Presentation
Left gluteal pain.
Patient Data
There is hyperattenuation and extensive subcutaneous air noted along the left gluteal fold extending superiorly and anteriorly involving the perineum. Additionally, air extends into the pelvic cavity with air seen within the left perivesicular fat.
Case Discussion
This is a case of Fournier's gangrene.
The patient initially presented to the emergency department with a chief complaint of left gluteal pain. The patient had a history of cellulitis secondary to insulin injections. Free air was found on imaging in the left gluteal and sacral regions, which prompted the concern for Fournier's gangrene. The patient then underwent surgical debridement utilizing excision with pulse lavage which revealed extensive areas of necrosis with dishwater drainage of soft tissue along the fascial planes.
Pathological examination showed acute suppurative necrotic subcutaneous and skeletal muscle tissue with polymicrobial (fungal and bacterial) colonization. A von Kossa stain showed calcified elastic fibers and stippled calcifications in the smaller vessels of the subcutaneous adipose tissue, raising concern for underlying calciphylaxis.
She was treated with piperacillin/tazobactam followed by amoxicillin/clavulanic acid. Throughout her hospitalization course, she required 13 courses of surgical debridement.
Co-author:
Jakob Dickson
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