Case Presentation Aug 2008

Carrie Fitzgerald

GCH URO-1

HPI

63 yo caucasian male admitted with acute mental status change, wife noted confusion at home; did not know his name, no unsteady gait, + lethargy. + RUQ pain, no fever, chills, N/V, + diarrhea. No GU sxs.

H/O ETOH abuse but not current, family concern after 24 hours ER

Initial work-up/tx Sepsis and encephalopathy; Intra-abdominal anterior

wall abscess on CT scan (8-16-08) WBC 25.7 bands 12, H/H 11.2/32.2, AlkP 281, Cr 1.22 Nh4 109

Bedside I and D, ICU pressors, IVF resuscitation, antibiotics

PMHx/PSHx

Cirrhosis secondary to etoh abuse on sandostatin Lupus Crohn’s disease on Entocort, prednisone; chronic Gi bleed CAD s/p MI 2006 Afib on coumadin and sotalol Legally blind secondary to retinal detachment Back pain with compression fractures thoracic spine GERD esopahgeal stricture Anemia of chronic disease

PSHx AICD, left inquinal hernia repair, r retinal detachment repair,

appendectomy age 10

Physical exam

VS T 94.7 P 102 R 18 BP 103/68 213 lbs 5’9” Morbidly obese Anasarca, with skin breakdwn Groin, upper thigh bullous edema Abdominal striae, RLQ pain, Fluctuant necrotic lesion on scrotum

(8cm-6cm) RLQ induration, erythema

around inguinal abscess

s/p I and D, no granulation

tissue, no adenopathy

Laboratory findings

WBC 24.6H/H 12.7Plt 73Na 141 K 5.2 Cl 111 bicarb 18.5BUN 44Cr 2.26Alb 1.7PT 17.8 INR 1.72 PTT 38

Cx 8-16-08 s/p bedside extra abdominal abscess I and D Corynebacterium Alpha streptococcous not group D Staphylococcus-coagulase negative

Imaging

CT scan Hosp day #1 CT scan Hosp day #2 Scrotal U/S

Impression

Fourniers gangrene vs scrotal abscess R inguinal extra-abdominal abscess with

eneterocutaneous fistula secondary to Crohn’s disease

Anterior abdominal wall abscess secondary to Crohn’s diease

Multiple enteroenetric fistulas secondary to Crohn’s disease

Adrenal insufficiency

Procedure

Emergent scrotal exploration Scrotal debridement R inguinal abscess debridement Drain placement

Post operative diagnosis

Fourniers gangrene of the scrotum

R inguinal extra-abdominal abscess with eneterocutaneous fistula secondary to Crohn’s disease

Cultures pending

Hematuria secondary to foley trauma

Fournier’s disease

Predisposing factors: DM, adrenal insufficiency, immune system disorders, etoh abuse, morbid obesity

10:1 male, age 60-80 Local trauma, paraphimosis, periurethral

extravasation or urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy, strictures with STD’s

Signs symptoms Crepitant ("spongy" to the touch) skin Swelling, blistering of the penis and scrotum Dead and discolored (gray-black) tissue; pus weeping from injury Foul odor Pain out of proportion Dysuria, urethral discharge, and obstructed voiding Marked systemic toxicity out of proportion to the local finding Sepsis; Altered mental status, tachypnea, tachycardia, and temperature greater

than 38.3° C (101° F) or less than 35.6° C (96° F) suggest gram-negative sepsis.

Pathophysiology

Infection arising from skin, urethra, rectum (uterus, bartholin glands in females)

Bacteria spread along the dartos fascia of the scrotum and penis, Colles' fascia of the perineum, and Scarpa's fascia of the anterior abdominal wall

Necrotizing fascitis of the skin and superficial and deep fascia No extension beyond Buck’s facsia that separate muscles and protect

nerves and vessels of the genital area. corpora cavernosa, testicles, and urethra are not usually affected. ~ 95% of the cases, a source identified

Mixed cultures; E. coli, Klebsiella, enterococci and anaerobes ie Bacteroides, Fusobacterium, Clostridium, microaerophilic streptococci

Treatment

Triple antibiotic therapy Intravenous hydration Emergent exploration, debridement to healthy tissue

margins May requires re-exploration in 24 hours +/- bariatric oxygen therapy Orchiectomy rarely required Reconstruction ie. myocutaneous flapsComplications 7-75% (16-40%) mortality Sepsis

Complications

References

Campbells’ urology 9th edition EMedicine