The Management of a Patient Presented with Fournier’s Gangrene Associated with Undiagnosed Ulcerative Colitis: A Case Report

Case Presentation

A Case Report. Ann Surg Perioper Care. 2016; 1(2): 1008.

The Management of a Patient Presented with Fournier’s Gangrene Associated with Undiagnosed Ulcerative Colitis: A Case Report

Balci B¹, Cetindag O¹, Demir HB¹, Yardim S², Calik B¹ and Akbulut G¹*

¹Department of General Surgery, Izmir Tepecik Education and Research Hospital, Izmir, Turkey

²Department of Pathology, Izmir Tepecik Education and Research Hospital, Izmir, Turkey

*Corresponding author: Akbulut G, Department of General Surgery, Izmir Tepecik Education and Research Hospital, Izmir, Turkey

Received: October 10, 2016; Accepted: October 27, 2016; Published: October 31, 2016

Abstract

Introduction: Fournier’s gangrene is a rare polymicrobial necrotizing fasciitis of the perineal and perianal regions, found to be associated with colorectal diseases and urogenital operations. We present here a difficult management of a patient presented with Fournier’s gangrene associated with undiagnosed Ulcerative colitis.

Case Presentation: A 25 year-old man presented with scrotal edema and pain was diagnosed with Fournier’s gangrene. The patient was hospitalized and treated with wide-spectrum antibiotics and surgical debridement of the necrotic tissue. During follow up the patient developed a toxic megacolon which was successfully treated by colectomy and end-ileostomy. The pathological findings of the surgical specimen were resulted as a diffuse active colitis supporting ulcerative colitis.

Conclusion: Fournier’s gangrene is an aggressive infection with high mortality rates which requires a multidisciplinary approach.

Keywords: Fournier’s Gangrene; Ulcerative Colitis; Toxic Megacolon

Abbreviations

CRP: C - Reactive protein; AST: Aspartate Aminotranspharase; ALT: Alanine Aminotranspharase, CT: Computer Tomography; VAC: Vacuum Assisted Closure; CBC: Complete Blood Count; ALP: Alkaline Phosphatase; GGT: Gamma Glutamine Transpharase

Introduction

Fournier’s gangrene is a rare form of necrotizing fasciitis localized in the perineal and perianal regions, with a mortality rate ranging from 15% to 50% [1]. There are multiple causes of this polymicrobial infection including urological diseases and procedures, colorectal diseases and superficial trauma by foreign bodies. Predisposing factors are including Diabetes mellitus, chronic alcoholism, immunosuppressive diseases such as HIV infection and myeloproliferative diseases and malnutrition [2-4]. The most common isolated microorganisms are Escherichia coli and Bacteriodes [5]. The standard treatment of Fournier’s gangrene is surgical debridement of the necrotic tissue and wide-spectrum antibiotics.

Fournier’s gangrene complicating inflammatory bowel disease has been reported in four patients so far, two with Ulcerative colitis and two with Crohn’s disease [6-9].

We present here an exceptional case management of a patient presented with a Fournier’s gangrene associated with undiagnosed Ulcerative colitis.

Case Presentation

A 25 year-old man complaining of the new onset of rectal pain, swelling and tenderness in the scrotum applied to the emergency service. The patient denied having abdominal pain, nausea, constipation or diarrhea. The patient had experienced rectal bleeding and mucus with defecation for three months. The patient was examined by colonoscopy in regarding of colitis and multiple biopsies were taken two days before admission to the hospital.

On physical examination bilateral scrotal congestion was significant with subcutaneous emphysema and hyperemia. Subcutaneous emphysema was reaching to the right groin and lower quadrant of the abdomen. In digital examination tenderness and the fluctuance was present in the right ischiorectal fossa.

In laboratory tests, leukocyte levels were 16.500 (normal limit: 4200-10.600), CRP (C - Reactive Protein) level was 300mg/L and billuribine levels were 3.7mg/dl (total billuribine) and 1.7mg/dl (direct billuribine). AST (Aspartate Aminotranspharase) and ALT (Alanine Aminotranspharase) levels were found to be mildly elevated. Our differential diagnosis included scrotal abscess, perianal abscess and Fournier’s gangrene. We decided to proceed with CT (Computer Tomography) scan of the abdomen.

CT scan of the abdomen revealed subcutaneous emphysema in the right lower quadrant reaching out the right inguinal region, right scrotum and ischiorectal fossa. Although the significant increased density and thickening in the subcutaneous soft tissue of the abdominal wall, the peritoneum was intact (Figure 1-2). There were not any other pathological findings detected in the abdomen.