Fournier's gangrene caused by urethral manipulation in a seven-year-old boy: A case report

Abstract

Fournier's gangrene is a rapidly spreading multi-microbial infection. Rapid diagnosis and treatment of the disease is important in saving patients. This disease usually occurs in adult men with immunodeficiency. In this study, a seven-year-old boy with Fournier's gangrene is presented. During debridement, we noticed a stone on the left side of the scrotum. The result of culture of scrotal secretions was Perteus.

1. Introduction

Fournier's gangrene (FG) is necrotizing poly-microbial fasciitis of the scrotum and perineal area. This infection is caused by a combination of aerobic and anaerobic organisms and can progress rapidly and become life-threatening¹

The main organisms associated with Fournier's gangrene are Escherichia coli and Bacteroides fragilis, which cause extensive tissue damage by releasing collagenase enzymes.²

The ratio of FG in men to women is 10:1 and the average age of onset is 50.9, although it can occur at any age.³

Some comorbidities such as immunodeficiency, diabetes, alcoholism, atherosclerosis, peripheral arterial disease, malnutrition, prostate cancer, human immunodeficiency virus (HIV) infection, leukemia, liver diseases and trauma or injury are considered risk factors for FG, although this serious disease can also occur in people with no medical history.⁴

Pain and discomfort in the genitalia and perineum are the initial presentation of FG, fever, palpitation erythema, swelling, crepitus and purulent discharge may be evident.²

Diagnosis and treatment of the disease should be started without delay. Extensive debridement of infected tissue and administration of intravenous broad-spectrum antibiotics should be prescribed.¹

The goal of timely treatment is to save the patient from sepsis and then minimize sexual and urinary complications.²

2. Case report

The patient is a 7-year-old boy with cerebral palsy who was referred due to erythema and swelling of the scrotum. The patient underwent medical treatment for 10 days in another hospital and after deteriorating in situation he was referred to shohada–e–tajrish hospital. There was no history of diabetes mellitus and immunodeficiency. In the clinical examination, we noticed swelling, erythema and necrosis in the skin of the scrotum (Fig. 1). Erythema was evident in the lower abdomen. His body temperature was 38° upon arrival at the hospital. In the computed tomography (CT) scan of the patient, the presence of air under the skin and a hyperdense lesion on the left side of the upper scrotum beside the urethra were evident (Fig. 2). He underwent empiric antibiotic treatment with intravenous ceftriaxone and clindamycin. With the diagnosis of Fournier's gangrene, he was immediately transferred to the operating room. Under general anesthesia extensive debridement of necrotic tissues was performed. There was a 6 mm stone on the left side of the scrotum near the base of the penis. Skin incision and fasciotomy of suprapubic and lower abdominal were performed by the general surgery team (Fig. 3). The result of culture of scrotal secretions was Proteus and the result of lower abdominal culture was Acinetobacter. Due to the lack of appropriate laboratory equipment, it was not possible to accurately determine the strains of Proteus and Acinetobacter. The patient was transferred to the operating room 3 more times for more debridement and wound irrigation. After 7 days, the scrotal wound underwent primary closure and after 2 weeks he was discharged (Fig. 1). abdominal wound closed with delayed primary closure protocol after one month.

Fig. 1.

Erythema, swelling and necrosis in the examination of the scrotum(A). View of the scrotum after debridement(B). View of the scrotum after primary closure(C).

Fig. 2.

A hyperdense lesion (Stone) demonstrates on the left side of the scrotum in the CT scan.

Fig. 3.

View of lower abdomen after debridement.

3. Discussion

Fournier's gangrene is a rare and fatal infectious disease that was described by the Persian physician and scholar Avicenna in the 10th century. After that, in the 18th century, Baurienne described it. Idiopathic perineal gangrene was described by The French professor of dermatology and venereology, Jean Alfred Fournier in the late 19th century. This disease is a necrotizing fasciitis of the perineum and scrotum that spreads rapidly and eventually it can lead to septic shock and death⁴

The prevalence of FG is higher in adult men, but it can be seen in women, children and even infants.¹ Immunodeficiency, diabetes, liver disease, malnutrition, burns, peri-urethral or anorectal disease and trauma are the risk factors for FG.⁴ The occurrence of Fournier's gangrene in children is very rare, but several cases of it have been reported.⁵

In our case, the patient was a child with cerebral palsy and had no history of immunodeficiency. There was no history of urinary system stones in the patient and his family members. The patient does not mention voiding disorder, and the insertion of the foley catheter was done easily for the patient. during exploration of the scrotum, the stone was seen near the urethra, and pus was observed around the urethra. Despite the fact that the urethra was intact, there is a possibility of trauma and manipulation of the urethra by placing the stone in it.

Due to the rapid spread of the disease, timely diagnosis and treatment are necessary to save the patient's life and reduce complications.¹ In our case, due to the young age of the patient, the health of the immune system, and the presence of only erythema and discomfort in the perineum as the initial symptom, the diagnosis of FG was missed at the first visit and with the suspicion of cellulitis he was treated as an outpatient. After ten days, with the spread of the disease and the discharge of pus from the scrotum and also lower abdominal involvement, he was referred to this center and underwent extensive debridement.

Fournier's gangrene is a multi-microbial infection caused by aerobic and anaerobic organisms. The result of the culture of secretions from the scrotal region of our patient was Proteus, and the result of the lower abdominal culture was Acinetobacter. Proteus and Acinetobacter are both gram-negative bacilli.

4. Conclusion

Although FG is more common in immunocompromised adult men, the disease can occur at any age. There may be no specific risk factor. In our case, maybe the stone on the left side of the scrotum was the source of the infection.

Ethics

Patient informed consent was obtained to publish his information. The patient's private information remained confidential with the researchers.

Financial support and sponsorship

None.

Rules

Amir Alinejad Khorram: Writing- Reviewing and Editing, Supervision, Validation, Writing- Original draft preparation.

Farzad Allameh:Conceptualization, Methodology, Visualization.

Amirhosein Eslami: Investigation.

Declaration of competing interest

The authors report no conflicts of interest in this work.