Fournier’s gangrene (FG) describes infection and necrosis of the genitalia and perineum due to mixed facultative and anaerobic bowel flora. After treating a patient who presented with necrotizing fasciitis (NF) of the left thigh following a toothpick perforation of the rectum, we hypothesized that NF of the abdominal wall, flank, or thighs might represent atypical Fournier’s gangrene (AFG).
We searched PubMed for English-language articles containing the terms FG, NF, “gastrointestinal,” “bowel,” or “perforation.” As a comparator cohort we used a series of 68 patients with FG described by A.T. Corcoran in 2008. Data were extracted from each case report and statistical analysis was conducted using Student’s t and chi-square tests.
Including own case, we identified 47 pts with AFG, defined as NF of abdominal wall, flank, or thighs; FG had not been diagnosed in any case. Patients with AFG and FG were similar in age (60.7 vs 55.8 years) and gender (63% vs 79% male; p=0.064). AFG pts were less likely to have diabetes than FG pts (13% vs 53%; p<0.001); in the AFG group the most frequent comorbidities were malignancy (32%, mostly colorectal), diabetes, and recent surgery (11%). In both groups, the onset of disease was insidious (mean duration of symptoms prior to presentation 9 and 6.6 days for AFG and FG pts, respectively). Microbiology in AFG and FG was similar; cultures were predominately polymicrobial (76% and 61.8%) with facultative gram-negative and gram-positive bacteria as well as anaerobes. AFG pts underwent a mean of 2.6 debridements while FG pts had a mean 3.4 debridements. Mortality was significantly higher in the AFG group versus the FG group (28% vs 10%, p=0.016).
We propose that NF of the abdominal wall, flank or upper legs that does not involve the perineum or scrotum represents AFG, with etiology, pathophysiology and microbiology closely resembling that of FG. The higher mortality in AFG may reflect the failure to recognize NF of abdominal wall, flank or thighs as a form of FG, one that requires immediate, and often repeat, surgical debridements.
D. M. Musher, None
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