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editorial
. 2006;29(1):15–16. doi: 10.1043/1079-0268(2006)29[15:LTTE]2.0.CO;2

LETTER TO THE EDITOR

Ibrahim M Eltorai 1
PMCID: PMC1900504  PMID: 16572560

FOURNIER GANGRENE IN SPINAL CORD INJURY: A CASE REPORT

Nambiar PK, Lander S, Midha M, Ha C

J Spinal Cord Med. 2005;28(2):121–124

This article is pretty comprehensive, but I would like to point out some issues, since I have been interested in this subject for many years. In spinal cord injury (SCI), possible specific causes for Fournier gangrene in addition to pressure ulcers are: (a) necrosis of the urethra by a catheter balloon (1), (b) extra-tight condom ring (2), (c) the use of vacuum constriction device for erection (2), and (d) urinary extravasation (3,4). However, sometimes Fourniers gangrene may be idiopathic (5–7).

Mortality can be reduced greatly by awareness about this condition, early diagnosis and aggressive management using wide-spectrum antibiotic therapy, aggressive debridement, and hyperbaric oxygen (HBO). HBO exerts the following effects: (a) bactericidal effects on Clostridium welchii if present (8–10), (b) bacteriostatic effect and inhibitory effect on anaerobes and some aerobes (11), although this is still questionable (12), (c) stops α-toxin (alphatoxin) production (13), but has no effect on the preformed toxin (14), (d) reduction of edema (15,16), (e) increased phagocytosis and killing capacity of white cells (17–19), and (f) after debridement, HBO stimulates wound healing (20–22) by stimulating angiogenesis, collagen tissue formation and epithelialization.

In conclusion, proper care of the urogenital, anorectal and perineal systems is very important for the prevention of serious complications, namely Fournier gangrene. Whenever possible, adjunctive HBO therapy can be helpful with medical, surgical, and antibiotic therapies. In my experience, extensive Fournier gangrene ought to be treated with HBO to lower the mortality (23). Other views have been published recently (24,25).

References

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J Spinal Cord Med. 2006;29(1):16.

Authors' response

Prabhakaran Nambiar 1

We thank Dr. Eltorai for adding his personal observations on Fournier gangrene and hyperbaric oxygen therapy. Some points about hyperbaric oxygen therapy (HBO) need to be mentioned. The primary management of Fournier gangrene consists of antibiotic therapy and aggressive debridement. This should not be deferred while arranging transfer to a facility with a hyperbaric chamber (1). Adjunctive HBO may decrease mortality and limit the extent of debridement in Fournier's gangrene (2), but results are conflicting (3). Among HBO-treated patients, observational study by Hollabaugh et al of 26 patients reported a significantly lower mortality rate (4), and one by Riseman et al of 29 patients noted significantly fewer debridements and a lower mortality rate (5). But a larger study of 42 patients by Mindrup et al suggested increased mortality, morbidity, and cost of therapy among patients treated with HBO. Their data did not support routine HBO in the treatment of Fournier gangrene. They reported a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill (6). Review of 1726 cases of Fournier gangrene by Eke concludes HBO therapy to be controversial (7). The review by Capelli-Schellpfeffer M et al suggests further investigation of the efficacy of hyperbaric oxygen is warranted for patients with necrotizing fasciitis (8). Green RJ et al conclude that hyperbaric oxygen therapy should be considered, although to their knowledge, there are no prospective, randomized clinical trials to support this (9). In conclusion, further prospective, randomized clinical trials are needed to institute HBO as routine part of management of Fournier gangrene.

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