Fournier gangrene is a type of

necrotizing fasciitis Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or p ...

or gangrene affecting the external genitalia or

perineum The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), includi ...

. It commonly occurs in older men, but it can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised. About one per 62,500 males are affected per year. Males are affected about 40 times more often than females. It was first described by Baurienne in 1764 and is named after a French venereologist,

Jean Alfred Fournier Jean Alfred Fournier () (21 May 1832 – 25 December 1914) was a French dermatologist who specialized in the study of venereal disease. Biography As a young man he served as an interne at the Hôpital du Midi as an understudy to Philippe Rico ...

, following five cases he presented in clinical lectures in 1883.

Signs and symptoms

Initial symptoms of Fournier gangrene include swelling or sudden pain in the

scrotum The scrotum or scrotal sac is an anatomical male reproductive structure located at the base of the penis that consists of a suspended dual-chambered sac of skin and smooth muscle. It is present in most terrestrial male mammals. The scrotum co ...

, fever, pallor, and generalized weakness. It is characterized by pain that extends beyond the border of the demarcated erythema. Most cases present mildly, but can progress in hours. Subcutaneous air is often one of the specific clinical signs, but is not seen in >50% of presenting clinical cases. More marked cases are characterized by a foul odor and necrotic infected tissue.

Crepitus Crepitus is "a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone". Various types of crepitus that can be heard in joint pathologies are: *Bone crepitus: This can be heard when two fragme ...

has been reported. It begins as a subcutaneous infection. However, necrotic patches soon appear in the overlying skin, which later develop into necrosis.

Cause

Most cases of Fournier gangrene are infected with both

aerobic Aerobic means "requiring air," in which "air" usually means oxygen. Aerobic may also refer to * Aerobic exercise, prolonged exercise of moderate intensity * Aerobics, a form of aerobic exercise * Aerobic respiration, the aerobic process of cel ...

and

anaerobic Anaerobic means "living, active, occurring, or existing in the absence of free oxygen", as opposed to aerobic which means "living, active, or occurring only in the presence of oxygen." Anaerobic may also refer to: * Anaerobic adhesive, a bonding a ...

bacteria such as ''

Clostridium perfringens ''Clostridium perfringens'' (formerly known as ''C. welchii'', or ''Bacillus welchii'') is a Gram-positive, rod-shaped, anaerobic, spore-forming pathogenic bacterium of the genus ''Clostridium''. ''C. perfringens'' is ever-present in nature an ...

''. It can also result from infections caused by

group A streptococcus Lancefield grouping is a system of classification that classifies catalase-negative Gram-positive cocci based on the carbohydrate composition of bacterial antigens found on their cell walls. The system, created by Rebecca Lancefield, was historic ...

(GAS), as well as other pathogens such as '' Staphylococcus aureus'' and ''

Vibrio vulnificus ''Vibrio vulnificus'' is a species of Gram-negative, motile, curved rod-shaped (bacillus), pathogenic bacteria of the genus ''Vibrio''. Present in marine environments such as estuaries, brackish ponds, or coastal areas, ''V. vulnificus'' is relat ...

''. Lack of access to

sanitation Sanitation refers to public health conditions related to clean drinking water and treatment and disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is hand washing with soap. Sanitation syste ...

medical care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health p ...

, and

psychosocial The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...

resources has been linked to increased mortality. A 2006 Turkish study reported that blood sugar levels were elevated in 46 percent of patients diagnosed with Fourniers. Another study reported that about one third of patients were

alcoholic Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomina ...

diabetic Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

, and

malnourished Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues ...

, while another ten percent had been immunosuppressed through

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs ( chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemothe ...

, steroids, or

malignancy Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...

. Fournier gangrene is a rare

side effect In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequence ...

SGLT2 inhibitor SGLT2 inhibitors, also called gliflozins or flozins, are a class of medications that modulate sodium-glucose transport proteins in the nephron (the functional units of the kidney), unlike SGLT1 inhibitors that perform a similar function in the ...

s (

canagliflozin Canagliflozin, sold under the brand name Invokana among others, is a medication used to treat type 2 diabetes. It is a third-line medication to be tried after metformin, a first-line medication for type 2 diabetes. It is used together with ex ...

dapagliflozin Dapagliflozin, sold under the brand names Farxiga (US) and Forxiga (EU) among others, is a medication used to treat type 2 diabetes. It is also used to treat adults with heart failure and chronic kidney disease. Common side effects include hy ...

, and

empagliflozin Empagliflozin, sold under the brand name Jardiance among others, is an antidiabetic medication used to improve glucose control in people with type2 diabetes, to reduce the risk of cardiovascular death in adults with type2 diabetes and establis ...

), which increase the excretion of glucose in the urine.

Diagnosis

Fournier gangrene is usually diagnosed clinically, but laboratory tests and imaging studies are used to confirm diagnosis, determine severity, and predict outcomes. X-rays and ultrasounds may show the presence of gas below the surface of the skin. A CT scan can be useful in determining the site of origin and extent of spread.

Treatment

Fournier gangrene is a urological emergency requiring intravenous antibiotics and

debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. In p ...

(surgical removal) of dead tissue. In addition to surgery and antibiotics,

hyperbaric oxygen therapy Hyperbaric medicine is medical treatment in which an ambient pressure greater than sea level atmospheric pressure is a necessary component. The treatment comprises hyperbaric oxygen therapy (HBOT), the medical use of oxygen at an ambient pressure ...

may be useful and acts to inhibit the growth of and kill the anaerobic bacteria. Multiple wound debridement may be required in cases with extensive tissue involvement. Simple reconstructive procedures following wound debridement yield satisfactory outcomes in majority of the cases.

Prognosis

While recent case series (n=980) studies have found a mortality rate of 20–40%, a large (n=1641) 2009 study reported a mortality rate of 7.5%.

Epidemiology

A 2009 epidemiological study found the incidence of Fournier gangrene to be 1.6 cases per 100,000 males, in the United States. Males 50 to 79 years old had the highest rate at 3.3 per 100,000. Of 1,680 cases identified in the study, 39 were women.

References

External links

* and {{Bacterial cutaneous infections Bacterium-related cutaneous conditions Gangrene Urological conditions