Stesura Seveso Archivio Italiano di Urologia e Andrologia 2017; 89, 3238 CASE REPORT Distant subcutaneous spreading of Fournier’s gangrene: An unusual clinical identification by preoperative ultrasound study Lucio Dell’Atti, Daniele Cantoro, Guevar Maselli, Andrea Benedetto Galosi Department of Urology, University Hospital “Ospedali Riuniti”, Ancona, Italy. We present here the first case of successful management via preoperative ultrasono- graphic (US) study to detect a distant spreading of Fournier’s gangrene (FG), which was happened in a 75-year-old man. US study showed the necrotizing infection in the periumbilical region distant 22 cm from the genital tract. A target incision of this periumbilical area and debridement of necrotic tissues was made. Computed tomography (CT) is superior to ultrasonogra- phy to confirm the diagnosis of FG and support in surgical management, but a CT evaluation in patients with FG may be limited by the frequent presence of concurrent acute renal fail- ure or patient hemodynamic instability. Ultrasonography is an ideal technique for evaluating patients in bedside settings and can be routinely used in an emergency. KEY WORDS: Fournier’s gangrene; Ultrasonography; Computed tomography. Submitted 6 March 2017; Accepted 27 March 2017 Summary No conflict of interest declared. body temperature 38°C. His blood count showed: haemoglobin level, 11.3 g/dL, white blood cell count, 17.000/mm3, and platelet count, 185.000/mm3. C-reactive protein level was 13 mg/dL, glucose 280 mg/ dL and creatinine level was 1.4 mg/dL. Physical examination showed genital and perineal swelling, with erythema, edema and necrotic tissue over his scrotum with extension to the perineum (Figure 1A); subcutaneous crepitation was also present. As part of the initial assessment, the patient received an US study that demonstrated marked thickening of the scrotal fascia with edema and high-amplitude echoes, as well as an area of subcutaneous gas in the periumbilical region was discovered distant 22 cm from the genital tract (Figure 1B). However, a contrast-enhanced com- puted tomography (CT) was performed to differentiate areas of subcutaneous gas in the periumbilical and genital regions (Figure 2). These findings were com- patible with Fournier gangrene. Immediate broad spectrum antibiotic administration were initiated. Although the initial vital signs were normal, he rapid- ly developed septic shock and was emergently taken to the operating room for aggressive surgical therapy including target incision on the periumbilical localiza- tion of infection and debridement of necrotic tissues until to be able to contain the progression of the gan- grene. The patient was discharged after a flap recon- struction over the scrotum and 28 days of hospitaliza- tion. The clinical follow-up was 6 months and showed no signs of infectious or ischaemic complications. DISCUSSION FG was first described by Jean Alfred Fournier, a French venereologist, in 1883. At that time, it was described as abrupt in onset with rapid progression to gangrene, but without a clear aetiology. The disease was noted to occur most commonly in young males (4). Today, FG is most commonly found in middle-aged men (50-60 years) and, to a much lesser extent, in women (2). FG shows vast het- erogeneity in clinical presentation, from insidious onset and slow progression to rapid onset and fulminant course. The characteristic of this necrotizing infection is gas pro- duction by the bacterial organisms, which can sometimes (but not always) be assessed on physical exam. However, DOI: 10.4081/aiua.2017.3.238 INTRODUCTION Fournier’s gangrene (FG) is an acute, rapidly progressive necrotizing soft-tissue infection of the external genitalia and perineum (1). If not recognized and treated early, it is associated with high morbidity and mortality (2). In addition to the physical exam, there are several diag- nostic procedures that can be used to evaluate this necro- tizing infection. Ultrasonographic (US) study allows to evaluate a scrotal pathology or soft tissue collection, and has been shown to identify subcutaneous gas, even prior to the overt development of crepitus on physical exam (3). We here report the first case of successful manage- ment via preoperative US study to detect a distant spreading of FG and allow proper surgical debridement. CASE REPORT A 75-years-old male patient presented to our Emergency Department for generalized malaise, fever, appearance of edema, scrotal erythema, and pain symptoms in the perianal region not responsive to the most common anti-inflammatory drugs. The patient's medical history was remarkable for a history of hyper- tension and diabetes mellitus, diagnosed twenty years ago. On admission, his vital signs were as follows: blood pressure 135/80 mmHg; heart rate 98 bpm and Dell'Atti2_Stesura Seveso 01/10/17 15:42 Pagina 238 239Archivio Italiano di Urologia e Andrologia 2017; 89, 3 Distant subcutaneous spreading of Fournier’s gangrene an early diagnosis is important because immediate surgi- cal debridement and aggressive antibiotic treatment are indicated (1, 3). Thorough physical examination and clin- ical assessment are favourable for a correct diagnosis of FG, but laboratory studies and imaging can be useful for risk stratification and to identify a potential source, respec- tively. Radiological exams, including radiography, ultra- sonography, and CT, can be of value to assess the extent of disease. Radiography is the least costly option and can, in some cases, show hyperlucency representing soft-tissue gas before the accompanying clinical crepitations (3). Traditionally, owing to its low cost, ready availability, US study has been the primary modality for imaging of the scrotum and can be utilized to examine the scrotal con- tents, and determine testicular involvement. Overall, CT is superior to both ultrasonography and radiography to con- firm the diagnosis of FG and support in surgical manage- ment. McGillicuddy et al. in a review of CT findings on adult patients undergoing imaging for the evaluation of a soft-tissue infection reported a sensitivity of 86.3% and a specificity of 91.5%, with a negative predictive value of 85.5% (5). However, imaging evaluation in patients with FG may be limited by the frequent presence of concurrent acute renal failure (thus precluding the use of intravenous contrast material) or patient hemodynamic instability making transport to the Radiology Department unsafe. US study can be readily performed in bedside settings, which is of particular benefit to patients who are hemodynami- cally unstable but whose physical examination findings are equivocal (6). The characteristic US features of necro- tizing infections comprise subcutaneous multiple hypere- choic foci that show reverberation artefacts, causing “dirty” shadowing that represents gas (Figure 3) (1, 6). In conclusion we believe that US study constitutes an excellent minimally invasive alternative in such situations, reduces the extension of surgical field allowing a quick recovery and the risk of under treatment, can value alter- nate pathologies, such as epididymitis and torsion, does not expose patients to radiation, and does not require con- trast-enhanced. Based on our experience, a preoperative US study may identify easy and precisely distant foci of infection spreading avoiding wide surgical field and pro- vide earlier control of disease. REFERENCES 1. Di Serafino M, Gullotto C, Gregorini C, et al. A clinical case of Fournier's gangrene: imaging ultrasound. J Ultrasound. 2014; 17:303-6. 2. Luján Marco S, Budía A, Di Capua C, et al. Evaluation of a sever- ity score to predict the prognosis of Fournier's gangrene. BJU Int. 2010; 106:373-6. 3. Levenson RB, Singh AK, Novelline RA. Fournier gangrene: role of imaging. Radiographics. 2008; 28:519-28. 4. Fournier AJ. Gangrene foundroyante de la verge. Semaine Med. 1883; 3:344-46. 5. McGillicuddy EA, Lischuk AW, Schuster KM, et al. Development of a computed tomography-based scoring system for necrotizing soft- tissue infections. J Trauma, 2011; 70:894-9. 6. Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR. 1998; 170:163-8. Correspondence Lucio Dell’Atti, MD, PhD (Corresponding Author) dellatti@hotmail.com Daniele Cantoro, MD - Daniele.Cantoro@ospedaliriuniti.marche.it Guevar Maselli, MD - guevarmaselli@katamail.com Andrea Benedetto Galosi, MD - galosiab@yahoo.it Department of Urology - Marche Polytechnic University University Hospital “Ospedali Riuniti” 71 Conca Street - 60126 Torrette, Ancona, Italy Figure 1. Genital and perineal swelling, with edema and necrotic tissue over the scrotum and perineum secondary to Fournier’s gangrene (A). Ultrasonographic probe reported an area of subcutaneous gas in the periumbilical region (distant 22 cm from the genital tract, B). Figure 2. Longitudinal scan of contrast- enhanced computed tomography shows a distant subcutaneous spreading of Fournier’s gangrene (yellow arrow). Figure 3. The characteristic ultrasonographic features of necrotizing infection comprise subcutaneous multiple echoic spots that show reverberation artefacts, causing “dirty” shadowing that represents gas (yellow arrow). Dell'Atti2_Stesura Seveso 01/10/17 15:42 Pagina 239