Case Report: Implications for a Patient Diagnosed with Fournier’s Gangrene
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Introduction
Fournier’s gangrene (FG) is a type of necrotizing fasciitis (NF). FG specifically involves the perineum and is a rare mixed aerobic and anaerobic soft-tissue infection. FG generally causes the perineal tissue to slough; in male patients, this includes the skin, subcutaneous tissue, and fascia of the scrotum and penis.1
Risk factors for the development of FG include advancing age, malnutrition, obesity, alcoholism, intravenous drug use, diabetes mellitus, peripheral vascular disease, and immunosuppression.2–8 Patients at risk for FG typically have at least one comorbidity that results in some degree of debilitation, hypo-perfusion, or compromised host immunity.3,9–11
Etiology
Usually local trauma or instrumentation creates a portal that allows skin flora to enter the subcutaneous tissue, which results in infection, although some cases of FG present without a clear mode of injury.
Signs and Symptoms
Signs and symptoms of FG include severe pain, nondemarcated wound edges, systemic toxicity, nausea, diaphoresis, vomiting, rigors, cloudy urine, dehydration, and cachexia.1,9,11–14 Wall, et al., found that tense edema and the presence of skin bullae are predictive physical examination findings, and elevated white blood cell count, elevated serum sodium levels, and elevated chloride levels are predictive lab findings of FG.15
Pathophysiology
FG is most commonly caused by a polymicrobial infection of aerobic and anaerobic organisms, which are most often clostridium species, streptococci, and enterobacteriaceae.16 The destruction of tissue by bacteria results in the formation of gas and a foul odor. The advancement of necrosis into muscle tissue is apparent with a rise in creatine phosphokinase levels. Once thrombosis causes blood supply to be compromised, the skin turns blue-gray in color, bullae form, and the skin becomes anaesthetic, gangrenous, and may begin to slough.2,15,17–22 This extensive tissue death prevents penetration of antibiotics into the affected tissue, requiring extensive debridement.12,18,19,23
Medical Management
Several diagnostic tools assist physicians in the medical management of FG. Although definitive diagnosis may only be made in the operating room when the typically adherent fascia shows no resistance to the blunt dissection of a probe, blood culture is an inexpensive initial method used to determine microbiology allowing for proper antibiotic coverage.14 A blood test is used to determine elevated levels of creatine phosphokinase, alerting physicians to the advancement of necrosis into the muscle tissue.7,18,24,25 Although radiographs are used to reveal subcutaneous air to determine the spread of the infection, computerized tomography (CT) scans more clearly establish the extent of the infection and allow for surgical management planning.6,14,20,22,26
Medical treatment of FG requires appropriate antibiotic therapy, monitoring of the level of electrolytes to prevent shock, doubling or tripling nutritional intake to prevent the loss of lean muscle mass, and care of preexisting comorbidities.12
Surgical debridement of all nonviable overlying skin, subcutaneous fat, and fascia should be prompt, extensive, and aggressive for managing and preventing the progression of FG.6,8,11,12,21,27,28 Without debridement of all necrotic tissue in a FG soft-tissue infection, the patient is at great risk for death.15,22 Subsequent debridements are necessary to ensure the wound bed is clean, which enhances the development of granulation tissue and allows for the application of a split-thickness skin graft (STSG) to provide wound closure.12,18
Physical Therapy Management
For the physical therapist (PT), wound assessment and management to maximize tissue healing while also minimizing the risk of infection is of primary importance.
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