gangrene and
determining the extent of infection. (Wong
et al., 2004) reported scores of Laboratory
Risk Indicators for Necrotizing Fasciitis
(LRINEC). Assessment is based on CRP,
WBC count, Hb, Na, Cr, and glucose levels;
and a total score of 6 indicates necrotizing
fasciitis. The LLINEC score offers 92.0%
positive and 96.0% negative predictive
value. (Fazekas et al., 1998) it was reported
that MRI offers 100% sensitivity and 86%
specificity for diagnosing necrotizing
fasciitis.
In both cases at our secondary
hospital, MRI was not available, while
ultrasound was not available for emergency
cases, for LLINEC CRP examination, nor was
it available in our hospital. So the ability to
diagnose FG based on clinical examination
and immediate referral to a surgeon is very
important for the diagnosis of FG in our
hospital.
Management of FG consists of three
main principles: rapid and aggressive
surgical debridement of necrotizing tissue,
hemodynamic support with immediate
fluid resuscitation, and broad-spectrum
parental antibiotics (Chennamsetty et al.,
2015). The first cases were admitted to the
surgical ward and planned for cito
debridement while the second case was
admitted to the internal medicine ward for
one day and planned cito debridement
after being consulted to the surgery
department. In the study of (El-Shazly et al.,
2016), cases with conservative
management required more debridement
sessions and had greater skin defects and
consequently more skin grafts than cases
with early exploration and debridement.
Mortality of FG patients also increased
with delayed surgical debridement,
mentioned (Lin et al., 2019) The mortality
rate for high-risk FG was 26.32% with
surgical time within 12 hours, 40% between
12-24 hours and 69.23% > 24 o'clock.18 In
both cases, a single debridement and a
right orchiectomy were performed.
Inpatients FG, serial debridement is often
required which can result in significant skin
and soft tissue loss, requiring
reconstructive surgery (Kuzaka et al., 2018).
Orchidectomy is rarely performed in
FG patients (Kuzaka et al., 2018).
Orchidectomy was performed when
intraoperative findings revealed testicular
gangrene. The number of procedures
performed on FG patients corresponds to
the intraoperative findings. In the study of
Chalya et al, unilateral orchiectomy was
performed for gangrenous testis in 3 (3.6%)
patients out of 88 cases (Chalya et al.,
2015). In the (Heijkoop et al., 2019) study,
five patients (38%) had tests requiring
orchiectomy during the debridement
procedure (Heijkoop et al., 2019).
In both cases the initial parenteral
antibiotics used were the same, namely
Cefotaxime and Metronidazole, the
administration of these two types of
498 | Diagnosis and Treatment of Fournier Gangrene In Secondary Hospital; A Report of Two Cases
antibiotics was routinely given in gangrene
cases in our hospital. Parenteral broad-
spectrum antibiotic regimens are required
in the management of Fournier's gangrene.
According to the recommendations of the
European Urological Association, the
antibiotics given include gram-positive and
gram-negative anaerobes, with a choice of
Vancomycin/linezolid in MRSA, clindamycin
in streptococci, fluoroquinolones in gram-
positive and broad-spectrum Gram-
negative, cephalosporins in gram-positive,
and metronidazole in anaerobes. Culture
and subsequent sensitivity can change the
choice of antibiotics. There are no
recommendations for optimal antibiotic
therapy in Fournier's gangrene and patient
management is dependent on local
hospital guidelines (Singh et al., 2016).
Various scoring systems and
prognostic factors have been proposed in
an attempt to predict survival and
prognosis in FG. The Fournier gangrene
severity index (FGSI), first described in 1995,
is a scoring system consisting of several
clinical and laboratory parameters that help
in predicting prognosis and survival
(Bozkurt et al., 2015). FGSI 9 has a 75%
probability of death and FGSI <9 has a 78%
probability of survival. In the case of
Tarchouli et al, the FGSI was significantly
higher in the non-surviving patients
(Bozkurt et al., 2015).
According tp (Yilmazlar et al., 2017)
using the Uludag FGSI (UFGSI), adding 2
parameters (age and disease extent) to the
classic FGSI score, with a score over 9.5
increasing mortality and morbidity.12 FGSI
requires the collection of at least nine
clinical parameters from FG patients. To be
more practical, (Lin et al., 2019) published
the Simplified Fournier Gangrene Severity
Index (SFG scoring system), with only three
parameters of serum creatinine, hematocrit
and potassium levels. Although the FGSI
remains the most widely used with a
sensitivity of 65-88% and a specificity of 70-
100%, the SFGSI showed a sensitivity of
87% and a specificity of 77%, when the total
score was greater than 2 in the study of
(Tenório et al., 2018).
The Laboratory Risk Indicator for
Necrotizing Fasciitis score (LRINEC) is a
scoring system composed primarily of
laboratory-specific parameters described
to differentiate necrotizing fasciitis and
other soft tissue infections (Bozkurt et al.,
2015). The LRINEC score is constructed and
converted into a diagnostic not a
prognostic tool.5 Neutrophil Lymphocyte
Ratio (NLR) and Platelet Lymphocyte Ratio
(PLR) are used as markers of subclinical
inflammation, by dividing the neutrophil
count by the lymphocyte count to obtain
the NLR, or by dividing the platelet count
by the lymphocyte count to produce a PLR.
(Yim et al., 2016), with NLR scores > 8, and
PLR > 140 compared with FGSI in their
study. FGSI High (>9) does not indicate a
poor prognosis, whereas high NLR and PLR
are associated with high mortality, with NLR
sensitivity = 76.9%, specificity = 63.8%,
positive predictive value = 60.6%, negative
predictive value = 79.3%, and PLR
sensitivity = 84.6%, specificity = 66.6%,
positive predictive value = 64.7%, negative
predictive value = 85.7%.22
According to (Saber & Bajwa, 2014)
advocate a simplified eight-scale
prognostic scoring system with a maximum
David Reiner Hutajulu , Hafizh Fanani Rizkyansyah | 499
score of eighteen points indicating the
highest risk of death and a minimum score
of eight points with a lower relative risk of
death. The proposed system contains
patient age, BMI, temperature, pulse,
systolic blood pressure, presentation time,
area involved and comorbidities (Sakr et al.,
2011).
Scoring system components such as
FGSI, UFGSI, SFGSI, LNRIEC can be
performed in tertiary health facilities.
Meanwhile, our possible settings are NLR,
PLR and Score from (Saber & Bajwa, 2014).
In the first case the NLR score of 6, PLR 115,
showed a low risk of mortality, while the
second case the NLR score of 6.75 and PLR
172.65, showed a higher risk of mortality in
the second case than in the first case, it
seems to be based on delays in diagnosis
and therapy compared to the first case. Still
the best management is rapid diagnosis
and prompt debridement for both cases.
CONCLUSIONS
FG is an emergency that is quite rare,
but the mortality is quite high. The best
approach management in FG is quick
diagnosis and treatment to reduce
mortality and morbidity. High suspicion of
Fournier's gangrene in infections of the
urogenital and early consultation with a
surgeon can improve early detection of this
disease. Quick debridement of FG can
provide good outcomes.
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