Presentation
Patient who is diabetic and tetraplegic following a road traffic accident attends the Emergency Department with a fever and deterioration of his pressure sores.
Patient Data
Selected axial slices show extensive gas within the subcutis and soft tissues of the pelvis as well as collections within the perineum and posterior compartment of the right thigh. The right spermatic cord is thickened and diffusely inflamed with extension to the scrotum. The destructive changes at the right ischial tuberosity and greater trochanter are related to chronic osteomyelitis when referring to the previous study.
Case Discussion
This is a case of Fournier's gangrene showing florid necrotizing fasciitis (infection of the deep soft-tissues) centered on the perineum and external genitalia.
The cause can be either mono or polymicrobial with Streptococcus Pyogenes often being the culprit in the former. Treatment is emergency debridement of the infected & nonviable tissue.
Garden-variety necrotizing fasciitis can often be difficult clinically to differentiate from severe cellulitis through several scoring systems to aid establish diagnosis. Severe pain in early stages & blister formation over the skin in late stages are often clues for the physician.
Indeed the surgical team found this diagnosis difficult to accept given the profound lack of pain but note the history of tetraplegia. Sometimes clinical correlation is truly required!
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