|Year : 2007 | Volume
| Issue : 2 | Page : 66-67
Clinical study of Fournier's gangrene with acute renal failure
C Krishna Kishore1, Rama Krishna1, P Rama Krishna1, VV Sai Naresh1, Y Mutheeswaraiah2, M Seetharam Sarma2, V Siva Kumar1
1 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences University, Tirupati, Andhra Pradesh, India
2 Department of Surgery, Sri Venkateswara Institute of Medical Sciences University, Tirupati, Andhra Pradesh, India
V Siva Kumar
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Fournier's gangrene is an uncommon infection of the genital, perineal and perianal regions. The infection is both dramatic in nature and highly lethal in course. The mortality of the disease is high, despite the advancements in management. Multiorgan dysfunction is one of the predictors of severity and mortality of the disease. The association of acute renal failure and Fournier's gangrene is not often discussed; hence, this study is being presented. This study comprised of six patients presented with Fournier gangrene and associated acute renal failure.
Keywords: Acute renal failure, Fournier′s gangrene
|How to cite this article:|
Krishna Kishore C, Krishna R, Rama Krishna P, Sai Naresh V V, Mutheeswaraiah Y, Seetharam Sarma M, Siva Kumar V. Clinical study of Fournier's gangrene with acute renal failure. Indian J Nephrol 2007;17:66-7
|How to cite this URL:|
Krishna Kishore C, Krishna R, Rama Krishna P, Sai Naresh V V, Mutheeswaraiah Y, Seetharam Sarma M, Siva Kumar V. Clinical study of Fournier's gangrene with acute renal failure. Indian J Nephrol [serial online] 2007 [cited 2020 Jun 6];17:66-7. Available from: http://www.indianjnephrol.org/text.asp?2007/17/2/66/37023
| Introduction|| |
Fournier's gangrene is a fulminant form of infective necrotizing fascitis of the perineal, genital or perianal regions, which commonly affects young men. This clinical entity is eponymously accredited to Jean-Alfred Fournier, although its existence was known much earlier.  Despite advances in management, mortality is still high averaging 30-50%.  A diligent search will point towards the source of infection as perineal, perianal or anorectal. The most common foci include the gastrointestinal tract (30-50%), followed by the genitourinary tract (20-40%) and cutaneous injuries (20%).  Comorbid systemic disorders are identified in increasing number of patients with Fournier's gangrene, the commonest being diabetes mellitus and alcohol misuse.  The emergence of HIV pandemic is of great concern. In Fournier's gangrene, suppurative bacterial infection results in microthrombosis of the small cutaneous vessels leading to the development of gangrene of the overlying skin. Cultures from the wounds commonly show polymicrobial infections by aerobes and anaerobes, which include coliforms, klebsiella, streptococci, staphylococci, clostridia, bacteroids and corynebacterium.  Fournier's gangrene shows vast heterogeneity in clinical presentation from insidious onset and slow progression to rapid onset and fulminant course, the latter being the most common presentation. Systemic signs are usually severe and out of proportion to the local extent of the disease. Crepitus of the inflamed tissue is a common feature owing to the presence of gas forming organisms. Treatment mainly includes broad spectrum antibiotics and intermittent debridement of the wound. The association of renal failure with Fournier's gangrene is not often discussed. Hence, we made an attempt to find out the association and outcome with regard to the association of acute renal failure with this entity. The data was collected from the medical records of all patients with Fournier's gangrene and renal failure who were treated and followed up between 2000 and 2006 in our institute.
| Case Report|| |
During the period of six years from 2000 to 2006 we encountered six patients who presented Fournier's gangrene with renal failure. The details of evaluation, management and outcome are presented in [Table - 1].
| Discussion|| |
Necrotizing fascitis, in the regions of perineum and genitalia, should be termed as Fournier's gangrene with or without proven infection.  Certain systemic conditions are encountered with sufficient frequency in those with Fournier's gangrene to suggest a cause-and-effect relationship. Comorbid factors such as diabetes mellitus, chronic alcoholism and HIV play an important role in the severity and outcome. , Rarer coexistences such as filariasis and scabies were reported in the literature.  Polymicrobial cultures of aerobes and anaerobes are the rule rather than an exception. In bacterial synergism, one bacterium produces a nutrient for another, which in turn produces a leucocidal toxin. Synergism also involves the production of exotoxins, whose activities result in tissue necrosis and synthesis of gases that produce the repulsive stench and crepitus, pathognomonic of anaerobic infection.  The causes of death include severe sepsis, coagulopathy, acute renal failure, diabetic ketoacidosis and multiorgan failure.  The most common source of infection was from the skin. Gangrene originating from anorectal source shows the highest associated mortality from the three major sources of sepsis. The extent of gangrene was calculated for each patient based on the modified body surface area nomograms routinely used to assess the extent of burn injuries: the penis, scrotum and perineum accounted for 1% surface area each and each ischiorectal fossa as 2.5%.  Fournier's gangrene severity index (FGSI) was devised to assess the significance of various laboratory and clinical parameters in predicting the mortality and severity of the disease.  Although we found higher values of FGSI [Table - 1], we could not correlate the severity of Fournier's gangrene with the associated acute renal failure. The treatment of Fournier's gangrene must be prompt, pragmatic and individualized. Among the modalities of treatment, surgical debridement is the most crucial one with antibiotic support. The management of acute renal failure was decided on basis of the severity. We encountered six patients with Fournier's gangrene in association with acute renal failure. Among them, the grade of renal failure was mild in three, moderate in one and severe in two. One of them received hemodialysis support. Of the total six patients with acute renal failure, three left against advice and the remaining three patients recovered.
In conclusion, we show that Fournier s gangrene is a fulminant form of infective necrotizing fascitis of the perineal, genital or perianal regions. It is associated with high mortality. During 2000-2006, we encountered six patients who presented with Fournier gangrene with acute renal failure; three patients recovered and the remaining left against advice and can be presumed to have died.
| References|| |
|1.||Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol 1998;81:347-55. [PUBMED] |
|2.||Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier's gangrene: Experience with 25 patients and use of Fournier's gangrene severity index score. Urology 2004;64:218-22. [PUBMED] [FULLTEXT]|
|3.||Thwain A, Khan A, Malik A, Cherian J, Barua J, Shergil I, et al . Fournier's gangrene and its emergency management. Postgrad Med J 2006;82:516-9. |
|4.||Laucks SS II. Fournier's gangrene. Surg Clin North Am 1994;74:1339-52. |
|5.||Eke N. Fournier's gangrene: A review of 1726 cases. Br J Surg 2000;87:718-28. [PUBMED] [FULLTEXT]|
|6.||Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier's gangrene. J Urol 1995;154:89-92. [PUBMED] [FULLTEXT]|
[Table - 1]