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34i
Case Report (it;.
.
:
.‘ : -
‘ a:
.
‘..
V
Fournier
Gangrene
Appendix: Michele
Gaeta,1
Caused
by a Perforated
Retroperitoneal
CT Demonstration Santi
Volta,1
Ansebmo
Minutobi,1
Giovanni
Bartiromo,1
First described in i 883 by Founnien [i ], gangrene of the male genitalia is recognized as a form of necrotizing fasciitis [2]. Although originally considered idiopathic, an underlying cause of the disease can be identified in the majority of patients [2]. Despite aggressive surgical and medical management, Fournier gangrene has a high mortality rate; however, the results of treatment can be improved by early recognition of the disease and its underlying cause. We describe the imaging findings in a case of Fournien gangrene caused by perforated netnopenitoneal appendicitis. To our knowledge, this is the first description of Fournien gangrene caused by appendicitis.
fossa
and
and pelvis
visible
in the
lgnazio
was seen.
retrocecal
Pandolfo2
A i-cm
calcified
appendicolith
also was
retroperitoneum.
A diagnosis of Fournier gangrene caused by perforating appendicitis was made. During surgery, extensive necrotizing fasciitis of the wall
of
the
vaginalis nous
scrotum
were
was
identified.
free of gangrene.
retroperitoneal
appendicitis
The
testes
A diagnosis with
extensive
and
their
of perforated
tunica
gangre-
retroperitoneal
gan-
grene was confirmed. Debridement was performed, and several drains were placed. Antibiotic and hyperbaric oxygen therapy were started after surgery. The patient made a full recovery and was discharged 50 days after admission.
Discussion
Case Report A 27-year-old
man was
admitted
with a 2-day
history
of intermittent
fever, vague pain in the right lumbar region, and a painful swelling of the
revealed
massive
of the right side of the scrotum
without
scrotum.
erythema Abdominal
Clinical tenderness
examination inthe
right lower
quadrant
swelling
and
skin necrosis.
also was present.
Temperature was 38.2#{176}C and WBC count was 6.0 x i09/l. Other laboratory data was unremarkable. A presumptive diagnosis of right epididymitis
was
made.
Sonography
showed
a normal
right
testis
and gas in the subcutaneous tissue of the scrotum. Plain radiographs obtained after sonography confirmed the presence of scrotal gas extending into the pelvis (Fig. iA). CT was performed in order to define better the extension of the disease gas-forming infection of the retroperitoneal
(Fig. 1 B-D). An extensive space in the right iliac
In i 883 Founnien [i] reported five cases of a syndrome characterized by abrupt onset in a healthy young male of rapid progressive gangrene of the scrotum and penis with no obvious cause. Founnien gangrene is a rare but life-threatening mixed anaerobic and aerobic infection [2]. The most common causes of the disease are peniunethnal and penianal infections [2]. Less commonly, gangrene can occur after scrotal skin disruption by trauma or local surgical procedures. Diabetes, immunodeficiency from chemotherapy, and advanced liver on kidney disease are predisposing factors. One case of Fournier gangrene was associated with penfonating sigmoid diverticulitis [2] and a case of gangrene complicating a retnopenitoneal infection has been reported [3]. Meyers [4] has described cases of netnoperitoneal infec-
Received April 30, 1990; accepted after revision July 19, 1990. I 2
Service Institute
of Diagnostic of Radiologic
AJR 156:341-342,
Imaging, Piemonte Hospital, via Spadafora. Sciences, University of Messina, Policlinico
February 1991 0361 -803X/91/1
562-0341
981 24 Messina, Italy. Address Gazzi, 981 00 Messina, Italy.
© American
Roentgen
Ray Society
reprint
requests
to S. Volta,
Bordonaro,
981 00 Messina,
Italy.
Downloaded from www.ajronline.org by 124.106.123.168 on 11/03/15 from IP address 124.106.123.168. Copyright ARRS. For personal use only; all rights reserved
342
GAETA
ET AL.
AJA:156,
February
1991
Fig. 1.-A, Plain radiograph shows mottled scrotal gas (arrowheads) extending upward into pelvis (arrows). B, CT scan through cecum (C) shows a 1-cm appendicolith (arrow), gas, and low-density inflammatory exudate in retroperitoneum. C, CT scan through acetabular roofs reveals gas and inflammatory exudate in posterior pararectal space (P) and in right paravesical space along expected course of ductus deferens (arrowheads). Infection extends anteriorly to deep inguinal ring (long arrow). Note subcutaneous gas in right inguinal region (short arrow). D, CT scan through perineum shows a normal perineum and gas in right spermatic cord (arrowheads) and scrotum (asterisk). Right testis (T) is displaced but not involved by gangrene.
A
tion spreading in the extnaabdominal soft tissues. However, to our knowledge, our case is the first description of a retnopenitoneal infection spreading to the scrotum and is the first reported case of Fournier gangrene caused by appendicitis. The cecum and netnoperitoneal appendix lie in the antenor panarenal space, which is open infeniorly and in communication with extraperitoneal pararectal and panavesicab spaces of the pelvis [4]. In our patient, the ductus deferens is the most likely pathway of spread of the gangrene into the scrotal wall. The ductus defenens lies in the extrapenitoneab paravesical space and exits the pelvis through the inguinal canal surrounded by layers of extrapenitoneal tissue. In our patient, surgery showed that the night ductus deferens was free of gangrene but surrounded by necrotic tissue at the level of the spermatic cord and inguinab canal. Recently, Begley et al. [5] described a case of Founnien gangrene studied with sonognaphy. The sonognaphic charactenistics of Fournien gangrene include thickening of the
scrotal skin and gas in the subcutaneous tissue [5]. Scrotal subcutaneous gas is the hallmark of the disease and is well shown on plain nadiognaphs [5]. In our patient, CT not only showed the scrotal involvement but also revealed the true extension and the underlying cause of the disease.
REFERENCES 1 . Fournier AJ. Etude clinique de Ia gangrene foudroyante de Ia verge. Med 1883;4:68-70 2. Spirnak JP, Resnick MI, Hampel N, Persky L. Foumier’s gangrene: of 20 patients. J Urol 1984;131 :289-291
3. Cope JC, Bunler VB. Gangrene of the scrotum as complication
Semin report
of retro-
peritoneal infection. J Urol 1953;69: 188-190 4. Meyers MA. Pathways of extrapelvic spread of disease. In: Meyers MA, ed. Dynamic radiology of the abdomen: normal and pathologic anatomy. New York: Springer Verlag, 1982:342-352 5. Begley MG, Shawker TH, Robertson CN, Bock SN, Wei JP, Lotze MT. Foumier gangrene: diagnosis with scrotal us. Radiology 1988:169: 387-389
34i
Case Report (it;.
.
:
.‘ : -
‘ a:
.
‘..
V
Fournier
Gangrene
Appendix: Michele
Gaeta,1
Caused
by a Perforated
Retroperitoneal
CT Demonstration Santi
Volta,1
Ansebmo
Minutobi,1
Giovanni
Bartiromo,1
First described in i 883 by Founnien [i ], gangrene of the male genitalia is recognized as a form of necrotizing fasciitis [2]. Although originally considered idiopathic, an underlying cause of the disease can be identified in the majority of patients [2]. Despite aggressive surgical and medical management, Fournier gangrene has a high mortality rate; however, the results of treatment can be improved by early recognition of the disease and its underlying cause. We describe the imaging findings in a case of Fournien gangrene caused by perforated netnopenitoneal appendicitis. To our knowledge, this is the first description of Fournien gangrene caused by appendicitis.
fossa
and
and pelvis
visible
in the
lgnazio
was seen.
retrocecal
Pandolfo2
A i-cm
calcified
appendicolith
also was
retroperitoneum.
A diagnosis of Fournier gangrene caused by perforating appendicitis was made. During surgery, extensive necrotizing fasciitis of the wall
of
the
vaginalis nous
scrotum
were
was
identified.
free of gangrene.
retroperitoneal
appendicitis
The
testes
A diagnosis with
extensive
and
their
of perforated
tunica
gangre-
retroperitoneal
gan-
grene was confirmed. Debridement was performed, and several drains were placed. Antibiotic and hyperbaric oxygen therapy were started after surgery. The patient made a full recovery and was discharged 50 days after admission.
Discussion
Case Report A 27-year-old
man was
admitted
with a 2-day
history
of intermittent
fever, vague pain in the right lumbar region, and a painful swelling of the
revealed
massive
of the right side of the scrotum
without
scrotum.
erythema Abdominal
Clinical tenderness
examination inthe
right lower
quadrant
swelling
and
skin necrosis.
also was present.
Temperature was 38.2#{176}C and WBC count was 6.0 x i09/l. Other laboratory data was unremarkable. A presumptive diagnosis of right epididymitis
was
made.
Sonography
showed
a normal
right
testis
and gas in the subcutaneous tissue of the scrotum. Plain radiographs obtained after sonography confirmed the presence of scrotal gas extending into the pelvis (Fig. iA). CT was performed in order to define better the extension of the disease gas-forming infection of the retroperitoneal
(Fig. 1 B-D). An extensive space in the right iliac
In i 883 Founnien [i] reported five cases of a syndrome characterized by abrupt onset in a healthy young male of rapid progressive gangrene of the scrotum and penis with no obvious cause. Founnien gangrene is a rare but life-threatening mixed anaerobic and aerobic infection [2]. The most common causes of the disease are peniunethnal and penianal infections [2]. Less commonly, gangrene can occur after scrotal skin disruption by trauma or local surgical procedures. Diabetes, immunodeficiency from chemotherapy, and advanced liver on kidney disease are predisposing factors. One case of Fournier gangrene was associated with penfonating sigmoid diverticulitis [2] and a case of gangrene complicating a retnopenitoneal infection has been reported [3]. Meyers [4] has described cases of netnoperitoneal infec-
Received April 30, 1990; accepted after revision July 19, 1990. I 2
Service Institute
of Diagnostic of Radiologic
AJR 156:341-342,
Imaging, Piemonte Hospital, via Spadafora. Sciences, University of Messina, Policlinico
February 1991 0361 -803X/91/1
562-0341
981 24 Messina, Italy. Address Gazzi, 981 00 Messina, Italy.
© American
Roentgen
Ray Society
reprint
requests
to S. Volta,
Bordonaro,
981 00 Messina,
Italy.
Downloaded from www.ajronline.org by 124.106.123.168 on 11/03/15 from IP address 124.106.123.168. Copyright ARRS. For personal use only; all rights reserved
342
GAETA
ET AL.
AJA:156,
February
1991
Fig. 1.-A, Plain radiograph shows mottled scrotal gas (arrowheads) extending upward into pelvis (arrows). B, CT scan through cecum (C) shows a 1-cm appendicolith (arrow), gas, and low-density inflammatory exudate in retroperitoneum. C, CT scan through acetabular roofs reveals gas and inflammatory exudate in posterior pararectal space (P) and in right paravesical space along expected course of ductus deferens (arrowheads). Infection extends anteriorly to deep inguinal ring (long arrow). Note subcutaneous gas in right inguinal region (short arrow). D, CT scan through perineum shows a normal perineum and gas in right spermatic cord (arrowheads) and scrotum (asterisk). Right testis (T) is displaced but not involved by gangrene.
A
tion spreading in the extnaabdominal soft tissues. However, to our knowledge, our case is the first description of a retnopenitoneal infection spreading to the scrotum and is the first reported case of Fournier gangrene caused by appendicitis. The cecum and netnoperitoneal appendix lie in the antenor panarenal space, which is open infeniorly and in communication with extraperitoneal pararectal and panavesicab spaces of the pelvis [4]. In our patient, the ductus deferens is the most likely pathway of spread of the gangrene into the scrotal wall. The ductus defenens lies in the extrapenitoneab paravesical space and exits the pelvis through the inguinal canal surrounded by layers of extrapenitoneal tissue. In our patient, surgery showed that the night ductus deferens was free of gangrene but surrounded by necrotic tissue at the level of the spermatic cord and inguinab canal. Recently, Begley et al. [5] described a case of Founnien gangrene studied with sonognaphy. The sonognaphic charactenistics of Fournien gangrene include thickening of the
scrotal skin and gas in the subcutaneous tissue [5]. Scrotal subcutaneous gas is the hallmark of the disease and is well shown on plain nadiognaphs [5]. In our patient, CT not only showed the scrotal involvement but also revealed the true extension and the underlying cause of the disease.
REFERENCES 1 . Fournier AJ. Etude clinique de Ia gangrene foudroyante de Ia verge. Med 1883;4:68-70 2. Spirnak JP, Resnick MI, Hampel N, Persky L. Foumier’s gangrene: of 20 patients. J Urol 1984;131 :289-291
3. Cope JC, Bunler VB. Gangrene of the scrotum as complication
Semin report
of retro-
peritoneal infection. J Urol 1953;69: 188-190 4. Meyers MA. Pathways of extrapelvic spread of disease. In: Meyers MA, ed. Dynamic radiology of the abdomen: normal and pathologic anatomy. New York: Springer Verlag, 1982:342-352 5. Begley MG, Shawker TH, Robertson CN, Bock SN, Wei JP, Lotze MT. Foumier gangrene: diagnosis with scrotal us. Radiology 1988:169: 387-389
