1. PRESENTATION
A 45‐year‐old male with type 2 diabetes presented to the emergency department (ED) with 1 week of testicular swelling. Despite receiving multiple antibiotics for cellulitis at another ED 3 days prior, he experienced increasing pain, swelling, fever, diaphoresis, and perineal desquamation accompanied by serosanguinous discharge. Initial vital signs were stable. Physical examination revealed scrotal swelling and erythema, two draining perianal lesions, and significant tenderness to touch without crepitus. Laboratory findings included leukocytosis, hyponatremia, hyperglycemia, and elevated inflammatory markers. Point‐of‐care‐ultrasound (POCUS) performed in the ED confirmed scrotal edema (Figure 1, Video S1) and a phlegmonous perineal area concerning for abscess formation without subcutaneous emphysema (SE) (Figure 2, Video S2). Computed tomography (CT) imaging corroborated POCUS findings.
FIGURE 1.
Point‐of‐care‐ultrasound (POCUS) image of scrotum with testes, revealing scrotal edema and bilateral hydrocele.
FIGURE 2.
Point‐of‐care‐ultrasound (POCUS) image of perineum, with heterogeneous area of phlegmon and early abscess formation.
Given failed outpatient antibiotics, markedly elevated inflammatory markers, and POCUS findings, necrotizing soft tissue infection was suspected. The patient received intravenous broad‐spectrum antibiotics and underwent surgical debridement.
2. DISCUSSION
Fournier gangrene (FG) is a necrotizing infection of the perineum that can rapidly extend to surrounding structures. 1 , 2 , 3 Mortality with treatment ranges from 22% to 40%. 2 , 3 , 4 , 5 Risk factors include obesity, alcoholism, diabetes, male gender, and so on. 1 SE is regarded as a classic imaging finding. Yet in one systematic review of diagnostic POCUS in necrotizing fasciitis, SE was the least sensitive (6.3%) compared to fluid accumulation (85.4%), thickened fascia (66.7%), and cobblestoning (16.7%). 6 In this case, POCUS, in conjunction with clinical and laboratory findings, was a valuable component in diagnosis of FG, identifying a soft tissue region indicative of evolving infection requiring surgical intervention.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Video 1. POCUS of scrotum with testes revealing scrotal edema and bilateral hydrocele.
Video 2. POCUS of perineum with heterogeneous area of phlegmon and early abscess formation.
Allen CW, Liao C, Hill C, Batchelor TJ, Ashenburg NG. Man with scrotal pain and swelling. JACEP Open. 2024;5:e13289. 10.1002/emp2.13289
REFERENCES
- 1. Lewis GD, Majeed M, Olang CA, et al. Fournier's gangrene diagnosis and treatment: a systematic review. Cureus. 2021;13(10):e18948. doi: 10.7759/cureus.18948 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Laucks SS 2nd. Fournier's gangrene. Surg Clin North Am. 1994;74(6):1339‐1352. doi: 10.1016/s0039-6109(16)46485-6 [DOI] [PubMed] [Google Scholar]
- 3. Stephens BJ, Lathrop JC, Rice WT, Gruenberg JC. Fournier's gangrene: historic (1764‐1978) versus contemporary (1979‐1988) differences in etiology and clinical importance. Am Surg. 1993;59(3):149‐154. [PubMed] [Google Scholar]
- 4. Noegroho BS, Adi K, Mustafa A, Haq RS, Wijayanti Z, Liarto J. The role of quick sepsis‐related organ failure assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's gangrene severity index: analysis of 69 patients. Asian J Urol. 2023;10(2):201‐207. doi: 10.1016/j.ajur.2021.11.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. Urology. 2004;64(2):218‐222. doi: 10.1016/j.urology.2004.03.049 [DOI] [PubMed] [Google Scholar]
- 6. Marks A, Patel D, Sundaram T, Johnson J, Gottlieb M. Ultrasound for the diagnosis of necrotizing fasciitis: a systematic review of the literature. Am J Emerg Med. 2023;65:31‐35. doi: 10.1016/j.ajem.2022.12.037 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Video 1. POCUS of scrotum with testes revealing scrotal edema and bilateral hydrocele.
Video 2. POCUS of perineum with heterogeneous area of phlegmon and early abscess formation.