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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 50  |  Issue : 4  |  Page : 145-149

A rare etiology of Fournier's gangrene: Pubic tubercle fracture complicated with hematoma and acute osteomyelitis


Division of Plastic and Reconstruction Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan

Date of Web Publication19-Jul-2017

Correspondence Address:
Chien-Liang Fang
#539, Jhongsiao Road, Chia-Yi City 60002
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_46_17

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  Abstract 

The etiologies of Fournier's gangrene are well described into four groups: anorectal, genitourinary, dermatologic, and idiopathic. Here, we present the case of a hematoma and acute osteomyelitis (related to a closed fracture of the pubis), which progressed to Fournier's gangrene 1 month after trauma. A 68-year-old woman was admitted to our emergency department because she had sustained a left side pubic bone fracture from a fall. On her first admission to our emergency department, conservative treatment had been prescribed; however, she was readmitted to our emergency department due to septic shock, local swelling, and pus discharge from the pubis and the left labium majus. A whole abdomen computed tomography scan revealed fluid accumulation in the left suprapubic and perineum region in addition to acute osteomyelitis of the pubis. Acute osteomyelitis-related Fournier's gangrene and sepsis were suspected; hence, she underwent urgent fasciotomy and sequestrectomy. After three rounds of sequestrectomies, partial wound reconstruction with local flap and 24-day hospitalization, she was discharged from our hospital with continuing wound care management. Conservative treatment of closed stable fractures of the pelvic bone along with bed rest is suggested by most orthopedists. However, surgical drainage of hematoma is necessary due to the poor hematoma absorption owing to pelvic fracture. The patient subsequently contracted acute osteomyelitis, a secondary infection associated with the etiology of Fournier's gangrene, particularly in the case of patients with diabetes mellitus. We concluded that this was a rare etiology of Fournier's gangrene and examined the complications of pelvic bone fracture in this context.

Keywords: Etiology, foam, Fournier's gangrene, hematoma, osteomyelitis


How to cite this article:
Fang CL. A rare etiology of Fournier's gangrene: Pubic tubercle fracture complicated with hematoma and acute osteomyelitis. Formos J Surg 2017;50:145-9

How to cite this URL:
Fang CL. A rare etiology of Fournier's gangrene: Pubic tubercle fracture complicated with hematoma and acute osteomyelitis. Formos J Surg [serial online] 2017 [cited 2019 Jun 18];50:145-9. Available from: http://www.e-fjs.org/text.asp?2017/50/4/145/211085




  Introduction Top


Fournier's gangrene is a fatal, rapidly progressing, infectious necrotizing fasciitis of the external genitalia or the perineal or perianal regions. Disclosed cases of Fournier's gangrene are on the rise, as indicated in recent studies, likely owing to high rates of early diagnosis due to a good awareness of this complication among health practitioners. Despite the advanced management of prompt radical fasciotomy, proper antibiotics, and intensive care for sepsis, the average mortality rate remains high and ranges between 20% and 30%.[1],[2],[3]

Following are the three types of etiologies of Fournier's gangrene along with their frequency of occurrence: anorectal (30%–50%) followed by genitourinary (20%–40%) and dermatologic injuries (10%–20%).[3],[4] Trauma was the main etiological factor in all the three above-mentioned groups, but there was no mention of pelvic bone fracture in the literature. We encountered a closed pubic fracture, which deteriorated to acute osteomyelitis and Fournier's gangrene, representing a rare etiology of the latter complication.


  Case Report Top


A 68-year-old woman presented with a previous history of diabetes mellitus, seizures, and dementia, who had been managing these conditions with medication for over 10 years. She had sustained a fall injury on December 4, 2015, which resulted in a left side pubic tubercle fracture; on the first admission to our emergency department without hospitalization, she was prescribed conservative treatment after being diagnosed with Tile classification of stable type A pelvic fracture [Figure 1]. Bed rest was also prescribed due to fracture-related tenderness and limited availability of family care. Progressive swelling of the left groin was noted after trauma, with poor activity and appetite noted subsequently. She was readmitted to our emergency department following these events on January 10, 2016, due to a deterioration of her condition. Physical examination revealed septic shock, local erythema, and swelling with moderate pus discharge from a small wound in the left side labium majus. Vital signs and abnormal laboratory data are shown in [Table 1]. Whole abdomen computed tomography (CT) scan revealed air and fluid accumulation in the left suprapubic and perineum region, and plain pelvic X-ray revealed acute osteomyelitis of the left side pubis [Figure 2]. Acute osteomyelitis-related Fournier's gangrene and sepsis were diagnosed, and she underwent urgent fasciotomy and sequestrectomy. She received intensive care for 6 days and was initially given broad-spectrum antibiotics comprising ceftazidime and vancomycin. Culture samples taken from the wound revealed the presence of Escherichia coli and Peptostreptococcus asaccharolyticus, and her antibiotics were later changed to Unasyn. After three rounds of sequestrectomy and fasciectomy and 24-day hospitalization, she was discharged from our hospital with her general condition being stable along with continued wound care with foam dressing. Two weeks later, the wound was noticeably smaller following local wound debridement as part of our plastic surgery outpatient service. The foam dressing continued to be changed every 3 days by family members until the wound was fully healed until approximately 5 months later [Figure 3] and [Figure 4].
Figure 1: Left side pubs closed stable fracture, initially classified as Tile classification stable type A

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Table 1: Vital signs and abnormal laboratory data on January 10, 2016

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Figure 2: Whole abdomen computed tomography scans revealed acute osteomyelitis of the left side pubis and Fournier's gangrene in the left suprapubic and perineum region

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Figure 3: (1) Photography of Fournier's gangrene in preoperative; (2) Status after urgent fasciotomy and sequestrectomy; (3) Status after third fasciectomy and local flap reconstruction of perineum region, and partial pubis bone exposure in the wound base; (4) Wound care with foam dressing for one month; (5) Smaller of wound after foam dressing for three months; (6) Healing of wound after foam dressing for five months

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Figure 4: No recurrence of osteomyelitis of pubic bone in sixth months following up after sequestrectomy

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  Discussion Top


Fournier's gangrene is well represented in the literature where early diagnosis, emergency debridement, and broad-spectrum antibiotics are described as key to patient survival. The incidence of Fournier's gangrene is about 1.6/100,000 of the population in male.[5] Male cases outnumber female cases by a ratio of 10:1, with the highest incidence in the group comprising individuals between the ages of 50–70 years.[1] The initial clinical manifestations were a perineal pain (75%–85%) and fever (60%–80%), and initial physical examination was most frequent when edema (91.4%), erythema (88.6%), or perineal skin necrosis (60%) are present.[6],[7] Diabetes mellitus, liver cirrhosis, uremia, alcoholism, advanced age, human immunodeficiency virus infection, and underlying malignancy were important contributing factors in terms of etiology.[1],[7]

The etiologies of Fournier's gangrene are separated into three subgroups, and the most frequently occurring etiology is anorectal (30%–50%) followed by genitourinary tract (20%–40%) and dermatological injuries (10%–20%).[3],[4] In the anorectal group, trauma; ischiorectal, perirectal, or perianal abscesses; appendicitis; diverticulitis; colonic perforations; perianal fistulotomy; perianal biopsy; rectal biopsy; hemorrhoidectomy; anal fissure excision; steroid enemas for radiation proctitis; and rectal cancer may lead to Fournier's gangrene. Urethral strictures with urinary extravasation, urethral catheterization or instrumentation, penile implant insertion, prostatic biopsy, vasectomy, hydrocele aspiration, genital piercing, intracavernosal cocaine injection, periurethral infection, chronic urinary tract infections, epididymitis or orchitis, penile artificial implant, foreign body, hemipelvectomy, cancer invasion to the external genitalia, septic abortion, Bartholin's duct abscess, and episiotomy were origin sources in the genitourinary tract subgroups. Dermatologic sources of injuries include scrotal furuncle, genital toilet (scrotum), and blunt perineal trauma; intramuscular injections, genital piercings, perineal or pelvic surgery/inguinal herniorrhaphy, infection of peritoneal dialysis and idiopathic.[8]

Our case suffered a closed stable fracture of the left side pubis, initially classified as Tile classification stable type A. She underwent conservative treatment at home without any outpatient follow-up by her families' reason. Acute osteomyelitis that further progressed to Fournier's gangrene and sepsis was found on her second admission to our emergency department 1 month later. No urinary tract infection and anorectal injuries could be identified by urinalysis and rectal examination, respectively. The clinical course was identified as a closed fracture of the left side pubis, hematoma at the fracture site, and skin necrosis of the left side labium majus caused by hematoma. Escherichia coli and Peptostreptococcus asaccharolyticus are normal inhabitants of lower intestine and lower reproductive tract in women.[9.10] However, they can cause in secondary retrograde infections of hematoma from small necrotic wound and progress to acute osteomyelitis and Fournier's gangrene. A pelvic fracture that complicated Fournier's gangrene is not presented or currently discussed in the literature, but needs to be called to the attention of emergency medicine specialists and orthopedists. Drainage of the hematoma is indicated in case of significantly large or poor resorption, particularly in patients with comorbid systemic disorders; close follow-up of the pelvic bone fracture is required to detect related complications as early as possible.

Multiple imaging techniques are used for the initial evaluation of Fournier's gangrene including radiography, ultrasonography, CT, and magnetic resonance imaging. However, the diagnosis of Fournier's gangrene is often made on clinical examination, with imaging being helpful in cases where there is an uncertain diagnosis and when clinical findings remain ambiguous. Emergency CT scans are efficient and effective and can lead to the early diagnosis of Fournier's gangrene with an accurate assessment of the extent of the disease. CT scan not only helps evaluate the perineal structures that can be involved in Fournier's gangrene but also help assess the retroperitoneum, to which the disease can spread.[11] Radiography and CT imaging played timely roles in the diagnosis of acute osteomyelitis and Fournier's gangrene in our patient and helped map the necrotic area and fasciotomy regions.

The mortality rate in Fournier's gangrene is still relatively high and averages to 20%–30% after advanced management.[1],[2],[3] Prognosis in patients with Fournier's gangrene is based on Uludag Fournier's gangrene severity index score, which includes the following indices: temperature; heart rate and respiratory rate; and Na+, K+, creatinine, hematocrit, leukocyte, and bicarbonate levels. At a severity index threshold value score >9, there is a 75% probability of death, while a score of 9, or less is associated with a 78% probability of survival.[12] Major complications in Fournier's gangrene, including respiratory failure, renal failure, septic shock, hepatic failure, and disseminated intravascular coagulopathy are significantly related to mortality.[2] The Uludag Fournier's gangrene severity index score in our patient's case was a score of 14 plus septic shock, but she survived as early fasciotomy, and intensive care was applied.

Fournier's gangrene is a community-acquired polymicrobial infection, most commonly caused by anaerobic bacteria. E. coli (25%–50%) is the most frequently identified microorganism followed by Bacteroides sp. (40%) and Prevotella sp. (30%).[13] Although antibiotic resistance is demonstrated by some causative pathogens, the current recommendation to prescribe broad-spectrum antibiotics adequately covers all pathogens in the initial stages of care [13] with switching over to more sensitive antibiotics after identification of the culprit microorganism.

The reconstruction options for fasciotomy wounds of the perineum region include skin grafts and flaps. Conventional and negative pressure treatments are equally effective in healing such wounds. In our case, the wound in the perineum region was reconstructed with partial local advanced flap surgery, and the remaining large pocket wound with exposure of the osteomyelitis of the left side pubis was dressed with a foam dressing. It is difficult to perform flap reconstruction because of the inability to perform adequate sequestrectomy of necrotic bone and poor general condition of the patient. Hyperbaric oxygen therapy is effective in patients with osteomyelitis and Fournier's gangrene,[14],[15] but our patient could not tolerate it because of a personal reason. The foam dressing was easy to apply as well as economical and practical for care at home by family members. The wound healed progressively and was considered fully healed after 5 months of outpatient wound care, without any secondary invasive operation.

Early diagnosis, urgent and repeated surgical intervention, and intensive medical care, including aggressive resuscitation and broad-spectrum antibiotic therapy, are the mainstay treatments of Fournier's gangrene. A pelvic fracture that complicated acute osteomyelitis and Fournier's gangrene is rare but practitioners need to be aware of this etiology, particularly in the presence of massive hematoma arising after the fracture or in patients with comorbid systemic disorders.

Declaration of patient consent

The author certifies that he has obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Wróblewska M, Kuzaka B, Borkowski T, Kuzaka P, Kawecki D, Radziszewski P. Fournier's gangrene – Current concepts. Pol J Microbiol 2014;63:267-73.  Back to cited text no. 4
    
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Sorensen MD, Krieger JN, Rivara FP, Broghammer JA, Klein MB, Mack CD, et al. Fournier's gangrene: Population based epidemiology and outcomes. J Urol 2009;181:2120-6.  Back to cited text no. 5
    
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Ruiz-Tovar J, Córdoba L, Devesa JM. Prognostic factors in Fournier gangrene. Asian J Surg 2012;35:37-41.  Back to cited text no. 6
    
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Chen SY, Fu JP, Wang CH, Lee TP, Chen SG. Fournier gangrene: A review of 41 patients and strategies for reconstruction. Ann Plast Surg 2010;64:765-9.  Back to cited text no. 7
    
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Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS. Fournier's Gangrene: Current Practices. ISRN Surg 2012;2012:942437.  Back to cited text no. 8
    
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Barbara H. Williams Gynecology. 2nd ed. New York: McGraw-Hill Medical; 2012. p. 65.  Back to cited text no. 9
    
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Singleton P. Bacteria in Biology, Biotechnology and Medicine. 5th ed. Hoboken: Wiley; 1999. p. 444-454.  Back to cited text no. 10
    
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Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging. Radiographics 2008;28:519-28.  Back to cited text no. 11
    
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Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier's gangrene. J Urol 1995;154:89-92.  Back to cited text no. 12
    
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Bjurlin MA, O'Grady T, Kim DY, Divakaruni N, Drago A, Blumetti J, et al. Causative pathogens, antibiotic sensitivity, resistance patterns, and severity in a contemporary series of Fournier's gangrene. Urology 2013;81:752-8.  Back to cited text no. 13
    
14.
Skeik N, Porten BR, Isaacson E, Seong J, Klosterman DL, Garberich RF, et al. Hyperbaric oxygen treatment outcome for different indications from a single center. Ann Vasc Surg 2015;29:206-14.  Back to cited text no. 14
    
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Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of fournier's gangrene. J Urol 2005;173:1975-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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