Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Figures & data

Table 1 Risk Factors for Development of Fournier Gangrene

Demographic	Male sex Advanced age (>50 years) Spinal cord injury^Citation26 Obesity (BMI >30 kg/m^2) Malnourishment Recent trauma or surgery Structural or functional anatomic defects Urethral stricture^Citation27 Inguinal hernia^Citation28 Rectal fistula Perianal abscess^Citation29 Lower extremity paralysis^Citation25 Neurogenic bladder^Citation26
Vascular Disease	Peripheral vascular disease Hypertension
Immunocompromised State	Diabetes mellitus HIV/AIDS Chronic/high-dose steroid use Cytotoxic drugs including chemotherapy Lymphoproliferative diseases Leukemia^Citation30 Systemic lupus erythematosus Inflammatory bowel disease^Citation31 Rectal/colon malignancy
Drug Use	Alcohol use Tobacco use Stimulant use Injection drug use SGLT2 inhibitor use^Citation20
Chronic Organ Dysfunction	Chronic kidney disease Hepatic insufficiency Heart failure
Iatrogenic/Procedural	Urologic Urinary catheterization or instrumentation Prostatic biopsy Vasectomy Urethral stricture manipulation
	Gastrointestinal Pancreatic stent dislocation Inguinal hernia repair^Citation32 Rectal biopsy
	Gynecologic Episiotomy wound/repair Hysterectomy^Citation24

Note: Data from these studies.^{9,15,20,22–25}

Figure 1 Physical examination findings of Fournier Gangrene. Note a large area of necrosis (white arrow) as well as soft tissue edema and erythema (yellow arrow).

Table 2 LRINEC Score for Necrotizing Soft Tissue Infection

Criteria	Value	Points	Criteria	Value	Points
CRP (mg/L)	<150	0	Sodium	≥135	0
	≥150	+4		<135	+2
WBC per mm^3	<15	0	Hemoglobin (g/dL)	>13.5	0
	15–25	+1		11–13.5	+1
	>25	+2		<11	+2
Creatinine	≤ 1.6 mg/dL	0	Glucose	≤180 mg/dL	0
	>1.6 mg/dL	+2		>180 mg/dL	+1
Total LRINEC Score: 0–13

Note: Adapted from Hsiao CT, Chang CP, Huang TY, Chen YC, Fann WC, Spratley J. Prospective validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for necrotizing fasciitis of the extremities. PLoS One. 2020;15(1):e0227748. Creative commons license and disclaimer available from: (http://creativecommons.Org/licenses/by/4.0/legalcode).⁷¹

Table 3 FGSI Score and Performance

Temperature (°C)	Score	Serum Sodium (mmol/L)	Score	Serum Potassium (mmol/L)	Score
> 41	4	<110 or >180	4	<2.5 or >7	4
30–31.9 or 39–40.9	3	111–119 or 160–179	3	6–6.9	3
32–33.9	2	120–129 or 155–159	2	2.5–2.9	2
34–35.9 or 38.5–38.9	1	150–154	1	3–3.4 or 5.5–5.9	1
36–38.4	0	130–149	0	3.5–5.4	0
Heart Rate (beats/min)	Score	Hematocrit (%)	Score	Serum WBC (total/mm^3 x1000)	Score
<39 or >180	4	<20 or >60	4	<1 or >40	4
40–54 or 140–179	3	20–29.9 or 50–59.9	2	1–2.9 or 20–39.9	2
55–69 or 110–139	2	46–49.9	1	15–19.9	1
70–109	0	30–45.9	0	3–14.9	0
Bicarbonate (mmol/L)	Score	Respiratory Rate (breaths/min)	Score	Test Characteristics
<15 or >52	4	<5 or >50	4	FGSI Score	>9
15–17.9 or 41–51.9	3	35–49	3	Sensitivity	67%
18–21.9	2	6–9	2	Specificity	96%
32–40.9	1	10–11 or 25–34	1	Positive LR	16
22–31.9	0	12–24	0	Negative LR	0.4

Note: Adapted by permission from Springer Nature, Int Urol Nephrol.  Kabay S, Yucel M, Yaylak F, et al. The clinical features of Fournier’s gangrene and the predictivity of the Fournier’s gangrene severity index on the outcomes. 40(4):997–1004, copyright (2008).⁷²

Abbreviations: WBC, white blood cell; LR, likelihood ratio.

Figure 2 Anterior-Posterior Radiography of the Pelvis. Note the diffuse scrotal swelling with extensive soft tissue gas formation (white arrows) tracking along the right groin (R). Case courtesy of Dr Ahmed Abdrabou. Fournier gangrene. Radiopedia.org; rID:30310. Available from: https://radiopaedia.org/cases/fournier-gangrene-5?lang=us.⁹⁸

Figure 3 Sagittal Computed Tomography (CT) Image of the Perineum. Note the subcutaneous and fascial emphysema tracking from the rectum throughout the perineum and scrotum (white arrows). Case courtesy of Dr Chris O’Donnell. Fournier gangrene - spontaneous perforation of rectal cancer. Radiopedia.org; rID: 16849 . Available from: https://radiopaedia.org/cases/fournier-gangrene-spontaneous-perforation-of-rectal-cancer?lang=us.⁹⁹

Figure 4 Point of care ultrasound image of the scrotum. Note the diffuse subcutaneous edema and subcutaneous gas adjacent to the testicles (white arrows). Case courtesy of Praveen Jha. Fournier gangrene. Radiopedia.org. rID: 18695. Available from: https://radiopaedia.org/cases/fournier-gangrene-1?lang=us.¹⁰⁰

Box 1 Empiric Antibiotic Regimen for Fournier’s Gangrene

Carbapenem (Imipenem, meropenem, or ertapenem) OR Beta lactam-beta lactamase inhibitor (piperacillin-tazobactam or ampicillin-sulbactam) PLUS Clindamycin for its activity against gram-positive organisms and anaerobes, as well as its antitoxin effects PLUS Vancomycin, daptomycin, or linezolid for activity against gram-positive organisms and MRSA

In patients with severe hypersensitivity to carbapenems or beta lactam-beta lactamase inhibitors, consider: Aminoglycoside OR Fluoroquinolone PLUS Metronidazole

In patients with salt or freshwater exposure, consider adding: Doxycycline

In patients with significant risk for fungal involvement, consider adding: Amphotericin B or fluoroconazoles

Note: Reprinted from J Emerg Med. 57(4): Montrief T, Long B, Koyfman A, Auerbach J. Fournier gangrene: a review for emergency clinicians. 488–500, Copyright (2019), with permission from Elsevier.⁵⁹

Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.

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