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LETTER TO THE EDITOR
Year : 2021  |  Volume : 54  |  Issue : 2  |  Page : 75-76

Pyuria in Fournier's gangrene: A curious presentation


1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Anaesthesiology and Critical Care, Military Hospital, Suratgarh, Rajasthan, India

Date of Submission23-Sep-2019
Date of Acceptance27-Oct-2019
Date of Web Publication20-Mar-2021

Correspondence Address:
Vishal Mangal
Department of Internal Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_179_20

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How to cite this article:
Kaur KB, Kumar D, Mangal V, Singh SP. Pyuria in Fournier's gangrene: A curious presentation. Formos J Surg 2021;54:75-6

How to cite this URL:
Kaur KB, Kumar D, Mangal V, Singh SP. Pyuria in Fournier's gangrene: A curious presentation. Formos J Surg [serial online] 2021 [cited 2021 Apr 13];54:75-6. Available from: https://www.e-fjs.org/text.asp?2021/54/2/75/311586



Dear Editor,

Fournier's gangrene (FG) is a rare but still prevalent condition in the Indian population.[1] It is defined as fulminant necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection. It is generally seen in individuals with diabetes mellitus or immunocompromised status.[2],[3]

We present a 76-year-old male who presented with altered sensorium, decreased oral intake, and decreased urine output of three days duration. On clinical examination, he had extensive scrotal cellulitis with abscess formation. His blood investigations showed neutrophilic leukocytosis (total leukocyte counts of 13.5 × 109/L with 80% neutrophils) (reference range: 4.5–11 × 109/L, neutrophils: 50%–70%), azotemia with blood urea nitrogen level of 42.46 mmol/L (reference range: 2.9–7.1 mmol/L) and serum creatinine of 406.73 μmol/L (reference range: 62–115 μmol/L), and deranged blood glucose profile.

The patient was catheterized with an 18Fr Foley's catheter, with drainage of 100 ml of frank pus with no subsequent urine output. The clinical diagnosis of pyonephrosis was considered, and he was started on broad-spectrum injectable antibiotics and liberal fluid therapy and supportive care. Ultrasonography of the kidney and urinary bladder revealed an average size of kidneys with maintained corticomedullary differentiation, thus negating pyonephrosis diagnosis. Over the next 24 h, the patient passed 400 ml of urine; his azotemia improved; however, there was no change in his clinical condition. He was taken up for the debridement of scrotal wound and pus drainage under general anesthesia. The patient was brought down to a lithotomy position, and a pouch-like cystic swelling was felt in the right inferior side of the scrotum; subsequently, it was ascertained to be urinoma [Figure 1].
Figure 1: Artery forceps are pointing at urinoma

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The incision was given to excise the necrotic tissue till healthy bleed was seen from the edges. Intraoperatively, the Foley's catheter was lying outside the urethra in the pus cavity in the scrotum, and the bulbar urethra was ruptured [Figure 2]a. The pus draining from the Foley's catheter was the pus of the scrotal abscess getting mixed with the urine draining into this cavity from the ruptured urethra's proximal part. Suprapubic catheterization was done using 16Fr Foley's catheter and urine drained. The abdominal wound was closed in two layers. Another Foley's catheter was inserted through the meatus and traced back into the bladder after negotiating through both distal and proximal parts of the ruptured urethra [Figure 2]b. The hemostasis was achieved, and the surgical wound was kept open after applying a sterile dressing. The patient recovered over the next 4 weeks and was discharged on oral antidiabetic drugs.
Figure 2: (a) The yellow arrow shows the tip of Foley's catheter lying outside the urethra in the pus cavity in the scrotum with the bulb of the catheter seen proximally. (b). The yellow arrow shows the Foley's catheter passing through both distal and proximal parts of the ruptured urethra with the missing part of the bulbar urethra in between

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FG, as the first presentation of diabetes mellitus, has been documented in literature earlier also, as it happened in our case.[4] In this case, pyuria is a very peculiar unfamiliar finding, diverting the clinical suspicion to renal involvement, but was attributed to iatrogenic injury to the bulbar urethra. FG is a life-threatening condition; however, favorable outcomes can be achieved with a high index of suspicion, early debridement, good supportive care, and adequate glycemic control.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sockkalingam VS, Subburayan E, Velu E, Rajashekar ST, Swamy AM. Fournier's gangrene: prospective study of 34 patients in South Indian population and treatment strategies. Pan Afr Med J. 2018 Oct 12;31:110>. doi: 10.11604/pamj.2018.31.110.15495.  Back to cited text no. 1
    
2.
Erol B, Tuncel A, Hanci V, Tokgoz H, Yildiz A, Akduman B, et al. Fournier's gangrene: Overview of prognostic factors and definition of new prognostic parameter. Urology 2010;75:1193-8.  Back to cited text no. 2
    
3.
Tenório CEL, Lima SVC, Albuquerque AV, Cavalcanti MP, Teles F. Risk factors for mortality in Fournier's gangrene in a general hospital: Use of simplified founier gangrene severe index score (SFGSI). Int Braz J Urol 2018;44:95-101.  Back to cited text no. 3
    
4.
Sehmi S, Osaghae S. Type II diabetes mellitus: New presentation manifesting as Fournier's gangrene. JRSM Short Rep 2011;2:51.  Back to cited text no. 4
    


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