Fournier's Gangrene as a Rare Complication in Patient With Uncontrolled Type 2 Diabetes Treated With Surgical Debridement: a Case Report and Literature Review
Conditions: Fournier Gangrene
Sponsor: University of Catania

Fournier’s gangrene as a rare complication in patient with 
uncontrolled type 2 diabetes treated with surgical 
debridement: a case report and literature review  
Provenzano D*, Lo Bianco S, Zanghì M, Campione A, Vecchio R, Zanghì G  
a Department of General Surgery and Medical-Surgical Specialties, Policlinico – Vittorio Emanuele Hospital, University of 
Catania, Italy  
*Corresponding author: E-Mail address: danieleprov@libero.it (Provenzano D.)  
  
Keywords: Fournier’s gangrene, Type 2 diabetes, surgical debridement, colostomy, Case 
Report  
  
Date of manuscript: 22/12/2020  
  
 
 
 
 
 
 
 
 
 
 
 

ABSTRACT  
INTRODUCTION: Fournier’s gangrene is a potentially fatal emergency condition, 
supported by an infection of perineal and perianal region, characterized by necrotizing 
fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may 
be sustained by many microbial pathogens.   
CASE REPORT: A 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity 
with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the 
Emergency Department with a large area of necrosis involving the perineal and perianal 
regions.  
CONCLUSION: We report a case of FG found as complication in a patient with 
uncontrolled type 2 diabetes, treated with effective combination therapy with surgical 
debridement and antibiotics infusion.  
  
INTRODUCTION  
Fournier’s gangrene (FG) is a rare disease which usually affects men. It is characterized 
by rapidly progressive necrotizing fasciitis of the perianal and genitourinary area (1). Jean  
Alfred Fournier described it in 1883 as an idiopathic process found only in young men (2). 
The epidemiology has changed considerably since it is currently recognized to occur at 
any age and in any gender and with several identifiable aetiological factors (3, 4). The 
report describes a case of a large area of necrosis involving the perineal and perianal 
region. Written informed consent was obtained from the patient for publication of this case 
report and accompanying images. A copy of the written consent is available for review by 
the editor-in-Chief of this journal on request.  
The work has been reported in line with the SCARE criteria (20).  
  

  
CASE REPORT  
A 66-year-old man with uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney 
failure and chronic heart failure presented to the Emergency Department with painful 
swelling in the scrotum and perianal region. The patient reported the onset of symptoms 
about 14 days before his hospitalization, without consulting any doctor due to Covid-19 
pandemic. His blood pressure was 175/75, his pulse 112 beats per minute and his 
temperature 38,5 °C. The physical examination of the perianal region revealed the 
presence of a large area of necrosis, extended laterally from the root of the thighs, 
upwards towards the scrotum and downwards towards the buttocks. The necrosis included 
the entire circumference of the last 3-4 cm of the rectum, extending to the plane of the 
elevators of the anus (Fig. 2). Laboratory tests showed the presence of anaemia, in 
addition to increased leukocyte count, thrombocytopenia and decreased levels of 
haematocrit, bicarbonate, potassium, sodium, calcium, hyperglycaemia, elevated serum 
creatinine level, azotaemia and hypoalbuminemia.   
CT revealed the presence of abscess with maximum diameters 6x4 cm and irregular and 
poorly delineated contours appreciable in the perianal and perirectal sites bilaterally. The 
terminal portion of the rectum appeared contralaterally displaced, in addition to the 
presence of some hydro aerial levels. The abscess extended to the level of the elevator 
anal muscle, bilaterally to the gluteal area and peripherally to the penis. The diagnostic 
imaging test also discovered a thickening of the subcutaneous fat with multiple and 
diffused gaseous bubbles both in the perianal and mesorectum region. CT found the 
presence of some small locoregional enlarged lymph nodes (Fig. 1). Consequently, the 
surgical team discussed the clinical case promptly and made a diagnosis of Fournier’s 
gangrene or necrotizing fasciitis of the perineum.  

The extension of the pathology would have required the execution of a faecal diversion 
such a colostomy. However, the overall clinical situation of the patient led the surgical 
team to proceed differently and to choose a surgical debridement. First therapy planned 
was the administration of resuscitation intravenous fluid. Subsequently, the surgical team 
set an antibiotic therapy based on a combination of Metronidazole and Meropenem. All the 
therapies were in agreement with the nephrologist as a result of known patient medical 
history regarding his chronic kidney failure.  
The patient entered the surgical room approximately two hours after the access to the 
Emergency Department. The surgical team performed an extended surgical debridement 
to healthy tissue of external genital, as well as perineal, perianal, and infrapubic regions.  
The microbiologic culture of the wound specimen revealed Escherichia Coli, so 
Meropenem and Metronidazole were administered until patient discharge. During 
hospitalization, the surgeons made three surgical debridement and five surgical wound 
revisions. The patient was discharged 20 days after the first surgical debridement.  
However, the surgical team scheduled a daily outpatient surgery visit until total healing of 
the perianal region (Fig. 3).  
 Fig.1 Computer Tomography of the abdomen and pelvis that showed the extent of disease.  
  

 
 
 Fig 2 Fournier’s gangrene before treatment.  
 
 
  
 Fig 3 Fournier’s gangrene after treatment.  
DISCUSSION  
Fournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and 
liver failure, as well as smoking, congestive heart failure and immunosuppression. The rate 
of patients affected by Fournier’s gangrene who presents diabetes mellitus is estimated 
between 36-56%, attributed to their small vessel disease, defective phagocytosis, 
neuropathy and immunosuppression (5). FG is one of the rarest but very serious and 
urgent conditions, which appears as a complication in patients with diabetes mellitus. 
Patients usually have a BMI > 30 or higher (6). Colorectal sources such as local infection, 
abscesses, anal fissures, and colonic perforations, in addition to urologic sources such as 

chronic urinary tract infection, neurogenic bladder, as well as Bartholin’s glands or vulvar 
abscess, and hysterectomy in women, may be considered as predisposing factors. 
Although the overall mortality rate is nearly 20-40%, it can be as high as 70-80% if the 
patient presents with sepsis, or lower than 10% whether it treated promptly (Table. 1). 
Most of the patients present fever, purulent collection and sepsis, reporting local 
discomfort. The diagnosis of FG is made by physical examination (7). Cellulitis, herpes 
infection, scrotal abscess, balanitis, orchitis, and polyarteritis nodosa could be considered 
as a differential diagnosis (8). Ultrasonography, x-rays, and magnetic resonance may be 
helpful when the diagnosis is uncertain (9). Radiology studies can be useful to assess the 
extent of disease. Radiography can show hyperlucency concerning soft-tissue gas; 
however, it is not effective to detect deep fascial gas. Scrotal contents and, in some cases, 
testicular involvement can be diagnosed by ultrasonography. CT provides the highest 
specificity for the diagnosis of Fournier’s gangrene and to aid in surgical planning (10); 
furthermore, it can be also useful to identify the presence of fascial air, muscle and fascial 
oedema, fluid tracking, lymphadenopathy and subcutaneous oedema. Magnetic 
Resonance Imaging can be used to evaluate soft tissue and define the extent of 
inflammatory disease, though it may be used occasionally in cases with unclear findings. 
Fournier’s gangrene is an infection of necrotizing soft tissues and Escherichia Coli is the 
most common microbial pathogen; however, additional pathogens could be found such as 
Klebsiella, Pseudomonas, Enterococcus, Streptococcus and Staphylococcus Aureus. The 
polymicrobial nature of Fournier’s gangrene, with contributions by both aerobic and 
anaerobic bacteria, is necessary to create the production of collagenase, streptokinase 
and hyaluronidase which promote the rapid spread of infection. The platelet aggregation, 
formation of clots and inhibit of the phagocytosis of bacteria aid further spread of the 
infection. Bacterial infection spreads from a localized infection as an obliterating 
endarteritis into an ischemia and tissue necrosis, based on the microbiological agent (11). 
The infection tends to spread from the superficial (Colles fascia) to deep fascial planes of 
the perineum. In patients with severe clinical presentation can be found malodorous 

drainage and sloughing in affected sites, with perianal pain, purulent discharge from the 
perineum, crepitus, and fever; due to these critical conditions, they can rapidly deteriorate 
to sepsis and multiorgan failure, the most common cause of death (12). Patients with 
Fournier’s gangrene can be critically ill, so they require immediate resuscitation. Fluid 
resuscitation, correction of electrolyte imbalances, and broad-spectrum intravenous 
antibiotics, including agents against aerobic, anaerobic, Gram-positive, and Gram-negative 
bacteria, must be administered as soon as possible (13). Gentamicin, clindamycin, and 
either ampicillin plus Sulbactam or a third-generation cephalosporin are the recommended 
antibiotics. Agents such as fluconazole, Vancomycin or Piperacillintazobactam should be 
chosen to cover fungal infections (14). The antibiotic therapy should be continued until the 
patient becomes clinically stable; tissue samples should be sent for culture and 
sensitivities in order to target the therapy.  
Early surgical intervention is the mainstay of treatment for Fournier’s gangrene and the 
extensive debridement should be performed within the first 12h of admission (15). 
Debridement includes removal of all nonviable tissue and resection until bleeding skin 
margins are encountered. The wound is irrigated with saline solution after the 
debridement, followed by accurate haemostasis using electrocautery or ligation. It is 
strictly recommended covering exposed tissue with saline-soaked gauze, which should be 
changed frequently throughout the day. VAC system can be used to achieve a clean 
wound to facilitate definitive reconstruction, reduce the length of hospital stay and cost 
(16). Hyperbaric oxygen, when combined with debridement and dressing changes, can 
reduce the healing time (17); however, in this case, it was not applicable due to the severe 
heart disease of the patient. In some cases, depending on the extent of the disease, 
Fournier’s gangrene needs other procedures in addition to wound debridement such as 
colostomy, cystostomy, or orchiectomy; nevertheless, clear indications regarding such 
procedures cannot be found in the literature. The faecal diversion can prevent wound 
contamination and promote healing, so it should be considered (18); however, the choice 
is at the discretion of the general surgery team and remains controversial (19).  

  
Primary author  Year  
Journal  
Number of Fournier's  Mortality rate, %  
Heijkoop et al.  2019  
ANZ J Surg  
14  
7  
C S Meki et al.  2018  
S Afr J Surg  
51  
27  
Chalya et al.  
2015  
BMC Res Notes  
84  
29  
Erdogan et al.  
2015  
Eur J Trauma EmergSurg  
84  
12  
Ngugi et al.  
2014  
AfrHealth Sci  
146  
21  
Ylmazlar et al.  2014  
UlusTravmaAcilCerrahiDerg  
120  
21  
Table 1.  
  
  
CONCLUSION  
Fournier’s gangrene remains a surgical emergency, which must be treated by a 
combination of medical and surgical therapy. The case report describes a large perineal 
and perianal necrotizing fasciitis as a complication in patients with diabetes mellitus. Due 
to the extent of the disease, the case could have been treated with a colostomy, as it has 
been done similarly in previous cases during our experience. However, the combination 
therapy of surgical debridement and antibiotics infusion was effective. In conclusion, it is 
required a prompt application of a multimodal approach with intravenous fluid support, 
antibiotic therapy, correction of metabolic disorders, and an aggressive surgical approach 
to improve the chance to successful therapy.  
Conflicts of interest  
There is no conflict of interest.  
Sources of funding  
There are no sources of funding.  
Ethical Approval  
Approved by ethical commission of our Hospital in Italy.  

Consent  
Written informed consent was obtained from the patient for publication of this case report 
and accompanying images. A copy of the written consent is available for review by the 
editor-in-Chief of this journal on request.  
  
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