Fournier’s Gangrene in a 29-Year-Old Male with Crohn’s Disease: A Rapidly Progressing Necrotizing Fasciitis of the Perineum

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Fournier’s Gangrene in a 29-Year-Old Male with Crohn’s Disease: A Rapidly Progressing Necrotizing Fasciitis of the Perineum

크론병을 앓고 있는 29세 남성의 푸르니에 괴저: 회음부의 급속 진행성 괴사성 근막염

Keywords: Fournier’s gangrene, necrotizing fasciitis, perineal infection, scrotal swelling, gas in soft tissue, urologic emergency, Crohn’s disease, surgical debridement

Introduction

Fournier’s gangrene is a fulminant and potentially fatal form of necrotizing fasciitis affecting the perineum, perianal, and genital regions, predominantly in males. Although it is typically seen in older patients with comorbidities such as diabetes or alcoholism, it can occur in younger individuals with predisposing conditions such as Crohn’s disease, as highlighted in this case of a 28-year-old man presenting with acute scrotal swelling.

Case Summary

A 29-year-old man with Crohn’s disease presented to the emergency department with rapidly worsening scrotal swelling. Initial evaluation included scrotal ultrasonography with color Doppler and abdominopelvic CT.

Imaging Findings

Figure 1. Scrotal Ultrasound with Color Doppler

Image shows hyperechoic foci in the subcutaneous tissue with posterior dirty acoustic shadowing, consistent with gas formation. The testes and epididymis were unremarkable.

Figure 2. CT Scan (Axial and Sagittal Views)

CT imaging demonstrates gas tracking along the left spermatic cord extending into the inguinal region. A fistulous connection from the anterior rectum to the left scrotum is also identified.

Quiz

1: Where is the most significant abnormality seen on ultrasound?

A. Testicle
B. Epididymal head
C. Subcutaneous tissue
D. Spermatic cord

2: What is the next best step in management?

A. Abdominopelvic CT
B. Urology follow-up in 4–6 weeks
C. Urgent urology consult
D. Chest CT

3: What is the most abnormal finding on CT?

A. Myositis
B. Fracture
C. Gas tracking along fascial planes
D. Small bowel obstruction

4: What is the most likely cause of the abnormal CT findings?

A. Rectal fistula
B. Trauma
C. Diabetes
D. Hematogenous spread of infection

5: Fournier’s gangrene is most often monomicrobial. True or False?

6: What is the next best step in management?

A. IV fluid resuscitation
B. Broad-spectrum antibiotics
C. Emergent surgery
D. (1) and (2)
E. All of the above

Answer & Explanation

1. Answer: C. Subcutaneous tissue. Explanation: The most striking finding is gas within the subcutaneous tissue, seen as echogenic foci with dirty posterior shadowing. The testicle and epididymis are normal.

2. Answer: C. Urgent urology consult. Explanation: The presentation is concerning for Fournier’s gangrene, a surgical emergency. Immediate urologic and surgical consultation is required.

3. Answer: C. Gas tracking along fascial planes. Explanation: CT reveals gas dissecting along fascial planes, a hallmark of necrotizing fasciitis.

4. Answer: A. Rectal fistula. Explanation: The CT identifies a fistulous tract between the rectum and the scrotum, indicating a perianal source of infection.

5. Answer: False. Explanation: Fournier’s gangrene is typically polymicrobial, often involving a mix of aerobic and anaerobic bacteria, including gas-producing organisms.

6. Answer: E. All of the above. Explanation: Management includes aggressive fluid resuscitation, empirical broad-spectrum antibiotics, and emergency surgical debridement.

Diagnosis

Fournier’s gangrene secondary to a rectoscrotal fistula in a patient with Crohn’s disease.

Pathophysiology

Fournier’s gangrene is a form of necrotizing fasciitis involving rapid bacterial spread through fascial planes, often starting in subcutaneous tissue. Bacterial toxins cause vascular thrombosis, ischemia, and tissue necrosis. The infection is polymicrobial, frequently involving anaerobes capable of gas formation.

Epidemiology

  • Incidence: ~1.6 per 100,000 males

  • Male-to-female ratio: ~10:1

  • Most common age: 50–80 years

  • Risk factors: Diabetes, Crohn’s disease, alcoholism, renal failure, obesity

Clinical Presentation

  • Scrotal/perineal pain, redness, swelling

  • Crepitus on exam

  • Sepsis, tachycardia, hypotension

  • Rapid clinical deterioration if untreated

Imaging Features

Ultrasound

  • Hyperechoic gas with posterior dirty shadowing in soft tissues

  • Skin thickening, hyperemia

  • Normal testicle/epididymis

CT

  • Gas tracking along fascial planes

  • Subcutaneous fluid collections

  • Fistulas or underlying abscesses (e.g., rectoscrotal)

Treatment

Emergency Measures

  • IV fluid resuscitation

  • Broad-spectrum antibiotics (e.g., carbapenem + clindamycin + vancomycin)

  • Emergent surgical debridement (often multiple stages)

Adjunctive Therapies

  • Hyperbaric oxygen therapy (select cases)

  • Wound vacuum-assisted closure (VAC)

  • Skin grafting or reconstructive surgery after resolution

Prognosis

  • Mortality rate: ~16% (can be higher with sepsis)

  • Early diagnosis and surgical intervention are critical for survival

  • Delays increase the risk of multiorgan failure and death

References

  1. D. Bahner, E. Kube, and S. Stawicki, "Ultrasound in the diagnosis of Fournier’s gangrene," Int J Crit Illn Inj Sci., vol. 2, no. 2, pp. 104–105, 2012.

  2. J. C. Hagedorn and H. Wessells, "A contemporary update on Fournier’s gangrene," Nat Rev Urol., vol. 14, no. 4, pp. 205–214, 2017.

  3. R. B. Levenson, A. K. Singh, and R. A. Novelline, "Fournier gangrene: role of imaging," Radiographics, vol. 28, no. 2, pp. 519–528, 2008.

  4. S. E. Sorensen et al., "A systematic review of surgical outcomes in Fournier’s gangrene," Surgery, vol. 167, pp. 731–738, 2020.

  5. M. Sorensen and C. Krieger, "Hyperbaric oxygen therapy in the management of Fournier’s gangrene," Clin Infect Dis., vol. 36, pp. e141–e143, 2003.

  6. T. Eke, "Fournier’s gangrene: a review of 1726 cases," Br J Surg., vol. 87, no. 6, pp. 718–728, 2000.

  7. S. A. Yilmazlar et al., "An easy way to predict the outcome of Fournier’s gangrene: FGSI," Ulus Travma Acil Cerrahi Derg., vol. 19, pp. 37–44, 2013.

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