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GRANDROUNDS Man, 32, With Severe Scrotal Pain and Swelling Donna Sabers, DPT, PA-C, Gregory Czajka, MPAS, PA-C, DFAAPA Donna Sabers 32-year-old man presents to the ur- a protein level of 100 mg/dL, and trace leu- practices at gent care center at a community kocyte esterase. Genesee hospital with severe scrotal pain and Urgent CT with contrast is obtained; it Orthopaedics & A Sports Medicine in swelling of five days’ duration. What began shows significant soft-tissue inflammatory Batavia, New York. as mild left scrotal discomfort is now causing changes in the left groin and scrotum that Gregory Czajka increasing pain, swelling, hematuria, dys- extend into the left thigh. In addition, a col- practices at Western uria, low-grade fever, and nausea, prompt- lection of fluid is seen in the inferior aspect New York Urology ing him to seek medical attention. of the left scrotal wall, indicating a probable Associates and is an Assistant The patient, who is a pipefitter in a hospi- abscess. There is no free air or lymphade- Professor in the tal, was at work when his symptoms began. nopathy. Physician Assistant He denies any history of scrotal trauma, Given the patient’s worsening condition Program at Daemen and his review of systems is otherwise unre- and his apparent advancement to a system- College in Amherst, markable. His medical history is significant ic inflammatory response syndrome, sur- New York. for mild hypertension and morbid obesity, gical consult is obtained. He is diagnosed but he is not immunocompromised. Two with a scrotal abscess and cellulitis; two months ago, he had an excision and re- blood and two scrotal cultures are obtained, pair of a left ureterocele, for which he was and the patient is empirically started on IV treated prophylactically with ciprofloxacin ampicillin and gentamicin. for one week. He has a 3–pack-year history Two hours later, he has a BP of 122/74 of smoking and consumes three alcoholic mm Hg; pulse, 112 beats/min; respiratory beverages per week. He denies illicit drug rate, 20 breaths/min-1; and temperature, use and has no report of sexually transmit- 103.1°F. His genital inflammation has ad- ted infection. vanced to the perineum and the left lower Upon arrival to urgent care, the patient abdomen. The purulent, bloody, foul- appears to be in moderate distress, with a smelling drainage from the opening in the blood pressure (BP) of 111/79 mm Hg; pulse, left perineum is increasingly apparent. The 104 beats/min; respiratory rate, 18 breaths/ patient is taken emergently to surgery for an -1 min ; temperature, 100.1°F; and SpO2, 94%. incision and drainage, along with explora- Physical exam reveals left scrotal erythema, tion of the scrotal abscess. During surgery, IN THIS severe tenderness upon palpation, marked the patient is discovered to have Fournier’s ARTICLE scrotal edema, and a slight amount of foul- gangrene. • Lab values for smelling discharge seeping from a pinpoint case patient, opening in the left perineum (see Figure DISCUSSION page 36 1a). Given his scrotal presentation, he is Fournier’s gangrene (FG) is a necrotizing • Differential quickly transferred to a regional emergency fasciitis of the perineal, perianal, and/or diagnoses, department (ED) for a urology consult. genital areas involving the superficial and page 37 In the ED, lab testing yields significant deep fascial planes while sparing the deep findings (see Table 1, page 36). His ECG muscular structures and overlying skin.1 A • Case outcome, demonstrates sinus tachycardia at 126 rare but potentially fatal disease, FG spreads 2,3 page 38 beats/min without rhythm or ST changes. at a rate of up to 3 cm/h. His urinalysis reveals a cloudy appearance, Mortality rates range from 7.5% to 88%, 34 Clinician Reviews • SEPTEMBER 2017 clinicianreviews.com GRANDROUNDS with the highest mortality oc- FIGURE curring within the first 96 hours Presentation and Urgent Management of Case Patient of hospitalization.1,4-7 Mortal- ity is often related to the onset of sepsis.4,5 Survival requires early recognition; immediate, aggres- sive surgical debridement of all necrotic tissue; and concomitant, early administration of appro- priate antibiotics.1,4,5,8 Mortality risk and prognosis are improved in patients younger than 60 with localized disease and no toxicity, along with sterile blood cultures.1 Risk Factors FG is most commonly seen in males between the ages of 50 and 70, with a 10:1 male-to-female ratio.3,9 Impaired immunity typi- cally increases a patient’s suscep- tibility to FG, with type 2 diabe- tes having the highest incidence Physical exam findings included left scrotal erythema, severe tenderness upon (85% of patients).1,4,6,8,10 Other palpation, and marked scrotal edema (a). CT with contrast revealed significant conditions that can increase the soft-tissue inflammatory changes in the left groin and scrotum that extended risk for FG include obesity, alco- into the left thigh. The patient's condition ultimately necessitated extensive holism, cirrhosis, cardiac disease, debridement down to healthy tissue in all affected areas (b). tobacco use, peripheral vascular disease, malignancy, chronic ste- roid use, renal insufficiency, IV drug abuse, various layers of fascia within the scrotum and HIV.1,4,6,8,9,11 and the anterior abdominal wall, as well as Trauma frequently initiates the infec- the independent blood supply of the com- tious process, with urogenital trauma (eg, partmentalized testicular tissue.1-3 placement of urethral instrumentation, sur- During an exam of the acute scrotum, gery, and urinary tract infection) being the the differential diagnosis includes cellu- main cause of bacterial introduction.1,3 Lo- litis, scrotal abscess, acute epididymitis, calized infection causes the development and testicular torsion, with scrotal abscess of an obliterative endarteritis, resulting in being most frequently diagnosed (57% of subcutaneous vascular ischemia, necrosis, patients).9,11,12 The distinguishing features and bacterial proliferation.3,7,9 of these diagnoses can be found in Table 2 (page 37). Necrotizing fasciitis in the form Presentation and Diagnosis of FG tends to be an unexpected, rare find- Presenting symptoms of FG include intense, ing usually only diagnosed during the surgi- abrupt genital pain that is disproportionate cal draining of an abscess.12 to the physical exam findings.9 This rap- CT is the test of choice to detect FG and idly escalates to include extreme swelling, determine the extent of its spread by iden- erythema, bullae, discolored skin, and tis- tifying subcutaneous air/gas within the sue crepitus with eventual necrosis.2,10 Lab involved fascial planes.10,13 However, an results typically show leukocytosis > 18.0 × incisional biopsy with culture is needed to 109/L.4 The testicle and spermatic cord are confirm the diagnosis.3,9 Most patients with generally unaffected (as in this patient), due FG require an average of four surgeries (eg, to the anatomic relationship between the reconstruction, skin grafting, and possibly clinicianreviews.com SEPTEMBER 2017 • Clinician Reviews 35 GRANDROUNDS TABLE 1 are more robust than HA-MRSA strains and Patient Lab Values can cause sepsis and other invasive, rapidly progressive, and possibly life-threatening Reference Initial ED Postoperative infections due to the amount of tissue de- Lab Test range results results struction and necrosis.16,18 Transmission of WBC count (x 109/L) 4.0-11.0 11.3 9.0 with 13% CA-MRSA is often associated with crowded bands environments, frequent skin-to-skin contact, compromised skin integrity, contaminated Hematocrit (%) 40-52 37 26 items or surfaces, and lack of cleanliness.16 Over the years, CA-MRSA has developed re- Platelets (x 1,000 µL) 150-450 126 106 sistance to multiple antimicrobials; provid- Lactate (mmol/L) 0.4-2.0 1.5 Not tested ers should therefore consider CA-MRSA on initial evaluation of necrotizing infections, Troponin (ng/mL) < 0.01 2.29 16.23 to ensure appropriate initiation of treat- ment.12,16 Abbreviation: WBC, white blood cell. CASE CONTINUED Extensive debridement was completed colostomy if the infection has entered the down to healthy tissue in all affected ar- peritoneal cavity) in order to eradicate the eas (see Figure 1b, page 35). The necrotiz- disease and achieve the best functional and ing fasciitis had spared the left testicle and cosmetic outcome.4 spermatic cord, and a colostomy was not required. Etiology The patient’s initial postoperative vital About 83% of FG cases are polymicrobial signs were unremarkable, except for his infections comprised of enterobacter, en- BP (86/54 mm Hg). The patient was taken terococci, Escherichia coli, group A strepto- postoperatively to the surgical intensive cocci, pseudomonas, and clostridium, with care unit (SICU) with the diagnosis of FG. symptoms evolving two to four days follow- Aggressive IV fluids were administered for ing the initial insult.4,7,11,14,15 Monomicrobial resuscitation, and he was closely monitored infections are much less common, but the for increasing sepsis. Metronidazole was symptoms progress even more rapidly.15 added for anaerobic and gram-positive cov- Methicillin-resistant Staphylococcus aureus erage. His postoperative lab results can also (MRSA) necrotizing fasciitis infections oc- be found in Table 1. cur in about 3% of monomicrobial cases.12 His ECG showed a normal sinus rhythm MRSA emerged in the early 2000s as an without ST changes, and he denied any additional causative pathogen for polymi- cardiac symptoms. His physical exam was crobial necrotizing fasciitis infections.12,14,15 significant for mild pallor, dry mucus mem- Prior to that time, S aureus strains were al- branes, and a left scrotal and pelvic packed most uniformly susceptible to penicillin- dressing. He was given two units of packed ase-resistant ß lactams.12 red blood cells for acute postoperative A distinction should be made between blood-loss anemia.

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