Case Presentation 57 yo WM with PMH of T2DM COPD and HFrEF 20 secondary to ASCVD presented with a 3day history of severe scrotal pain and swelling VS T 372 C P 88 R 18 BP 8040 BMI 241 ID: 1048515
Download Presentation The PPT/PDF document "Fournier’s Gangrene Scott Cordts, MD" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Fournier’s GangreneScott Cordts, MD
2. Case Presentation57 yo WM with PMH of T2DM, COPD and HFrEF (20%) secondary to ASCVD presented with a 3-day history of severe scrotal pain and swelling. VS: T 37.2 C, P 88, R 18, BP 80/40 BMI 24.1He appears ill. Mucous membranes are dry.
3. Case PresentationExtensive edema, erythema, and warmth to the entire scrotum that extends into the perineum and right buttocks. Necrotic black eschar of the lower scrotum with crepitance. Minimal discharge but foul smell present.
4. Case PresentationWBC 15.6 (10% Bands)Glucose 145, Na 127, BUN 119, Cr 4.2Serum lactate 1.6 (Normal)
5. Questions for DiscussionIs this patient stable or unstable and why?He is unstable. He appears ill, dehydrated and is hypotensive.What should be your first intervention to address his blood pressure?Isotonic fluid bolusIf his blood pressure does not improve despite adequate fluid resuscitation, what further intervention should you take?Addition of vasopressors
6. Questions for DiscussionDoes he require any diagnostic imaging prior to treatment?No — although CT or MRI can delineate the extent of infection, they should not delay definitive treatmentThe definitive treatment for this condition is?Surgical debridement + IV antibioticsIs this infection typically caused by a single microorganism or is it polymicrobial?Fournier’s gangrene is typically a polymicrobial infection.(Goldstein, et al., 2007)
7. Questions for DiscussionWhat would be an appropriate initial empiric antibiotic regimen?Carbapenem or beta-lactam-beta lactamase inhibitor PLUS agent with activity against MRSA (vancomycin or daptomycin) PLUS clindamycinWhy is clindamycin always added, even in the presence of other agents with gram positive and anaerobic coverage?It also inhibits exotoxin formation.Can this infection occur in women?Yes, although it is more common in men, women can present with the infection typically involving the labia.(Stevens, et al., 2014)
8. Practice PearlsFournier’s gangrene is a necrotizing infection of the perineum and is a surgical emergency requiring prompt debridement when diagnosed.The infection is polymicrobial and should be treated with broad-spectrum antibiotics until culture results are available and the patient is improving clinically.
9. ReferencesGoldstein EJC, Anaya DA, Dellinger EP. Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clinical Infectious Diseases. 2007;44(5):705-710. Stevens DL, Bisno AL, Chambers HF, et al. Executive Summary: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014;59(2):147-159.