It’s 2 am and an 89 yo male from LTCÂ presents with fever and scrotal swelling x 2 days. He was transferred to the ER for decreasing LOC. His Pmhx is significant for dementia, BPH and high cholesterol. On exam, he has a temp of 37.9, HR 91, RR 18, BP 111/57 and O2 sat 96%. His scrotum and perineum appear swollen and there is diffuse erythema extending up to the inguinal area. On palpation, the skin is warm, tender and firm with no obvious crepitus.
Bedside ultrasound reveals soft tissue gas in the scrotal wall and perineum (bright hyperechoic areas with hyperechoic shadowing)
The diagnosis of Fournier’s Gangrene is quickly made and the patient is started on a cocktail of IV antibiotics and referred to urology for possible urgent surgical debridement. In the end, after much discussion with the family, the decision is made to treat the patient palliatively.
Fournier’s gangrene is a life threatening necrotizing fasciitis of the genital area that can spread by 2-3cm/hour (1). Early in the course of the disease, the physical exam cannot reliably distinguish it from other less frightening diagnoses such as cellulitis and abscess. Up to 1/3 of patients won’t have crepitus on exam (2)! Fortunately bedside ultrasound can help expedite the diagnosis and management of these sick patients (3,4).
References
(1) Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992 Feb;19(1):149-162.
(2) Carroll PR, Cattolica EV, Turzan CW, McAninch JW. Necrotizing soft-tissue infections of the perineum and genitalia. Etiology and early reconstruction. West J Med 1986 Feb;144(2):174-178.
(3) Kube E, Stawicki SP, Bahner DP. Ultrasound in the diagnosis of Fournier’s gangrene. Int J Crit Illn Inj Sci 2012 May;2(2):104-106.
(4) Morrison D, Blaivas M, Lyon M. Emergency diagnosis of Fournier’s gangrene with bedside ultrasound. Am J Emerg Med 2005 Jul;23(4):544-547.
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