DOI: 10.1148/radiol.2261010714
(Radiology 2003;226:115-117.)
© RSNA, 2003
Case 54: Fournier Gangrene1
Raul N. Uppot, MD,
Howard M. Levy, MD and
Pankaj H. Patel, MD
1 From the Departments of Radiology (R.N.U., H.L.) and Surgery (P.P.), Christiana Health Care System, 4755 Ogletown-Stanton Rd, Newark, DE 19718. Received April 2, 2001; revision requested May 23; revision received July 12; accepted August 9. Address correspondence to R.N.U. (e-mail: ruppot@aol.com).
Index terms: Diagnosis Please • Scrotum, diseases, 847.2111 • Scrotum, US, 847.1298, 847.12983
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HISTORY
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A 52-year-old man had scrotal pain at presentation. Ultrasonography (US) (Fig 1) of the scrotum was performed. Doppler US showed symmetric blood flow in the testicles. The epididymis appeared normal.
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Figure 1a. (a) Transverse and (b) sagittal US scans of the right testicle show marked thickening of the skin (small arrow) overlying the right testicle. Multiple echogenic foci (large arrows) and associated dirty shadowing, which were consistent with the presence of gas, are seen.
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Figure 1b. (a) Transverse and (b) sagittal US scans of the right testicle show marked thickening of the skin (small arrow) overlying the right testicle. Multiple echogenic foci (large arrows) and associated dirty shadowing, which were consistent with the presence of gas, are seen.
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IMAGING FINDINGS
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US of the scrotum showed diffuse marked thickening of skin overlying the right testicle (Fig 1). Within the area of skin thickening, multiple echogenic foci were present with associated dirty shadowing, which was consistent with the presence of gas. The testicles appeared normal in echotexture.
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DISCUSSION
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The imaging findings were indicative of Fournier gangrene, or necrotizing fasciitis. Fournier gangrene is a rapidly progressive fasciitis of the perineum. It was described in 1883 by Jean Alfred Fournier, a French venereologist (1). Although most cases described occur in diabetic men 50–70 years old, Fournier gangrene also has been described in women (2). Often there is a point of entry (ie, through urethral, rectal, or subcutaneous tissue) by polymicroorganisms; then, a rapidly progressive necrotizing fasciitis spreads through the tissue planes in the perineum (3). The rate of fascial necrosis has been documented to be as rapid as 2–3 cm/h (4). The most commonly isolated organisms are Klebsiella, Proteus, Streptococcus, Staphylococcus, Peptostreptococcus, and Escherichia coli. Soft-tissue gas comes from the byproducts of anaerobic metabolism and is composed of hydrogen, hydrogen sulfide, nitrogen, and nitrous oxide (3).
At presentation, patients have a sudden onset of perineal pain and swelling. In addition, they have a fever and leukocytosis. Physical examination reveals pain, redness, and swelling of the perineal area. Sometimes crepitus from the soft-tissue gas can be palpated.
Treatment is immediate radical débridement of all necrotic areas. Patients are hemodynamically stabilized, and after antibiotics are administered intravenously, surgical débridement is performed. Fournier gangrene has up to a 33% mortality rate, and, therefore, rapid diagnosis and treatment are crucial.
Because, historically, Fournier gangrene is a diagnosis determined clinically, radiologists are often not exposed to this disease. However, in examining a scrotal US scan in a patient with scrotal pain, besides the more common diagnoses of testicular torsion and acute epididymo-orchitis, Fournier gangrene has to be considered.
The imaging findings of Fournier gangrene have been described in the literature (3,5,6).
On abdominal radiographs, there is soft-tissue edema of the perineal tissues. Subcutaneous emphysema may be seen tracking along the extent of the involved tissue planes (3) (Fig 2).
On a US scan, thickening of the scrotal skin can be seen. Gas within the scrotal skin, seen as hyperechoic foci with dirty shadowing, is pathognomonic for Fournier gangrene (3,5,6). The hyperechoic foci are not within the testicle and should not be confused with calcifications of testicular microlithiasis, germ cell tumors, teratomas, teratocarcinomas, sarcoidosis, tuberculosis, or chronic infarct. The testicle is often normal because of a separate blood supply.
On a computed tomographic (CT) scan, there was fascial thickening and fat stranding of the involved areas. CT can more completely depict the extent of soft-tissue gas and can often show the cause of Fournier gangrene, such as perianal abscesses, incarcerated inguinal hernias, or fistulous tracts (3).
Differential diagnosis for acute scrotal pain includes testicular trauma, testicular torsion, acute epididymo-orchitis, and Fournier gangrene. Testicular trauma (blunt or penetrating) can be distinguished from Fournier gangrene based solely on history and physical evidence of trauma. Although testicular torsion and acute epididymo-orchitis can manifest with acute scrotal pain without history of trauma and physical examination can show a swollen, erythematous scrotum, color Doppler flow US can help distinguish between these diagnoses. Color Doppler flow US is 86% sensitive in showing absence of testicular and epididymal flow in testicular torsion (7). In acute epididymo-orchitis, there is increased epididymal and/or testicular flow (7). Our case showed a normal testicle with normal testicular and epididymal flow. There was scrotal skin thickening with subcutaneous gas. These findings are pathognomonic for Fournier gangrene.
After initial administration of intravenous fluids and antibiotics, this patient underwent surgical débridement of all necrotic tissue. After several weeks of healing, his exposed testicles were replaced into the remaining portion of his scrotum. He was discharged from the hospital in stable condition.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
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REFERENCES
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- Fournier JA. Gangrène foudroyante de la verge. Semaine Medecine 1883; 3:345-348.
- Addison WA, Livengood CH, Hill GB, Sutton GP, Fortier KJ. Necrotizing fasciitis of vulvar origin in diabetic patients. Obstet Gynecol 1984; 63:473-478.[Abstract/Free Full Text]
- Rajan DK, Scharer KA. Radiology of Fournier’s gangrene. AJR Am J Roentgenol 1998; 170:163-168.[Free Full Text]
- Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992; 19:149-162.[Medline]
- Fan C, Whitman GJ, Chew FS. Necrotizing fasciitis of the scrotum (Fournier’s gangrene). AJR Am J Roentgenol 1996; 166:1164.[Free Full Text]
- Begley MG, Shawker TH, Robertson CN, Bock SN, Wei JP, Lotze MT. Fournier’s gangrene: diagnosis with scrotal US. Radiology 1988; 169:387-389.[Abstract/Free Full Text]
- Dambro TJ, Stewart RR, Carroll BA. The scrotum. In: Rumack CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St Louis, Mo: Mosby, 1997; 791-822.
Congratulations to the 91 individuals who submitted the most likely diagnosis (Fournier Gangrene) for Diagnosis Please, Case 54. The names and locations of the individuals, as submitted, are as follows:
- Gholamali Afshang, MD, Tinley Park, Ill
- Okan Akinci, MD, Istanbul, Turkey
- Philip A. Araoz, MD, Rochester, Minn
- Patricia A. Athey, MD, Houston, Tex
- Richard Beedie, Auckland, New Zealand
- Marcelo Bordalo Rodrigues, São Paulo, Brazil
- John W. Breckenridge, MD, Abington, Pa
- Eric Bressler, Minnetonka, Minn
- Michael P. Buetow, MD, Okemos, Mich
- Brian J. Burke, Manhasset, NY
- Manuel Cabal Naranjo, MD, Merida, Yucatan, Mexico
- Dr Tirso Cascajares Murillo, Los Mochis, Sinaloa, Mexico
- Antonio Cavalcanti, MD, São Paulo, Brazil
- James W. Cole, MD, Cincinnati, Ohio
- Estelle Cooke-Sampson, Washington, DC
- Cecilia M. Coutsias, MD, Chandler, Ariz
- Federico Dalla Torre, MD, Cipolletti, Rio Negro, Argentina
- Holt Daniel, MD, Fort Worth, Tex
- Rafal Darecki, MD, Koscierzyna, Poland
- M. G. de Baets, MD, Lugano, Switzerland
- Mustafa Kemal Demir, MD, Ataköy, Istanbul, Turkey
- Sergio San Juan Dertkigil, São Paulo, Brazil
- María Jesús Díaz Candamio, MD, PhD, La Coruña, Spain
- Ian Doris, Hamilton, Ontario, Canada
- Gabriel C. Fernández Pérez, Vigo, Spain
- Mario Finazzo, Palermo, Italy
- Arie Franco, MD, PhD, Livingston, NJ
- Akira Fujikawa, Tokyo, Japan
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Mark Goldshein, MD, Andover, Mass
- Bhaskar Golla, Kingston, Pa
- Tom Grant, DO, Chicago, Ill
- Sid Green, MD, Salem, Ore
- Ferris M. Hall, MD, Boston, Mass
- W. Mark Hamilton, MD, Dallas, Tex
- Thomas C. Hoffer, MD, El Paso, Tex
- Dr Alberto Iaia, Wilmington, Del
- Vinay Jain, Pontiac, Mich
- Kartik Jhaveri, MD, Toronto, Ontario, Canada
- Nurettin Katranci, MD, Manavgat, Antalya, Turkey
- Douglas S. Katz, MD, Mineola, NY
- Mark Kutler, MD, Dallas, Tex
- Mario Laguna, West Allis, Wis
- Mitchell P. Laks, MD, PhD, Flushing, NY
- John T. Lim, Irvine, Calif
- Mark E. Lockhart, MD, Birmingham, Ala
- Dieter Lungenschmid, MD, Innsbruck, Austria
- Dr R. Madan, Lucknow, India
- N. B. S. Mani, MD, Nassau, Bahamas
- A. C. Matteoni de Athayde, MD, Salvador, Bahia, Brazil
- Frank McKowne, MD, Vancouver, Wash
- Flávia Méndez, MD, Porto Alegre, Brazil
- Ari Mintz, MD, Lake Forest, Ill
- Eduardo Mondello, MD, Buenos Aires, Argentina
- Carlos F. Munoz-Nunez, Villajoyosa, Spain
- Sanford M. Ornstein, MD, Phoenix, Ariz
- Harish Panicker, MD, Detroit, Mich
- Narendrakumar P. Patel, MD, Newburgh, NY
- Steven Perlmutter, MD, Mineola, NY
- Carlo L. E. Petralli, MD, Bruderholz, Switzerland
- M. Ali Pourbagher, Adana, Turkey
- Le-ping Pu, MD, Potomac, Md
- Luiz Antonio Rossi, MD, São Paulo, Brazil
- Luc Roussel, MD, Sijsele, Belgium
- Mourad Said, MD, Monastir, Tunisia
- Steven M. Schultz, MD, Fort Worth, Tex
- Matt Shapiro, MD, Lowell, Mass
- Kevin S. Shea, MD, Buffalo, NY
- Taro Shimono, MD, Osaka, Japan
- Richard Silberstein, MD, Monte Sereno, Calif
- Paolo Siotto, MD, Cagliari, Italy
- Stephen Smith, Peoria, Ill
- Simon Strauss, MB, ChB, Kfar Shmaryahu, Israel
- Margaret M. Szabunio, Tampa, Fla
- Douglas L. Teich, MD, Brookline, Mass
- Shendee Teng, MD, Monterey Park, Calif
- D. Dean Thornton, MD, Birmingham, Ala
- Eugene Tong, Austin, Tex
- Herminia Tyminski Al-Saffar, MD, Manama, Bahrain
- Juan Antonio Valdez, MD, Lima, Peru
- Piet K. Vanhoenacker, Morsel, Belgium
- Christopher Vittore, MD, Rockford, Ill
- P. M. Vos, Vancouver, British Columbia, Canada
- Zhen Jane Wang, MD, San Francisco, Calif
- Thomas Waslen, Saskatoon, Saskatchewan, Canada
- Edward Williams, Jersey, Channel Islands
- Tatsuya Yamamoto, Obama, Japan
- Benjamin M. Yeh, MD, San Francisco, Calif
- Joe Yut, Olathe, Kan
- Jeffrey H. Zapolsky, MD, Oshkosh, Wis
- Yu Zhang, Nagoya, Japan
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R. B. Levenson, A. K. Singh, and R. A. Novelline
Fournier Gangrene: Role of Imaging
RadioGraphics,
March 1, 2008;
28(2):
519 - 528.
[Abstract]
[Full Text]
[PDF]
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TOP
HISTORY
IMAGING FINDINGS
