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Case 415

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A 48-year-old man with uncontrolled type 2 diabetes presents with a 4-day history of progressive scrotal and penile pain, scrotal swelling and fever. Physical examination showed: regular general appearance, severe scrotum edema with local erythema and crepitus; positive cremasteric reflex. Digital rectal exam without masses or collections. Capillary blood glucose: 247 mg/dL, white blood cells: 12420 cells/mm³ (87% neutrophils, 3% band neutrophils) and C-Reactive Protein: 347 mg/L. Computed tomography of the pelvis was requested.

a) Testicular torsion

25%

b) Acute epididymo-orchitis

25%

c) Appendiceal torsion

25%

d) Fournier's gangrene

25%
   

Image Analysis

Image 1: Axial computed tomography (CT) of the pelvis, section level of the inguinal region, without intravenous contrast. Fat stranding (blue arrows), gas – subcutaneous emphysema (orange circle) and lymph node enlargement (green circles) are observed in the left inguinal region. Soft-tissue gas collection without trauma history suggests the presence of anaerobic microorganisms that produce gas through anaerobic metabolism.

Image 2: Axial computed tomography (CT) of the pelvis, section level at the base of the penis, without intravenous contrast. Fat stranding (blue arrows) and gas in the perineum and left scrotum (orange) are observed.

Image 3: Axial computed tomography (CT) of the pelvis, section level of the scrotum, without intravenous contrast. Tunica dartos and spermatic fascia thickening (yellow), mostly in the left side, and gas in the perineum and left scrotum (orange) are observed.

Highlights

  • - Among acute scrotal pain, the conditions that require urgent medical intervention are: testicular torsion, acute epididymo-orchitis and Fournier's gangrene;

  • - Fournier's gangrene high mortality is due to its severity and fast dissemination;

  • - Male patients between 50 and 79 years old are the most affected and its main risk factor is diabetes mellitus;

  • - Diagnosis is clinical and includes presence of erythema, edema and diffuse local pain, which can advance to bullae, necrosis and crepitus;

  • - Treatment includes early broad-spectrum antibiotic therapy and aggressive surgical exploration with debridement of necrotic tissue.

References

  • 1. Voelzke B, Hagedorn J. Presentation and Diagnosis of Fournier Gangrene. Urology. 2018;114:8-13;

  • 2. Eyre RC. Acute scrotal pain in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 10, 2021.);

  • 3. Hagedorn J, Wessells H. A contemporary update on Fournier's gangrene. Nat Rev Urol. 2016;14(4):205-214;

  • Ballard D, Mazaheri P, Raptis C, Lubner M, Menias C, Pickhardt P et al. Fournier Gangrene in Men and Women: Appearance on CT, Ultrasound, and MRI and What the Surgeon Wants to Know. Can Assoc Radiol J. 2020;71(1):30-39;

  • 4. Bonkat G, Bartoletti RR, Bruyère F, Cai T, Geerlings SE, Köves B, Schubert S, Wagenlehner F, Mezei T, Pilatz A, Pradere B, Veeratterapillay R. EAU Guidelines on Urological Infections. Edn. presented at the EAU Annual Congress Amsterdam 2020. 978-94-92671-07-3. Publisher: EAU Guidelines Office. Place published: Arnhem, The Netherlands.

Author

Gabriella Yuka Shiomatsu, 6th year medical student at Universidade Federal de Minas Gerais (UFMG).

E-mail: gabriellashiomatsu[at]gmail.com

Supervisors

Rafael Fagionato Locali, urologist at the Kidney Transplantation Unit of Hospital das Clínicas de São Paulo.

E-mail: rafael.locali[at]gmail.com 

 

Júlio Guerra Domingues, radiologist, professor at the Department of Anatomy and Image at UFMG.

Email: jgdjulio [at] gmail.com

Reviewers

Almir Marquiore Júnior, Mariana Dinamarco Mestriner, Melina Assunção Gomes de Araújo, Rafael Arantes Oliveira, Katharina Lanza.

Translated by

Gabriella Yuka Shiomatsu, 6th year medical student at UFMG.

E-mail: gabriellashiomatsu[at]gmail.com

 

Test question

[Universidade Federal de Goiás Residency Exam, 2013] The presence of necrotizing soft-tissue infection in the genital region and perineum leads to the diagnosis of Fournier's gangrene. Among its clinical characteristics, the one that is NOT included is:

 

a) Presence of lesions such as hyperemia, inflammation and necrosis of the penis and scrotum.

25%

b) High morbidity and mortality due to the aggressive infection.

25%

c) Broad-spectrum antibiotic therapy (gram-positive, gram-negative and anaerobic).

25%

d) Hyperbaric oxygen therapy as first-line treatment.

25%

e)

25%
   

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