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Fournier’s gangrene: US and MR imaging findings
European Journal of Radiology Extra 50 (2004) 81–87
Fournier’s gangrene: US and MR imaging findings Suna Özhan Oktar∗ , Cem Yücel, Nil Tokgöz Ercan, Davut Çapkan, Hakan Özdemir Department of Radiology, School of Medicine, Gazi University, Besevler, Ankara 06510, Turkey
Abstract Fournier’s gangrene is an uncommon, potentially lethal and rapidly progressive necrotizing infection of perineum and genitalia. Early and prompt diagnosis of this synergistic infection is essential for institution of appropriate surgical and medical treatment. Here, we report the imaging findings of a case of Fournier’s gangrene diagnosed preoperatively with sonography and magnetic resonance imaging (MRI). © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Scrotum; Gangrene; US; MRI
Fournier’s gangrene is a rapidly progressive synergistic necrotizing fasciitis that involves the perineum and genitalia, occasionally extending to the abdominal wall [1,2]. It results in development of gangrene in overlying dermal and epidermal tissues by leading to thrombosis of small subcutaneous vessels with endarteritis [3]. It is a rare but serious urologic problem that is still accepted as a potentially lethal disease necessitating aggressive surgical intervention. Since successive treatment depends on early diagnosis and appropriate surgical intervention, it is important to recognize it radiologically [4,5]. This report describes the plain radiography, ultrasound (US) and magnetic resonance imaging (MRI) findings of a rare case of Fournier’s gangrene secondary to anal fistula.
1. Case report A 23-year-old man admitted to the emergency department with fever, pain and swelling in the perineoscrotal region, he also had a 2 weeks history of constipation with perianal pain. On physical examination, there was edema and skin hyperemia on right perineoscrotal region. Digital rectal examination revealed two fistulous openings at 6 and 8 o’clock position. He had a white blood cell count of 19,000 mm3 , and CRP level was 29.6 mg/dl. Pelvic radiography revealed radiolucent areas overlying perineal soft tissue and scrotum, consistent with gas. ∗
Corresponding author. Tel.: +312-222-97-30; fax: +312-212-19-40. E-mail address: [email protected] (S.Ö. Oktar).
The patient was referred to our department for sonographic evaluation, with the presumptive diagnosis of anorectal or scrotal abscess. The ultrasound examination was performed with a GE Logic 9 ultrasound system (GE Corp. Waukesha, WI) using 7–10 MHz linear transducer, demonstrated thickened and edematous scrotal wall and peritesticular fluid. Also numerous discrete, hyperechoic foci with posterior acoustic shadowing consistent with gas within the scrotal wall and scrotal sac was observed (Fig. 1a and b). The patient was also scanned in the lateral decubitus position. The thickened subcutaneous tissue with fluid collection and air extending from the posterior scrotal skin to the perineum and perianal area were demonstrated (Fig. 1c). Both testicles and epididymis were of normal size and echo texture with normal vascularity on color Doppler examination. On the same day, MR examination was performed to evaluate the extent of the process. MRI examination was performed with a 1.0 T imager (Signa, HiSpeed, GE Medical Systems, Milwaukee, WI) and body phased array coil. Axial T1-weighted spin-echo images (TR 640 ms, TE 8 ms, 7 mm slice thickness, 1 mm gap) and coronal fat suppressed T1-weighted images (TR 590 ms, TE 9 ms, 7 mm slice thickness, 2 mm gap) were obtained before and after injection of gadopentetate dimeglumine. Axial T2-weighted spin-echo images (TR 5320 ms, TE 104 ms, 7 mm slice thickness, 1 mm gap) and coronal fast spin-echo inversion recovery images (TR 5300 ms, TE 28 ms, TI 140 ms, 6 mm slice thickness, 2 mm gap) were also acquired. An area of fluid collection was observed in the perianal and periurethral regions extending anteriorly along inferior aspect of
1571-4675/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2004.03.001
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Fig. 1. Transverse (a) and longitudinal (b) US scans of right testicle show marked thickening of the scrotal skin (arrowheads), peritesticular fluid. Multiple echogenic foci and associated dirty shadowing in posterior scrotal wall which were consistent with gas are seen (arrows). Testis and epididymis show normal echo pattern. Longitudinal US scan (c) over perineum and bulb of penis demonstrates perineal fluid accumulation (arrowheads) and air producing high amplitude echoes with posterior shadowing (arrows).
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Fig. 1. (Continued ).
urogenital diaphragm to peritesticular area and bulb of penis on right, involving perineum. This area was hypointense on T1-weighted images, hyperintense on T2-weighted images and showed marked peripheral enhancement after contrast injection, which was consistent with abscess formation (Fig. 2). The fluid collection around right testicle and perineum also contained coalescent signal void areas on all sequences corresponding to echogenic foci observed in US images that are compatible with gas bubbles. After contrast agent administration, fascial planes and superficial subcutaneous tissue around the penis and right testicle also enhanced indicating cellulitis (Figs. 3 and 4). The signal intensity of both testicles and epididymis were normal in all acquired sequences. All these MRI findings supported the preoperative diagnosis of necrotizing fasciitis suggested by US. Gram-negative bacilli and colonic flora Escherichia coli was isolated from the culture. After the initial administration of IV fluids and antibiotics, as the overall condition of the patient deteriorated he was taken to surgery with the preoperative diagnosis of Fournier’s gangrene. At the operation, a perineal and bulbar abscess surrounding testes, extending to penile urethra and corpora cavernosa was observed, as well as focal necrosis of subcutaneous tissues. The patient underwent an immediate wide incision and drainage of all involved areas and an aggressive debridement of devitalized area of the perianal area and penis. A diverting colostomy was performed to protect the wound. The wound was left open. Repeated debridement and ablation with saline resulted in an improvement in his condition. The patient was discharged 2 weeks post-operatively with uneventful recovery.
2. Discussion Fournier’s gangrene is a synergistic, polymicrobial, necrotizing fasciitis of the perineum and genitalia initially described in the literature by Jean Alfred Fournier in 1883. It is a potentially lethal disease causing considerable morbidity and prolonged periods of hospitalization. The number of Fournier’s gangrene cases reported has always been limited. Vick has estimated that only 750 patients have suffered from the disease world-wide till 1999 [1,6]. Despite appropriate antibiotic therapy and aggressive surgical treatments, reported mortality rates ranged between 7 and 33% within the last decade [4]. The disease is not limited to certain age groups, although most or the cases described were 50–70-year-old diabetic men. It has also been described in women [7]. In Fournier’s gangrene severe soft tissue infection usually begins as cellulitis at the portal of entry. Due to the local ischemia caused by characteristic obliterative endarteritis of small arterioles, infection rapidly involves adjacent soft tissue and deep fascial planes of perineum, resulting in myositis, and fasciitis [5]. In most of the cases, a primary focus of primary infection can be found either from a urogenital or a colorectal source [8,9].Trauma to the scrotal or perineal area, extension from a genitourinary infection with dissection along fascial planes, and extension of an infection from the perianal or colorectal focus are the most common causes of Fournier’s gangrene [3,6]. Superficial perineal fascia, also known as, Colles’ fascia, fuses with the inferior fascia of urogenital diaphragm and extends anteriorly as the dartos fascia surrounding scrotum and penis. It is not a continuous layer
84
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Fig. 2. Axial T1-weighted spin-echo (a) and gadolinium enhanced T1-weighted images (b) show fluid collection with significant peripheral enhancement in perianal and periurethral region involving perineum (arrows) and infiltrated subcutaneous tissue anteriorly (arrowhead).
and its connection to urogenital diaphragm is interrupted. Gas producing organisms that are present in colonic flora and in perirectal abscess can penetrate Colles’ fascia due to its fenestrated structure and spread anteriorly involving the penis and scrotum [10]. The bacteriology of Fournier’s
gangrene is typically a combination of aerobic and anaerobic bacteria, resulting in extensive tissue necrosis by synergistic effect that necessitates wide excision and drainage for adequate treatment. The most common causative organisms are Staphylococcus aureus, Streptococci, E. coli, and
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
85
Fig. 3. Axial gadolinium enhanced T1-weighted spin-echo image reveals gas containing fluid collection at the level of scrotum (arrows) and enhancement of subcutaneous tissue and fascial planes on the right (arrow) compatible with cellulitis.
Bacteroides species. Clostridium welchii has also been described rarely as a causative agent. Different types of organisms have been isolated depending on the origin of infection [6,11]. Fournier’s gangrene usually has an insidious onset with pruritus and discomfort of the external genitalia associated with fever and chills. Crepitus is a common finding indicating the presence of insoluable subcutaneous gases, such as hydrogen and nitrogen [5]. To reduce the mortality of Fournier’s gangrene early aggressive surgical intervention together with hemodynamic support and broad spectrum antibiotics is essential [2]. The majority of cases with Fournier’s gangrene have a significant comorbid disease like diabetes mellitus, chronic alcoholism, old age, associated malignancy, and prolonged hospitalization. Any condition compromising the immune system of the patient enhances the growth and progression of bacterial infection. Fournier’s gangrene has been increasingly reported recently in patients with AIDS [12,13]. The patient reported here lacked such underlying diseases. Direct radiography, sonography, CT and MRI are useful imaging techniques in establishing the diagnosis, assessing the origin, and determining the extent of Fournier’s gangrene. Plain radiographs of the abdomen and pelvis may show soft tissue gas tracking along the extent of involved tissue planes before crepitus is evident on physical examination [5]. Sonographic evaluation of the patient with Fournier’s gangrene shows a thickened and edematous scrotal wall with unilateral or bilateral peritesticular fluid. Subcutaneous gas within the scrotal wall is the sonographic hallmark of the dis-
ease which appears as numerous discrete, hyperechoic foci with posterior acoustic shadowing due to the high reflectivity of fluid–gas interface [4,5,14]. Since the blood supply of the testicles and epididymis is from the testicular arteries which originate directly from the aorta, they rarely are involved in the gangrenous process. Scrotal ultrasonography can also be helpful in differentiating other causes of acute scrotum such as scrotal hernia with gas-containing bowel, scrotal torsion, tumor, scrotal abscess, and acute epidydimo-orchitis [15]. Examining a scrotal US scan in a patient with scrotal pain, Fournier’s gangrene has to be considered besides the more common causes of acute scrotum. In patients with Fournier’s gangrene the main advantage of MR imaging is that it can more clearly depict the extent of infection to perineum, fascial planes and buttocks more clearly than ultrasonography. It can often detect the source of infection such as perianal abscess, incarcerated hernia, or fistulas and it is advantageous in patients with advanced skin lesions. Characteristic CT appearance is stranding of fat planes surrounding the involved structures and soft tissue thickening along with gas [5]. CT of the pelvis, although not performed in our patient, can also be useful in defining the source of infection and evaluating extent of the disease. Both MR and CT can assist in planning debridement. In conclusion, Fournier’s gangrene still remains as a serious condition because of rapid progression of the disease to sepsis and death, despite the advances in medical therapy and intensive care procedures [2]. It necessitates early and accurate diagnosis for achieving a successful outcome. US and plain radiography are useful initial diagnostic tools
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S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
Fig. 4. Coronal fast spin-echo inversion recovery images at different levels (a and b) reveal gas containing collection (arrow) together with minimal peritesticular fluid, fascial thickening (arrowheads) and extension of infection to anterior abdominal wall (curved arrow).
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
in the evaluation of Fournier’s gangrene which can demonstrate the necrotizing infection before it becomes clinically evident, facilitating early diagnosis and management. Only few cases of Fournier’s gangrene have been documented in the literature emphasizing the role of MR [16]. We present another case in which MR imaging confirmed the preoperative diagnosis made by US and demonstrated the anatomic pathways of spread which is important in planning the debridement and surgical intervention.
References [1] Vick R, Carson CC. Fournier’s disease. Urol Clin North Am 1999;26:841–9. [2] Xeropotamos NS, Nousias VE, Kappas AM. Fournier’s gangrene: diagnostic approach and therapeutic challenge. Eur J Surg 2002;168:91–5. [3] Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992;19:149–62. [4] Kane CJ, Nash P, Mc Anninch JW. Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis. Urology 1996;48:142–4. [5] Rajan DK, Scharer KA. Radiology of Fournier’s gangrene. AJR 1998;170:163–8.
87
[6] Ochiai T, Ohta K, Takahashi M, Yamazaki S, Iwai T. Fournier’s gangrene: report of six cases. Surg Today 2001;31:553–6. [7] Smith GL, Bunker CB, Dinneen MD. Fournier’s gangrene. Br J Urol 1998;81:347–55. [8] Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vincente E. Fournier’s syndrome of urogenital and anorectal origin. Dis Colon Rectum 1987;30:33–7. [9] DiFalco G, D’Annibale A. Fournier’s gangrene following a perianal abscess. Dis Colon Rectum 1986;29:582–5. [10] Kattan S, Youssef A. Fournier’s gangrene of the scrotum following anorectal disorders. Int Urol Nephrol 1993;26:215–22. [11] Rudolph R, Soloway M, DePalma RG, Persky L. Fournier’s syndrome: synergistic gangrene of the scrotum. Am J Surg 1975;129: 591–6. [12] Nielsen PR, Nielsen JH, Jensen EB, Jacobsen E. Fournier’s gangrene: 5 patients treated with hyperbaric oxygen. J Urol 1984;132:918– 20. [13] McKay TC, Waters WB. Fournier’s gangrene as a presenting sign of undiagnosed human immunodeficiency virus infection. J Urol 1994;152:1552–4. [14] Nelson MR, Cartledge J, Barton SE. Fournier’s gangrene following hyfrecation in a male infected with the human immunodeficiency virus. Genitourin Med 1992;68:401–2. [15] Dogra VS, Smeltzer JS, Poblette J. Sonographic diagnosis of Fournier’s gangrene. J Clin Ultrasound 1994;22:571–2. [16] Okizuka H, Sugimura K, Yoshizako T. Fournier’s gangrene: diagnosis based on MR findings. AJR 1992;158:1173–4.
Fournier’s gangrene: US and MR imaging findings Suna Özhan Oktar∗ , Cem Yücel, Nil Tokgöz Ercan, Davut Çapkan, Hakan Özdemir Department of Radiology, School of Medicine, Gazi University, Besevler, Ankara 06510, Turkey
Abstract Fournier’s gangrene is an uncommon, potentially lethal and rapidly progressive necrotizing infection of perineum and genitalia. Early and prompt diagnosis of this synergistic infection is essential for institution of appropriate surgical and medical treatment. Here, we report the imaging findings of a case of Fournier’s gangrene diagnosed preoperatively with sonography and magnetic resonance imaging (MRI). © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Scrotum; Gangrene; US; MRI
Fournier’s gangrene is a rapidly progressive synergistic necrotizing fasciitis that involves the perineum and genitalia, occasionally extending to the abdominal wall [1,2]. It results in development of gangrene in overlying dermal and epidermal tissues by leading to thrombosis of small subcutaneous vessels with endarteritis [3]. It is a rare but serious urologic problem that is still accepted as a potentially lethal disease necessitating aggressive surgical intervention. Since successive treatment depends on early diagnosis and appropriate surgical intervention, it is important to recognize it radiologically [4,5]. This report describes the plain radiography, ultrasound (US) and magnetic resonance imaging (MRI) findings of a rare case of Fournier’s gangrene secondary to anal fistula.
1. Case report A 23-year-old man admitted to the emergency department with fever, pain and swelling in the perineoscrotal region, he also had a 2 weeks history of constipation with perianal pain. On physical examination, there was edema and skin hyperemia on right perineoscrotal region. Digital rectal examination revealed two fistulous openings at 6 and 8 o’clock position. He had a white blood cell count of 19,000 mm3 , and CRP level was 29.6 mg/dl. Pelvic radiography revealed radiolucent areas overlying perineal soft tissue and scrotum, consistent with gas. ∗
Corresponding author. Tel.: +312-222-97-30; fax: +312-212-19-40. E-mail address: [email protected] (S.Ö. Oktar).
The patient was referred to our department for sonographic evaluation, with the presumptive diagnosis of anorectal or scrotal abscess. The ultrasound examination was performed with a GE Logic 9 ultrasound system (GE Corp. Waukesha, WI) using 7–10 MHz linear transducer, demonstrated thickened and edematous scrotal wall and peritesticular fluid. Also numerous discrete, hyperechoic foci with posterior acoustic shadowing consistent with gas within the scrotal wall and scrotal sac was observed (Fig. 1a and b). The patient was also scanned in the lateral decubitus position. The thickened subcutaneous tissue with fluid collection and air extending from the posterior scrotal skin to the perineum and perianal area were demonstrated (Fig. 1c). Both testicles and epididymis were of normal size and echo texture with normal vascularity on color Doppler examination. On the same day, MR examination was performed to evaluate the extent of the process. MRI examination was performed with a 1.0 T imager (Signa, HiSpeed, GE Medical Systems, Milwaukee, WI) and body phased array coil. Axial T1-weighted spin-echo images (TR 640 ms, TE 8 ms, 7 mm slice thickness, 1 mm gap) and coronal fat suppressed T1-weighted images (TR 590 ms, TE 9 ms, 7 mm slice thickness, 2 mm gap) were obtained before and after injection of gadopentetate dimeglumine. Axial T2-weighted spin-echo images (TR 5320 ms, TE 104 ms, 7 mm slice thickness, 1 mm gap) and coronal fast spin-echo inversion recovery images (TR 5300 ms, TE 28 ms, TI 140 ms, 6 mm slice thickness, 2 mm gap) were also acquired. An area of fluid collection was observed in the perianal and periurethral regions extending anteriorly along inferior aspect of
1571-4675/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2004.03.001
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Fig. 1. Transverse (a) and longitudinal (b) US scans of right testicle show marked thickening of the scrotal skin (arrowheads), peritesticular fluid. Multiple echogenic foci and associated dirty shadowing in posterior scrotal wall which were consistent with gas are seen (arrows). Testis and epididymis show normal echo pattern. Longitudinal US scan (c) over perineum and bulb of penis demonstrates perineal fluid accumulation (arrowheads) and air producing high amplitude echoes with posterior shadowing (arrows).
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
83
Fig. 1. (Continued ).
urogenital diaphragm to peritesticular area and bulb of penis on right, involving perineum. This area was hypointense on T1-weighted images, hyperintense on T2-weighted images and showed marked peripheral enhancement after contrast injection, which was consistent with abscess formation (Fig. 2). The fluid collection around right testicle and perineum also contained coalescent signal void areas on all sequences corresponding to echogenic foci observed in US images that are compatible with gas bubbles. After contrast agent administration, fascial planes and superficial subcutaneous tissue around the penis and right testicle also enhanced indicating cellulitis (Figs. 3 and 4). The signal intensity of both testicles and epididymis were normal in all acquired sequences. All these MRI findings supported the preoperative diagnosis of necrotizing fasciitis suggested by US. Gram-negative bacilli and colonic flora Escherichia coli was isolated from the culture. After the initial administration of IV fluids and antibiotics, as the overall condition of the patient deteriorated he was taken to surgery with the preoperative diagnosis of Fournier’s gangrene. At the operation, a perineal and bulbar abscess surrounding testes, extending to penile urethra and corpora cavernosa was observed, as well as focal necrosis of subcutaneous tissues. The patient underwent an immediate wide incision and drainage of all involved areas and an aggressive debridement of devitalized area of the perianal area and penis. A diverting colostomy was performed to protect the wound. The wound was left open. Repeated debridement and ablation with saline resulted in an improvement in his condition. The patient was discharged 2 weeks post-operatively with uneventful recovery.
2. Discussion Fournier’s gangrene is a synergistic, polymicrobial, necrotizing fasciitis of the perineum and genitalia initially described in the literature by Jean Alfred Fournier in 1883. It is a potentially lethal disease causing considerable morbidity and prolonged periods of hospitalization. The number of Fournier’s gangrene cases reported has always been limited. Vick has estimated that only 750 patients have suffered from the disease world-wide till 1999 [1,6]. Despite appropriate antibiotic therapy and aggressive surgical treatments, reported mortality rates ranged between 7 and 33% within the last decade [4]. The disease is not limited to certain age groups, although most or the cases described were 50–70-year-old diabetic men. It has also been described in women [7]. In Fournier’s gangrene severe soft tissue infection usually begins as cellulitis at the portal of entry. Due to the local ischemia caused by characteristic obliterative endarteritis of small arterioles, infection rapidly involves adjacent soft tissue and deep fascial planes of perineum, resulting in myositis, and fasciitis [5]. In most of the cases, a primary focus of primary infection can be found either from a urogenital or a colorectal source [8,9].Trauma to the scrotal or perineal area, extension from a genitourinary infection with dissection along fascial planes, and extension of an infection from the perianal or colorectal focus are the most common causes of Fournier’s gangrene [3,6]. Superficial perineal fascia, also known as, Colles’ fascia, fuses with the inferior fascia of urogenital diaphragm and extends anteriorly as the dartos fascia surrounding scrotum and penis. It is not a continuous layer
84
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Fig. 2. Axial T1-weighted spin-echo (a) and gadolinium enhanced T1-weighted images (b) show fluid collection with significant peripheral enhancement in perianal and periurethral region involving perineum (arrows) and infiltrated subcutaneous tissue anteriorly (arrowhead).
and its connection to urogenital diaphragm is interrupted. Gas producing organisms that are present in colonic flora and in perirectal abscess can penetrate Colles’ fascia due to its fenestrated structure and spread anteriorly involving the penis and scrotum [10]. The bacteriology of Fournier’s
gangrene is typically a combination of aerobic and anaerobic bacteria, resulting in extensive tissue necrosis by synergistic effect that necessitates wide excision and drainage for adequate treatment. The most common causative organisms are Staphylococcus aureus, Streptococci, E. coli, and
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
85
Fig. 3. Axial gadolinium enhanced T1-weighted spin-echo image reveals gas containing fluid collection at the level of scrotum (arrows) and enhancement of subcutaneous tissue and fascial planes on the right (arrow) compatible with cellulitis.
Bacteroides species. Clostridium welchii has also been described rarely as a causative agent. Different types of organisms have been isolated depending on the origin of infection [6,11]. Fournier’s gangrene usually has an insidious onset with pruritus and discomfort of the external genitalia associated with fever and chills. Crepitus is a common finding indicating the presence of insoluable subcutaneous gases, such as hydrogen and nitrogen [5]. To reduce the mortality of Fournier’s gangrene early aggressive surgical intervention together with hemodynamic support and broad spectrum antibiotics is essential [2]. The majority of cases with Fournier’s gangrene have a significant comorbid disease like diabetes mellitus, chronic alcoholism, old age, associated malignancy, and prolonged hospitalization. Any condition compromising the immune system of the patient enhances the growth and progression of bacterial infection. Fournier’s gangrene has been increasingly reported recently in patients with AIDS [12,13]. The patient reported here lacked such underlying diseases. Direct radiography, sonography, CT and MRI are useful imaging techniques in establishing the diagnosis, assessing the origin, and determining the extent of Fournier’s gangrene. Plain radiographs of the abdomen and pelvis may show soft tissue gas tracking along the extent of involved tissue planes before crepitus is evident on physical examination [5]. Sonographic evaluation of the patient with Fournier’s gangrene shows a thickened and edematous scrotal wall with unilateral or bilateral peritesticular fluid. Subcutaneous gas within the scrotal wall is the sonographic hallmark of the dis-
ease which appears as numerous discrete, hyperechoic foci with posterior acoustic shadowing due to the high reflectivity of fluid–gas interface [4,5,14]. Since the blood supply of the testicles and epididymis is from the testicular arteries which originate directly from the aorta, they rarely are involved in the gangrenous process. Scrotal ultrasonography can also be helpful in differentiating other causes of acute scrotum such as scrotal hernia with gas-containing bowel, scrotal torsion, tumor, scrotal abscess, and acute epidydimo-orchitis [15]. Examining a scrotal US scan in a patient with scrotal pain, Fournier’s gangrene has to be considered besides the more common causes of acute scrotum. In patients with Fournier’s gangrene the main advantage of MR imaging is that it can more clearly depict the extent of infection to perineum, fascial planes and buttocks more clearly than ultrasonography. It can often detect the source of infection such as perianal abscess, incarcerated hernia, or fistulas and it is advantageous in patients with advanced skin lesions. Characteristic CT appearance is stranding of fat planes surrounding the involved structures and soft tissue thickening along with gas [5]. CT of the pelvis, although not performed in our patient, can also be useful in defining the source of infection and evaluating extent of the disease. Both MR and CT can assist in planning debridement. In conclusion, Fournier’s gangrene still remains as a serious condition because of rapid progression of the disease to sepsis and death, despite the advances in medical therapy and intensive care procedures [2]. It necessitates early and accurate diagnosis for achieving a successful outcome. US and plain radiography are useful initial diagnostic tools
86
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
Fig. 4. Coronal fast spin-echo inversion recovery images at different levels (a and b) reveal gas containing collection (arrow) together with minimal peritesticular fluid, fascial thickening (arrowheads) and extension of infection to anterior abdominal wall (curved arrow).
S.Ö. Oktar et al. / European Journal of Radiology Extra 50 (2004) 81–87
in the evaluation of Fournier’s gangrene which can demonstrate the necrotizing infection before it becomes clinically evident, facilitating early diagnosis and management. Only few cases of Fournier’s gangrene have been documented in the literature emphasizing the role of MR [16]. We present another case in which MR imaging confirmed the preoperative diagnosis made by US and demonstrated the anatomic pathways of spread which is important in planning the debridement and surgical intervention.
References [1] Vick R, Carson CC. Fournier’s disease. Urol Clin North Am 1999;26:841–9. [2] Xeropotamos NS, Nousias VE, Kappas AM. Fournier’s gangrene: diagnostic approach and therapeutic challenge. Eur J Surg 2002;168:91–5. [3] Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992;19:149–62. [4] Kane CJ, Nash P, Mc Anninch JW. Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis. Urology 1996;48:142–4. [5] Rajan DK, Scharer KA. Radiology of Fournier’s gangrene. AJR 1998;170:163–8.
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[6] Ochiai T, Ohta K, Takahashi M, Yamazaki S, Iwai T. Fournier’s gangrene: report of six cases. Surg Today 2001;31:553–6. [7] Smith GL, Bunker CB, Dinneen MD. Fournier’s gangrene. Br J Urol 1998;81:347–55. [8] Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vincente E. Fournier’s syndrome of urogenital and anorectal origin. Dis Colon Rectum 1987;30:33–7. [9] DiFalco G, D’Annibale A. Fournier’s gangrene following a perianal abscess. Dis Colon Rectum 1986;29:582–5. [10] Kattan S, Youssef A. Fournier’s gangrene of the scrotum following anorectal disorders. Int Urol Nephrol 1993;26:215–22. [11] Rudolph R, Soloway M, DePalma RG, Persky L. Fournier’s syndrome: synergistic gangrene of the scrotum. Am J Surg 1975;129: 591–6. [12] Nielsen PR, Nielsen JH, Jensen EB, Jacobsen E. Fournier’s gangrene: 5 patients treated with hyperbaric oxygen. J Urol 1984;132:918– 20. [13] McKay TC, Waters WB. Fournier’s gangrene as a presenting sign of undiagnosed human immunodeficiency virus infection. J Urol 1994;152:1552–4. [14] Nelson MR, Cartledge J, Barton SE. Fournier’s gangrene following hyfrecation in a male infected with the human immunodeficiency virus. Genitourin Med 1992;68:401–2. [15] Dogra VS, Smeltzer JS, Poblette J. Sonographic diagnosis of Fournier’s gangrene. J Clin Ultrasound 1994;22:571–2. [16] Okizuka H, Sugimura K, Yoshizako T. Fournier’s gangrene: diagnosis based on MR findings. AJR 1992;158:1173–4.