A 58-year-old man with a history of diabetes mellitus and obesity presents to the emergency department reporting groin pain, fever, and malaise. HR 112, BP 105/68, RR 18, SpO2 98%, Temp 101.3F.
Physical examination reveals erythema, foul-smelling drainage. You appreciate crepitus in the perineal region.
Laboratory studies show a white blood cell count of 21,000/μL, blood glucose of 350 mg/dL, and serum lactate of 4.3 mmol/L.
Which of the following is the most appropriate next step in the management of this patient?
A) Start intravenous antibiotics and perform wide surgical debridement.
B) Obtain a CT scan of the pelvis to evaluate the extent of tissue involvement.
C) Administer intravenous antibiotics and observe for clinical improvement.
D) Perform bedside incision and drainage in the emergency department.
E) Consult urology for elective surgical management.
Answer: A) Start intravenous antibiotics and perform wide surgical debridement.
Explanation:
The patient is presenting with history and physical exam findings concerning for Fournier’s Gangrene
Correct Answer:
A) Fournier’s gangrene is a rapidly progressive, necrotizing fasciitis of the perineum, scrotum, and/or genital area. It is a surgical emergency that requires prompt intervention. The mainstay of treatment includes broad-spectrum intravenous antibiotics (1st line: Vancomycin and Zosyn) to cover aerobic and anaerobic bacteria. If concern for shock, or known Group A strep infection, add Clindamycin to suppress toxin and cytokine production.
Urgent surgical debridement should be performed to remove necrotic tissue and control the spread of infection. Delay in surgical intervention significantly increases mortality.
Incorrect Answers:
B) Obtain a CT scan of the pelvis: While imaging such as CT may provide detailed information about the extent of tissue involvement, it should not delay definitive surgical treatment. Clinical findings are typically sufficient to diagnose Fournier’s gangrene.
C) Administer intravenous antibiotics and observe for clinical improvement: Antibiotics alone are insufficient for the treatment of Fournier’s gangrene. Without surgical debridement, the infection will likely progress.
D) Perform bedside incision and drainage in the emergency department: Fournier’s gangrene requires wide surgical debridement under appropriate sterile conditions in the operating room, rather than limited bedside procedures.
E) Consult urology for elective surgical management: Fournier’s gangrene is a medical and surgical emergency that demands immediate intervention. Elective management is inappropriate in this life-threatening condition.
Teaching Points:
- Risk Factors: Diabetes mellitus, obesity, immunosuppression, and trauma to the perineal region
- Clinical Presentation: Severe pain, swelling, erythema, crepitus, systemic signs of sepsis, and foul-smelling discharge
- Management:
- Broad-spectrum antibiotics (e.g., Vancomycin + piperacillin-tazobactam + clindamycin)
- If Penicillin allergy: Cefepime + Metronidazole
- Emergent surgical debridement in OR to remove necrotic tissue
- Supportive care, including fluid resuscitation and glycemic control
- Broad-spectrum antibiotics (e.g., Vancomycin + piperacillin-tazobactam + clindamycin)
- Complications: High mortality rate if not treated promptly
References
CorePendium, Fournier Gangrene
