Background

The Fournier’s gangrene (FG) is a necrotizing fasciitis caused by polymicrobial aerobic and anaerobic bacterial infection that involves genitalia and perineum [1]. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year and the male:female ratio is 10:1. Main recognized risk factors are states of immune system impairment as oldness, alcohol and tobacco consumption, cardiovascular diseases, renal and liver impairment, diabetes mellitus, malignancy and inflammatory bowel disease [2,3,4,5].

FG is a potentially lethal disease with a rapid and progressive involvement of the skin, the subcutaneous fat tissue until fascial planes. Inflammation and oedema lead to obliterating endarteritis with thrombosis of blood subcutaneous vessels and consequent ischemia and necrosis along dartos fascial, Colle’s fascia, Scarpa’s fascia and abdominal wall [6].

FG is a potentially lethal condition with a high mortality rate of 20–30% [7]. The standard of care is a prompt multimodal approach including intravenous fluid resuscitation, broad-spectrum antibiotic therapy, surgical extensive debridement and successive wound cares [8, 9]. In this aggressive disease the time is gold.

In order to improve the knowledge on the field, we describe a case of a male affected by several predisposing conditions at high risk of death for FG, immediately treated with a successful multimodal approach during the Covid-19 pandemic period.

A narrative review of the literature was performed on PubMed and Scopus using as researching terms “Fournier’s gangrene” and “necrotizing fasciitis”. All the available English language full-text original article, case series, case report of interest, published from January 2013 until December 2021, were reported in the Table 1 [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198]. Review articles, meeting reports and congress poster and abstracts were all excluded.

Table 1 Narrative review of the literature about fournier’s gangrene
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Case presentation

A 60 years old man affected by diabetes mellitus, Leriche syndrome, with ileostomy after emicolectomy for ulcerative colitis (RCU), was admitted to our Emergency Department with fever, acute pain, oedema, dyschromia of right hemiscrotum, penis, and perineal region (Fig. 1). At the level of the scrotum a visible suppuration was present and vivid pain was evocable.

Fig. 1
figure 1

Emergency Department presentation of the case. Clinical presentation with oedema, dyschromia of right hemiscrotum, penis, and perineal region

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The blood exams revealed a neutrophilic leukocytosis with 19.1 × 109 white blood cells 83.2% of which neutrophiles, hemoglobin 9.3 g/dl, glucose 314 mg/dl, creatinine 1.2 mg/dl, C-reactive protein 42.7 mg/L, procalcitonin 29.44 ng/ml. The modified Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC score) was 7, suspicion for necrotizing fasciitis [61]. The Charlson Comorbidity Index score was of 6, the Fournier’s Gangrene Severity Index was 9 with a risk of death > 75% [199, 200].

The emergency ultrasound exam revealed a marked thickening of the scrotal wall associated with intrafascial anechogen film and multiple hyperechoic spots with posterior echoes as for aerial component.

Computed Tomography revealed an abundant air-gas content in the context of the soft and peripheral tissues at the level of the right scrotal lodge reached the cutaneous plane at the lower pole and more cranially, further gas was localized at the base of the root of the penis, in the paramedian perineum homolaterally up to floor below the ischium pubic branch (Fig. 2). A marked fluid-edematous thickening of the tunics and scrotal walls were present bilaterally but more evident on the right side of the scrotum.

Fig. 2
figure 2

Title. Pre-operative CT-scan. CT-scan revealed air-gas content (green arrow) in the context of the soft and peripheral tissues at the level of the right scrotal lodge. A marked fluid-edematous thickening of the tunics and scrotal walls were present bilaterally but more evident on the right side of the scrotum

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Intravenous fluid resuscitation and broad-spectrum antibiotics such as Piperacillin/Tazobactam (4.5 gr iv q8h), Imipenem/Cilastatin (500 mg iv q8h) and Daptomycin (700 mg iv q24h) were administered.

A prompt surgical debridement of genitalia and perineal region with an accurate necrotic tissue removal up to exposure of healthy tissue was performed (Fig. 3). A Penrose drain was left in place anterior to the rectum where a more destructive debridement was performed. It was removed on the 4th postoperative day after daily withdrawal due to granulated tissue formation. A single blood transfusion was performed for anemia.

Fig. 3
figure 3

Surgical debridement. Surgical extensive debridement of genitalia and perineal region with exposure of healthy tissue

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Based on intra-operative scrotal ulcer swab, positive for Escherichia coli, Enterococcus faecium, Streptococcus oralis, Candida albicans, Bacteroides fragilis e Staphylococcus lugdunensis, on the 5th postoperative day, the antibiotic therapy was switched to Piperacillin/Tazobactam (4.5 gr iv q8h), Teicoplanin (600 mg iv q24H) and Fluconazole (400 mg iv q24h). Hemocultures and urinocultures were negative.

High-intensity care was carried on in the next days with a bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, until discharge on the 40th postoperative day (Fig. 4).

Fig. 4
figure 4

Discharge. Clinical condition at discharge

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Plastic surgeons decide to not perform a skin graft due to an excellent wound improvement with local medication. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day.

Discussion

Predisposing factors to Fournier’s gangrene include all conditions with an impaired micro-circulation and immunosuppression such as diabetes mellitus, obesity, chronic alcoholism, smoking habit, renal and liver failure, malignancies, bowel inflammatory diseases and HIV infection [201,202,203,204]. In our case the patient suffered from diabetes, chronic arteriopathy, RCU for which he carried a colostomy following intestinal resection. The presence of a fecal diversion has certainly improved the wound management and therefore promoted its healing, reducing the contamination of the same with fecal material, ensuring a more accurate hygiene of the scrotal and perineal region [183]. The fact that ileostomy was already well established probably allowed to enjoy the benefits described above without exposing the patient to the typical complications of the creation of a neo-stoma, such as parastomal hernia, incisional hernia, colostomy prolapse, necrosis and stenosis which may necessitate additional surgery [183].

Once described as idiopathic, the FG is secondary to aerobic and anaerobic bacterial infection that involves genitalia and perineum and the cause is recognizable in more than 90% of the cases. In most cases the origin site infection is the ano-rectum (30–50%), uro-genitalia (20–40%) and genital surface (20%) [52]. In an immunodeficient host a polymicrobial flora are usually involved with a synergic mechanism of aggressiveness. The latter was present also in our case with several single-management not aggressive pathogens developing a synergism. Polymicrobial infection is reported as cause in 54% of cases [205].

The onset of this necrotizing fasciitis is insidious with up to 40% of cases asymptomatic. When signs and symptoms are the reason of emergency access, they are characterized by genital and perineal regions pain with little to no visible cutaneous damage in the early stage and erythematous and dusky skin, crepitus of subcutaneous tissue, maleodorant and purulent exudates of perineal and genital regions [206].

A successful management of the Fournier’s gangrene is challenging. The risk of death in about 20% of patients makes FG an emergency health condition [68, 99]. Fluid resuscitation for adequate systemic perfusion, empiric intravenous broad-spectrum antibiotic therapy to reduce the risk of septic shock and a prompt extensive surgical debridement ensured an improvement in prognosis in accordance with current guidelines [207]. The surgery plays a cardinal role because a delay in surgical debridement is associated with a significant increase in mortality [208]. From the review of the literature, a risk of death up-to-date is of 14.3% (Table).

In addition, the necrotizing fasciitis could benefit from hyperbaric oxygen therapy (HBOT) to reduce the spread of anaerobic germs, from the vacuum-assisted closure (VAC) that can be used to promote wound healing physiologically reducing the need for reconstructive surgery with skin graft in the setting of a personalized medicine [206, 209,210,211]. HBOT has been related to a better wound control as an adjuvant treatment by promoting wound healing. It acts as bactericide and bacteriostatic especially over anaerobic bacteria, almost always involved in this necrotizing fasciitis. HBOT increases local circulation and tissue oxygenation which prevents the progression of necrosis; furthermore, HBOT seems have synergism with certain antibiotics [18, 45, 209]. In our case the patient hospitalization was long due to the difficulties related to the COVID pandemic era, the choice to not perform a skin graft and the need for daily medications in order to obtain a natural restitutio of the lesion as possible. This type of management made it possible to avoid the use of common tools for resolving Fournier's gangrene such as HBOT, VAC and surgical graft. In our hospital there is not the HBOT so it would have been necessary to transfer the patient to another hospital and one of the COVID-19 pandemic period problem was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management.

Conclusions

FG is burdened of high risk of death and a prompt multimodal approach is mandatory. This necrotizing fasciitis also needs a post-operative rigid management to reduce a risk of relapse and allow a complete restoration. In our case, for reason of necessity, an immediate multimodal approach and a daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding HBOT, VAC or surgical graft without foregoing optimal outcomes.