ID Case Conference

1. ID Case Conference Yvonne L. Ballard, MD 26 March 2008

2. CC: weakness/dizziness • 44yo AAM with no known PMH admitted 3/15 for a 2-week h/o blurry vision, weakness, dizziness, polyuria, polydipsia, and SOB. • On admission, found to be in DKA • Also had leukocytosis and fever, but denied localizing symptoms

3. History… • 3 weeks ago, pt experienced hematuria that resolved spontaneously • Reports history of recurrent abcesses, beginning 10 years ago (groin, axilla, thigh) • Sexually active, monogamous with wife • No history of STDs • No history of HIV

4. PMH: HTN Diabetes Mellitus (HgA1c = 12.3%) Large Subcut Cyst FamHx: Mom – healthy Dad – DM “my whole family has sugar” Social Hx: Lives in Moncure with Mom Married, wife lives in Chapel Hill Construction worker 1ppd smoker Previously heavy Etoh No illicits, No IVDA

5. History, cont… • On the evening of admission, pt began to complain of right-sided groin pain that quickly progressed overnight • Also noted new onset of a large swelling in suprapubic area • Worsened overnight, and began to have drainage from the scrotum the following day • Denies testicular pain, urethral discharge • No dysuria or pain with defecation

6. Physical Exam • Temp 36.8, P 86, RR 14, BP 99/71, Pox 98% on RA • Gen: WD, WN, NAD. Large cyst over right eye • HEENT: Peerla, Eomi, anicteric, conj pink. OP clear. • Axilla: No LAD. Under right axilla, ~1cm area of induration without fluctuance, erythema. Nontender. • CV: RRR, Nrml S1S2, No m/g/r • Pulm: CTA b/l, no w/w/r • Abd: Soft, ND, NT, NABS. No organomegaly • GU: Very firm indurated area superior to iliac crest, above the penis. No erythema or warmth. His penis appears normal, without lesion. No urethral drainage. The testicles are normal on palpation, without mass or tenderness. In the middle of his scrotum, he has an area of thickened skin, and central in that area is a small area of draining purulent yellow fluid. There are no abcesses palpated. • Rectal: No masses, abcesses, or ulcers. • Ext: No c/c/e

7. 138 107 11 142 3.2 20 1.2 Laboratory Data 8.6 2.1 3.2 UA - 163 WBCs, 5 RBCs, 2+ LE, No Nitr, No blood. 4+ glu, 2+ ket. 6.7 15.5 299 19.5

8. CT Scan, 3/17:

9. Repeat CT Scan, 3/18:

10. Discussion…

11. Fournier’s Gangrene

12. History • Reported by Bauriene in 1764 • Affliction of King Herod the Great of Judaea (whom had DM) • Credited to Professor Jean-Alfred Fournier, a Parisian Dermatologist and Venereologist, who described it in 1883 • “Fulminant gangrene of the penis and scrotum” • (1) sudden onset in a hitherto healthy young man • (2) rapid progression to gangrene • (3) absence of a definite cause • Redefined in 1998: “an infective necrotizing fasciitis of the perineal, genital, or perianal regions”

13. Etiology • Local Skin Infection • Urinary Tract Infection • Renal Abcesses • Urethral Stones • Urethral Strictures • Colorectal Infections • Ruptured Appendicitis • Colonic Carcinoma • Diverticulitis British Journal of Surgery 2000, 87, 718-728

14. J Microbiol Immunol Infect. 2007; 40:500-506

15. Comorbid and Predisposing Conditions • Diabetes Mellitus • Alcoholism • HTN • Chronic Liver Disease • HIV • Malignancy • Trauma/Surgery Am Surg. 2002 Aug;68(8):709-13.

16. J Microbiol Immunol Infect. 2007; 40:500-506

17. Bacteriology • Classically a MIXED infection • Most common organisms: • Escherichia coli • Bacteroides fragilis • Streptococcus • Staphylococcus • Enterococcus spp. • Klebsiella pneumoniae • Corynebacteria • Clostridium • Proteus mirabilis • Synergistic Relationships

18. J Microbiol Immunol Infect. 2007; 40:500-506

19. Bacteriology • Increase in atypical organisms suggested in one study • Shewanella putrefaciens, Vibrio vulnificus, Candida albicans • Decrease in anaerobic infections, as evidenced by decrease in use of hyperbaric oxygen chamber for treatment? BJU Int. 2007 Dec;100(6):1218-20.

20. Clinical Presentation • Early – swelling, erythema, tenderness • Spreading – pain, fever, systemic toxicity • Late – swelling and crepitus of the scrotum rapidly progresses, dark purple areas develop and progress to extensive scrotal gangrene • Abdominal wall usually involved last…but accelerated spread in patients with Diabetes

21. British Journal of Surgery 2000, 87, 718-728

22. Morbidity and Mortality • Hospital stays from 2 to 278 days • Complications • Resp failure, Renal failure, Shock, DKA, Pneumonia, Hepatic failure, DIC, UGIB • Mortality 0-45% • EARLY, aggressive treatment associated with a reduced mortality rate Am Surg. 2002 Aug;68(8):709-13.

23. Treatment • Broad-spectrum antibiotics – triple therapy favored in most studies • Penicillins – Streptococci • Metronidazole – Anaerobes • 3rd gen. Cephalosporin (with/without Gent) • Enteric organisms and staphylococci • Surgical debridement • Unprocessed honey • Hyperbaric Oxygen

24. Hyperbaric Oxygen • Initially used for presumed clostridial infection when crepitus was observed • Increases tissue oxygenation to a level that inhibits and kills anaerobes • Reduces systemic toxicity • Improvement in neutrophil function • Increased fibroblast proliferation • Promotes angiogenesis

25. Hospital Course • Urology Consult – Bedside I&D • Cultures: Beta-hemolytic Group B Streptococci and Anaerobes • Treatment: Vanc, Zosyn, Clinda  Ceftriaxone and Clindamycin • Fever resolved, continued drainage • Superior aspect - ? Hematoma?

26. Have a Great Day!!!