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CASE REPORT |
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| Year : 2007 | Volume
: 52
| Issue : 3 | Page : 155-157 |
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| Varicella and Fournier's gangrene |
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Rekha Arcot, Ravi Annamalai
Sri Ramachandra Medical College and Research Institute (Deemed University), Porur, Chennai - 600 116, India
Correspondence Address:
Rekha Arcot
1/756, Sabari Nagar, Mugallivakkam Extension, Porur, Chennai - 600 116
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.35351
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 Abstract | | |
Fournier's gangrene is the necrotizing fasciitis of the scrotum and the perineum. The treatment involves early recognition, aggressive resuscitation, radical debridement and appropriate antibiotics. Even though its association with varicella is known to occur in children, it is found to be uncommon in adults. We present our findings and review literature regarding the associations, clinical presentations and management of Fournier's gangrene.
Keywords: Fournier′s gangrene, necrotizing fasciitis, scrotum, varicella
How to cite this article:
Arcot R, Annamalai R. Varicella and Fournier's gangrene. Indian J Dermatol 2007;52:155-7 |
| Introduction | |  |
In 1883, Prof. Jean Alfred Fournier coined the term Fournier's gangrene (FG) for the gangrene of the scrotum. [1] In 1924, Wilson coined the term necrotizing fasciitis (NF). When NP of the perineum occurs, we call it Fournier's gangrene. It is the spreading synergistic gangrene of the subcutaneous tissue and fascia, which usually spares the muscles. There is a predilection for the affliction of elderly males, although it also affects the children and females.
| Case Report | | |
A 45-year-old male came to the hospital with complaints of a foul-smelling discharge and ulceration over the genitalia in a duration of 2 days. He revealed that he was convalescing from chicken pox. Examination revealed the scabs of varicella infection all over the body [Figure - 1]. He said that it was the third week since the first vesicles had appeared. Local examination showed the entire penile skin to be necrotic, sloughy and foul smelling with a dirty gray discharge. The anterior two-thirds of the scrotum showed the same observations [Figure - 1]. He was observed by the dermatologist and debridement was performed. At admission, the patient had leucocytosis; he was febrile and had elevated creatinine levels, although his coagulation profile was unaltered. He was human immunodeficiency virus (HIV) negative. Under regional anesthesia, a radical debridement of all the necrotic tissues was performed, leaving the anterior scrotum and penis denuded of skin [Figure - 2]. A culture swab taken grew Streptococcus pyogenes . The patient was started on Inj. Ampicillin and he recovered well. Later, split skin grafting was performed to provide a skin cover for the scrotum.
Surgical anatomy
The spread of FG is observed to be along the fascial layer and is determined by the attachments of Colles' fascia of the perineum and abdominal wall. The dartos is a continuation of this layer over the scrotum and penis. The fascia is attached posteriorly to the perineal body and urogenital diaphragm, and it is attached laterally to the pubic rami. These posterior and lateral attachments tend to limit the spread of the infection in these directions. However, anterosuperiorly, Colles' fascia merges with Scarpa's fascia of the anterior abdominal wall; therefore, there is no barrier to spread in this direction, thereby resulting in a widespread gangrene. [2]
| Discussion | | |
FG is the obliterative endarteritis and thrombosis of the scrotal vessels (which arise from pudenal arterial branches of the femoral artery).The testes are usually spared because blood is directly supplied to them by the aorta. Usually, a polymicrobial infection occurs, and this infection predisposes to the thrombosis of the vessel, leucocyte infiltration and necrosis. [2]
NF is known to occur more often in diabetic patients, patients with renal failure and in patients with peripheral vascular diseases. They also occur in the patients who are immunosuppressed, those on chemotherapy and in those with HIV.
A few distinct NF syndromes should be recognized. The most important are type I or polymicrobial; type II or group A streptococcal; and type III gas gangrene or clostridial myonecrosis. A variant of NF type I is saltwater NF, in which an apparently minor skin wound is contaminated with saltwater containing a Vibrio species. [2]
NF may occur as a complication of a variety of surgical procedures, including cardiac catheterization. Familiarity with NF may facilitate the earlier diagnosis and initiation of the appropriate therapy.
Type 2 infections, due to group A streptococcus, is associated with history of blunt trauma, varicella, intravenous drug use, penetrating injury and possibly with nonsteroidal anti-inflammatory drugs. Important bacterial factors include surface protein expression and toxin production. M-1 and M-3 surface proteins that increase the adherence of the streptococci to the tissues also protect the bacteria against phagocytosis by neutrophils. [2]
While there are several reports of NF following the varicella infections in children [3],[4],[5] there are few reports of the occurrence of Fournier's gangrene following varicella infections in the adults. [6] There are also reports on the occurrence of NF after the occurrence of zoster. [7]
Clinical features
The patient with FG typically presents with a greyish white slough at the scrotal area, with foul smelling discharge and fever. When there is extension onto the thigh or the abdominal wall, it is typically characterized by a bluish red blister; when this is debrided, the necrotic, underlying fascia is revealed. If untreated, the patients develop symptoms of sepsis and the infection overwhelms the patient. The complications include acute renal failure, respiratory failure, pneumonia, gastrointestinal bleeding, heart failure and hypocalcemia. Patients usually die of multiorgan failure secondary to fulminant sepsis. The outcomes have been attributed to the number of organs in failure, number of days of hospitalization, extent of the infection and duration of symptoms to the first debridement.
Diagnosis
The diagnosis is based on clinical judgments. An ultrasound is useful to exclude other testicular pathologies, particularly in early cases. The examination of the scrotum may show the crepitus, particularly in Type 3 NF.
Treatment
The mainstay of treatment is radical debridement. After initial resuscitation, the person is debrided, where all the necrotic tissues are ruthlessly excised. A swab culture as well as a blood culture are taken immediately and appropriate antibiotics are started. It is important to periodically monitor all the doubtful areas at the margins of the debrided area and re-debride if there are extended areas. Hyperbaric oxygen has been advocated as a treatment option for NF. In NF involving the limbs, in the presence of overwhelming infection, amputations may be required as a life-saving option. Once the infection is controlled, the skin cover for the scrotum may be a split skin graft or a myocutaneous flap. In most cases, the testis is not involved; therefore orchidectomy is not advocated. The transposition of the testis into the thigh was a surgical option in earlier days. Scrotal skin cover for the testis is necessary for both hormone production and spermatogenesis. [8]
The term FG now encompasses the NF of the perineum and genitalia. The diagnosis requires a high index of suspicion, particularly in early lesions. The classic FG requires aggressive debridement, appropriate antibiotics and an aesthetic reconstruction. While children are susceptible to develop FG after varicella infection, we highlight a case that shows that adults also might have the same vulnerability. Physicians should have an awareness of this association while conducting the treatment for varicella.
| Footnote | | |
A unique social practice is prevalent in the remote villages in South India. The occurrence of chickenpox is considered as a visit of the local goddess Amman to the house. The villagers mark their homes with a clump of neem leaves, and in this period, there is no interaction between that family and the rest of the community. This self-imposed exile often delays or prevents the populace to seek medical attention, which is disastrous at times.
| References | | |
| 1. | Fournier JA. Gangrene foudroyante de la verge. Medecin Pratique 1883;4:589-97. Sem Med 1883. Dis Colon Rectum. 1988;31:12. PMID: 3063473.  |
| 2. | Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol 1998;81:347-55. [PUBMED] |
| 3. | Ford LM, Waksman J. Necrotizing fasciitis during primary varicella. Pediatrics 2000;105:1372-5. [PUBMED] [FULLTEXT] |
| 4. | Guneren E, Keskin M, Uysal OA, Ariturk E, Kalayci AG. Fournier's gangrene as a complication of varicella in a 15-month-old boy. J Pediatr Surg 2002;37:1632-3. |
| 5. | Clark P, Davidson D, Letts M, Lawton L, Jawadi A. Necrotizing fasciitis secondary to chickenpox infection in children. Can J Surg 2003;46:9-14. [PUBMED] [FULLTEXT] |
| 6. | Nathan S, Pang AS, Singh Sidhu DS, Lam KS, Low JM. Necrotizing soft tissue infections as a complication of chickenpox. Singapore Med J 1995;36:656-60. [PUBMED] |
| 7. | Jarrett P, Ha T, Oliver F. Necrotizing fasciitis complicating disseminated cutaneous herpes zoster. Clin Exp Dermatol 1998;23:87-8. [PUBMED] [FULLTEXT] |
| 8. | Sewell GS, Hsu VP, Jones SR. Zoster gangrenosum: Necrotizing fasciitis as a complication of herpes zoster. Am J Med 2000;108:520-1. [PUBMED] [FULLTEXT] |
[Figure - 1], [Figure - 2] |
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| This article has been cited by | | 1 |
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| Azhar, A.H., Rashidi, A., Cheah, P.-K., Ashraf, M.D., Azman, W.S. | | Journal of Emergency Medicine, Trauma and Acute Care. 2008; 8(3): 186-188 | | [Pubmed] | |
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