Zgraj et al. Journal of Medical Case Reports 2011, 5:576 http://www.jmedicalcasereports.com/content/5/1/576 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Neonatal scrotal wall necrotizing fasciitis (Fournier gangrene): a case report Oskar Zgraj1*, Sri Paran1, Maureen O’Sullivan2 and Feargal Quinn1 Abstract Introduction: Necrotizing fasciitis in neonates is rare and is associated with almost 50% mortality. Although more than 80 cases of neonates (under one month of age) with necrotizing fasciitis have been reported in the literature, only six of them are identified as originating in the scrotum. Case presentation: We report the case of a four-week-old, full-term, otherwise-healthy Caucasian baby boy who presented with an ulcerating lesion of his scrotal wall. His scrotum was explored because of a provisional diagnosis of missed torsion of the testis. He was found to have necrotizing fasciitis of the scrotum. We were able to preserve the testis and excise the necrotic tissue, and with intravenous antibiotics there was a successful outcome. Conclusions: Fournier gangrene is rarely considered as part of the differential diagnosis in the clinical management of the acute scrotum. However, all doctors who care for small babies must be aware of this serious condition and, if it is suspected, should not hesitate in referring the babies to a specialist pediatric surgical center immediately. Introduction Testicular torsion is a surgical emergency and is com- monly seen in children between five and 15 years of age. Neonatal torsion of the testis is a well-recognized condi- tion in which an extravaginal torsion of the testis is known to occur before birth and invariably is associated with a necrotic testis [1]. A firm and often painless testi- cular mass is detected at birth, with or without skin dis- coloration and edema. Necrotizing fasciitis in neonates is extremely rare and is associated with almost 50% mortality [2]. Although more than 80 cases of neonates (under one month of age) with necrotizing fasciitis have been reported in the literature [2], only six of them are identified as originat- ing in the scrotum [3-7]. There are also reports of peri- testicular abscess mimicking or resulting from neonatal torsion [8,9]. Fournier gangrene is rarely considered as part of the differential diagnosis in the clinical manage- ment of the acute scrotum. * Correspondence: oskarzgraj@mp.pl 1Department of Paediatric Surgery, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland Full list of author information is available at the end of the article Case presentation A 10-day-old, full-term Caucasian baby boy presented with viral gastroenteritis to his local hospital. During admission, pediatric surgical services were consulted for left scrotal swelling and a diagnosis of a left hydrocele was made and patient was discharged. Seventeen days later (at four weeks of age), he presented with a 24-hour history of left scrotal swelling, erythema, pyrexia, and a pus-like discharge from an ulcerated area in his left hemi-scrotum. The results of an abdominal examination were normal, and a scrotal examination revealed a left scrotal abscess with a hard swollen left testis. No hernia was identified. A provisional diagnosis of missed neona- tal testicular torsion was made and the baby was pre- pared for immediate surgical exploration. Intravenous antibiotics (amoxicillin with clavulanic acid and flucloxa- cillin) and fluids were commenced in light of the local scrotal infection. A midline raphe scrotal incision was used. A small amount of pus was evacuated, and a necrotic scrotal wall with an appearance similar to that of Fournier gangrene was excised back to the healthy tissue margin. The excised tissue was sent for histology and microbiology. The tunica vaginalis was thickened, and the testis was found to be edematous with normal blood supply. There © 2011 Zgraj et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.