fournier gangrene

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This discusses a case of Fournier gangrene which usually occur in diabetic patients

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Fournier Gangrene:

Fournier Gangrene Case presentation by Ibrahim Al- bagalati urologist

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Fournier gangrene is usually defined as a necrotizing infection that involves the soft tissues of the ( male genitalia) but actually this is not true as it can also affect the (female genitalia) ( 10/1) It is a specific form of !! Necrotizing Faciitis introduction

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Necrotizing fasciitis (NF) is an insidiously advancing soft tissue infection characterized by widespread fascial necrosis. Necrotizing Faciitis a necrotizing infection of soft tissue that involves the deep and superficial fascia, regardless of location. Or:

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The organisms most closely linked to necrotizing fasciitis are group A beta-hemolytic streptococci A few distinct necrotizing fasciitis syndromes should be recognized. Type I, or polymicrobial ; T ype II, or group A streptococcal ; and T ype III, gas gangrene, or clostridial myonecrosis . Necrotizing Faciitis

Fournier Gangrene :

Fournier Gangrene In 1764, Baurienne originally described an idiopathic, rapidly progressive soft-tissue necrotizing process that led to gangrene of the male genitalia. Jean-Alfred Fournier (1860-1902) Parisian venereologist clinical lectures in 1883 Fournier tibia Fusiform thickening and anterior bowing of the tibia in congenital syphilis. Fournier sign The formation of scars at the mouth following the healing of syphilitic lesions in congenital syphilis. history

Fournier Gangrene :

Fournier Gangrene Un-common but not rare 750 cases had been reported since 1883 1-7500 persons Male are 10 times affected than females No seasonal variation Not indigenous to any region although the largest clinical series originate from the African continent . Frequency history

Fournier Gangrene :

Although originally described as idiopathic gangrene of the genitalia, Fournier gangrene has an identifiable cause in approximately 95% of cases . The necrotizing process commonly originates from an Infection in the: Anorectum , Urogenital tract Fournier Gangrene Frequency Etiology Skin of the genitalia

Fournier Gangrene :

Fournier Gangrene Etiology Anorectum , Urogenital tract Skin of the genitalia

Fournier Gangrene :

Fournier Gangrene Etiology Anorectum , Urogenital tract Skin of the genitalia Infection in the perianal glands C olorectal injury C olorectal malignancy D iverticulitis

Fournier Gangrene :

Fournier Gangrene Etiology Anorectum , Urogenital tract Skin of the genitalia Infection in the bulbourethral glands. Urethral injury. Iatrogenic. L.UTI

Fournier Gangrene :

Fournier Gangrene Etiology Anorectum , Urogenital tract Skin of the genitalia Hydradenitis suppurativa Ulceration due to scrotal pressure Trauma. Skin popping or piercing Complications of surgery.

Fournier Gangrene :

Fournier Gangrene Etiology Anorectum , Urogenital tract Skin of the genitalia Bone marrow malignancy Systemic lupus erythematosus Crohn disease HIV Iatrogenic or traumatic. Perineal injury. Others

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Cirrhosis Diabetes mellitus High-risk behaviors (alcohol or IV drug abuse) Immunosuppression Malignancies Malnutrition Morbid obesity Vascular disease of the pelvis Fournier Gangrene predisposing comorbidities Etiology

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Circumcision Episiotomy Extravasations of urine ( periurethrally or through cutaneous fistula) Hernioplasty Hysterectomy Local trauma or instrumentation to the perineum Paraphimosis Septic abortion Urethral stricture caused by sexually transmitted diseases. Fournier Gangrene Risk factors predisposing comorbidities

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Infection represents an imbalance between Host immunity, which is frequently compromised by one or more of the above comorbid systemic processes, and The virulence of the causative microorganisms. The etiologic factors allow the portal for entry of the microorganism into the perineum, the compromised immunity provides a favorable environment to initiate the infection, and the virulence of the microorganism promotes the rapid spread of the disease. Fournier Gangrene Pathophysiology Risk factors

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The following are pathognomonic findings of Fournier gangrene upon pathologic evaluation of the involved tissue: Necrosis of the superficial and deep fascial planes Fibrinoid coagulation of the nutrient arterioles Polymorphonuclear cell infiltration Microorganisms identified within the involved tissues. Fournier Gangrene Histology pathophysiology

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Streptococcal species Staphylococcal species Genera of the Enterobacteriaceae family Anaerobic organisms Fungi Fournier Gangrene Causative microorganisms histology

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Most authorities believe the polymicrobial nature of Fournier gangrene is necessary to create the synergy of enzyme production that promotes rapid multiplication and spread of the infection. For example, one microorganism might produce the enzymes necessary to cause coagulation of the nutrient vessels. Thrombosis of these nutrient vessels reduces local blood supply; thus, tissue oxygen tension falls. The resultant tissue hypoxia allows growth of facultative anaerobes and microaerophilic organisms. These latter microorganisms, in turn, may produce enzymes ( eg , lecithinase , collagenase), which lead to digestion of fascial barriers, thus fueling the rapid extension of the infection . Fournier Gangrene Causative microorganisms

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The fascial necrosis and digestion are hallmarks of this disease process; this is important to appreciate because it provides the surgeon with a clinical marker of the extent of tissue involvement. Specifically, if the fascial plane can be separated easily from the surrounding tissue by blunt dissection, it is quite likely to be involved with the ischemic-infectious process; therefore, any such dissected tissue should be excised. Far-advanced or fulminate Fournier gangrene can spread from the fascial envelopment of the genitalia throughout the perineum, along the torso, and, occasionally, into the thighs. Fournier Gangrene Causative microorganisms

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Fournier Gangrene presentation Causative microorganisms The clinical course usually progresses through the following phases:

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Fournier Gangrene presentation d egree of necrosis Local tenderness No toxicity Florid septic shock A typical patient with Fournier gangrene is an elderly man in his sixth or seventh decade of life with comorbid diseases; females are not immune to this disease but are affected much less frequently.

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Fournier Gangrene Work up presentation Laboratory Studies Chemistry panel Blood tests Others Imaging Studies Radiography Ultrasonography CT scanning MRI

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Fournier Gangrene treatment Work up Medical Aggressive resuscitation Antibiotics with broad-spectrum coverage Surgical Emergent surgical excision of all necrotic tissue The skin should be wide opened Re-debridement Fecal diversion Urinary diversion Orchiectomy?

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Fournier Gangrene treatment Reconstruction Primary closure of the skin, if possible. Local skin flap coverage. Split-thickness skin grafts. Muscular flaps, which are used to fill a cavity.

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Fournier Gangrene complication treatment unresolved sepsis : The main complication associated with Fournier disease is, often caused by one of the following: Unrecognized cause of the infection (perforated peptic ulcer disease, appendicitis, diverticulitis) or extension of the necrotizing process outside the obvious wound. Complication of severe acute illness. ( bacterial endocarditis, pneumonia) The plethora of comorbid conditions. ( acute myocardial infarction, respiratory failure, pressure ulcerations, delirium) or the bed-rest conditions imposed on patients who are acutely ill (pulmonary embolus, deep venous thrombosis, atelectasis, pneumonia)

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Fournier Gangrene prognosis complications In the pre-antibiotic era, Fournier’s gangrene was commonly fatal; even today, it poses a significant risk of morbidity and mortality. Despite aggressive therapy, the mortality rate for patients with Fournier’s gangrene is nearly 50% because of the aggressive nature of the infection and the presence of underlying comorbidities .

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Fournier Gangrene prognosis complications Delays in diagnosis or treatment increase the mortality rate . A 24-hour delay in radical debridement increases the mortality rate by 11.5 %; A 6-day delay is associated with a mortality rate of 76% . Additional factors associated with high mortality include: Anorectal origin Advanced age. Extensive disease Shock Sepsis at presentation, Renal failure Hepatic dysfunction. Multiorgan system failure secondary to gram-negative sepsis is the most common cause of death

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55 Ys old Yemeni patient Diabetic RTA perineal laceration Kept in the MSF camp for 9 days Fournier Gangrene Case Presentation

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Generally: Ill , toxic& jaundiced Very bad smell Not febrile locally Jet black scrotum and friable perineum with cut-through sutures & pus weeping from the inguinal areas Fournier Gangrene Case Presentation

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Lab works HB : 13 gm % TLC :9.5 S.Cr : 0.7 mg/ dl RBS: 400 mg/dl LFT: ALP 632.7 u/L SGOT 222 u/L SGPT 129 u/L Bil 4.9 mg/L Fournier Gangrene Case Presentation LIVER DYSFUNCTION

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MANAGEMENT: Triple antibiotic regimen, followed by proper antibiotic according C/S of swabs from the wound. Aggressive debridement immediately after admission. Daily debridement under G.A for one week Daily dressing. Swab culture combined growth of staphylococci and streptococci. Fournier Gangrene Case Presentation

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After 3 months he was discharged with a completely healed wound and in a very satisfactory shape Fournier Gangrene Case Presentation

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After 3 months he was discharged with a completely healed wound and in a very satisfactory shape Fournier Gangrene Case Presentation THANK YOU