A 43-year-old man comes to the hospital following 24 hours of increasing pain in the lower abdomen, scrotum, and perineum. He also has experienced malaise and nausea. He has had no abdominal surgeries or recent perianal or scrotal trauma. The patient has a history of morbid obesity, hypertension, type 2 diabetes mellitus, hypercholesterolemia, and heart failure with preserved systolic function. Temperature is 39.7 C (103.5 F), blood pressure is 80/60 mm Hg, pulse is 112/min, and respirations are 18/min. Pulse oximetry shows 96% on room air. BMI is 47 kg/m². The patient appears ill and uncomfortable. There is no jugular venous distension. Lungs are clear to auscultation. Heart sounds are normal. The skin over the lower abdomen, scrotum, and perineum is tense, tender, erythematous, and swollen with evidence of crepitus. Mild, bilateral, lower extremity edema is present. Laboratory results are as follows: Blood cultures are obtained, and intravenous fluids and antibiotics are initiated. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient's rapid-onset skin infection of the lower abdomen, scrotum, and perineum with crepitus and significant systemic manifestations (eg, hypotension, high fever, leukocytosis) likely indicates Fournier gangrene, a life-threatening necrotizing fasciitis that quickly progresses to sepsis and death without intervention. Most cases arise in the setting of cutaneous breakdowns in the perianal or genital region, which allow a portal of entry for polymicrobial colonic or urogenital organisms. The infection then spreads along the subcutaneous fat via fascial planes and results in microthrombi of cutaneous vessels, leading to subsequent gangrene of the skin. Risk is greatest in those with poorly controlled diabetes mellitus and obesity. Manifestations generally arise rapidly and include: Swelling, tenderness, and crepitus in the perineum, scrotum, and/or lower abdomen Severe systemic symptoms such as high fever and hypotension Significant but nonspecific laboratory abnormalities such as leukocytosis, acidemia, renal insufficiency, and coagulopathy Broad-spectrum antibiotics and intravenous fluids should be administered with urgency, but definitive diagnosis and treatment requires early surgical exploration and debridement. Although early surgical intervention improves outcomes and survival rates, >20% of patients with Fournier gangrene die during hospitalization. (Choice A) Imaging delays surgical intervention and is generally not recommended when the presentation is highly suspicious for Fournier gangrene (eg, skin crepitus, rapid onset of symptoms, hypotension). (Choice C) Hyperbaric oxygen therapy increases oxygen tissue delivery and may help reduce the ischemia seen in Fournier gangrene. However, surgery is required first in order to remove nonviable tissue and prevent the propagation of the infection. (Choice D) Glucocorticoids are sometimes given to patients in refractory septic shock (eg, systolic blood pressure <90 mm Hg for >1 hour despite intravenous fluids and vasopressor agents) as they speed shock resolution (although effects on mortality are limited). This patient with a necrotizing skin infection requires surgery and does not meet criteria for refractory septic shock (eg, no vasopressors); glucocorticoids would not be indicated at this time. (Choice E) This patient would likely receive supportive care in the intensive care unit following surgery; surgical intervention to remove necrotic tissue is required first. Educational objective: Fournier gangrene is a life-threatening necrotizing fascitis that typically affects perineal, scrotal, and lower abdominal skin. Patients generally have rapid-onset swelling, tenderness, and crepitus of the affected region and significant systemic symptoms (eg, hypotension, high fever). Rapid surgical intervention is required to prevent death and should not be delayed for imaging. References: Fournier's gangrene and its emergency management. (http://www.ncbi.nlm.nih.gov/pubmed/16891442)

A 43-Year-Old Man Comes to the Hospital Following 24 Hours