Fournier Gangrene with Preperitoneal Extension: A Rare Case Report
Article information
Abstract
Fournier gangrene (FG) is a rare life-threatening infection j that can occasionally extend beyond the perineum into the retroperitoneal space. Preperitoneal involvement in female patients is extremely rare. We report a unique case of a 59-year-old female with FG, characterized by atypical preperitoneal extension. Despite initial treatment failure, the patient recovered following emergency debridement, and targeted antibiotic therapy. This case underscores the importance of early diagnosis, timely surgical intervention, and multidisciplinary care in managing atypical FG presentations in female patients. It emphasizes the need for prompt and aggressive management to improve survival in these rare instances.
Introduction
Fournier gangrene (FG) is an uncommon but life-threatening form of necrotizing fasciitis that affects the perineal and genital areas [1]. Key risk factors for FG include having diabetes mellitus, being obese, and immunosuppressed, and having a localized infection (such as a perianal abscesses or infection due to trauma). FG is pathologically defined as a bacterial infection leading to thrombosis in the feeding arteries, resulting in ischemia and tissue necrosis resulting in gangrene of the skin and subcutaneous tissue. Clinically, the initial symptoms such as pain, swelling, and erythema can progress rapidly to skin discoloration, crepitus, and septic shock [2], and if left untreated, causes severe intoxication and multi-organ failure [3]. Notably, higher mortality rates have been observed in female patients, likely due to retroperitoneal and abdominal cavity involvement [4].
Timely diagnosis and treatment are critical for survival. Early identification relies on clinical suspicion which is supported by computed tomography or magnetic resonance imaging. Management requires prompt surgical debridement and the administration of broad-spectrum antibiotics; delays or insufficient intervention significantly correlates with higher mortality rates [1]. The lethality of FG in cases complicated by septic shock can reach 90%, underscoring the need for rapid and comprehensive care [5]. Early surgical debridement within 6 hours of diagnosis has been associated with improved outcome and survival rates [6].
We present a rare case of FG with an unusual spread into the preperitoneal space. This report emphasizes the importance of prompt diagnosis and aggressive management to improve survival rates in patients with atypical presentations of FG.
Case Report
A 59-year-old female with a history of myomectomy, cesarean section, hypertension, and obesity (Body Mass Index 27.77) presented to the Emergency Department with progressive perianal and lower abdominal pain. Four days earlier, she had visited a local Emergency Department for perianal pain and underwent incision and drainage of the perianal abscess, along with a 4 day course of intravenous antibiotics (3rd generation cephalosporin, aminoglycoside, and metronidazole). Despite treatment, her condition deteriorated and manifested as worsening left buttock and lower abdominal pain, and fever, and chills which prompted her transfer to our facility.
On examination, the patient exhibited erythema, and induration in the left buttock and lower abdomen. A Penrose drain was inserted into the left buttock perianal abscess. Her vital signs were: blood pressure 132/84 mmHg, heart rate 71 beats per minute, respiratory rate 20 breaths per minute, oxygen saturation 98% on room air, and body temperature 38.1°C. Abdominopelvic computed tomography revealed a gas-forming abscess extending from the perianal region into the lower abdomen (Figure 1). The patient was subsequently diagnosed with FG and underwent emergency surgery which entailed wide excisional debridement of necrotic tissue in the perianal region, left buttock, and lower abdomen. A Pfannenstiel incision was performed to provide access to the preperitoneal space through the abdominal fascia. The procedure involved the removal of extensive necrotic tissue and a substantial volume of purulent material from the affected areas. The Penrose drain in the left buttock was replaced, and the surgical site was irrigated with povidone-iodine.
Computed tomography imaging conducted after hospital transfer. (A) Axial view - lower abdomen: the red arrow indicates subcutaneous emphysema, suggesting necrotizing fasciitis with infection spreading along the fascial plane. (B) Axial view - plevic region: the red arrow shows extensive gas in the perineal and pelvic soft tissues, indicating Fournier gangrene extending into deeper pelvic structures. (C) Axial view - perineal region: the red arrow indicates infection and gas spreading to the left buttock and perineum, suggesting extensive necrotizing fasciitis. (D) Coronal view: the red arrow indicates necrotizing infection spreading to the inguinal region and upper thigh, with extensive gas formation confirming deep tissue involvement in Fournier gangrene.
Following surgery, the patient was admitted to the Intensive Care Unit and was started on empirical broad-spectrum antibiotics (vancomycin and meropenem). Subsequent blood and wound cultures isolated Enterococcus avium and Proteus mirabilis which prompted a change in the antibiotic regimen to gentamicin and ampicillin/sulbactam, as recommended by an infectious disease specialist. The patient received comprehensive wound care including serial dressing changes and continued intravenous antibiotics. By postoperative Day (POD) 5, the patient’s condition had stablized (Figure 2), and she was transferred to the General Ward. On POD 11, the patient was able to tolerate a soft diet. The abdominal and buttock drains were removed, and the patient was discharged on POD 15 with plans for close outpatient follow-up and continued oral antibiotic therapy.
Computed tomography imaging conducted 4 days post-hospital transfer. (A) Coronal view: red arrow- indicates gas and fluid collection, blue arrow- shows a surgical drain for abscess drainage and infection control. (B) Coronal view: red arrow- indicates gas and infection spreading to the inguinal region, showing improvement compared to the preoperative state. (C) Axial view: red arrow- show bilateral pelvic soft tissue involvement with gas and inflammation. Blue arrow- shows a surgical drain for abscess drainage and infection control. (D) Axial view: red arrow- indicates deep pelvic inflammation, showing improvement compared to the preoperative state. Blue arrow- shows a surgical drain for abscess drainage and infection control.
Discussion
FG is predominantly observed in males [7]. It has been documented in children [8,9], and a recent study reported significant incidence in females (31.6%) which was primarily associated with vulvar and Bartholin gland abscesses in addition to postoperative complications following an episiotomy or hysterectomy [4].
The current study illustrates an uncommon manifestation of FG in a female patient, characterized by an atypical spread into the preperitoneal space. FG is predominantly diagnosed clinically; however, radiological evaluation can offer a valuable insight in cases of uncertainty. Whilst radiography may detect gas within soft tissues [10,11], advanced imaging modalities, such as computed tomography, facilitates a definitive diagnosis and aids delineation to determine the extent of the disease. FG represents a surgical emergency with a high rate of mortality and morbidity. Although clinical presentations vary, FG progresses aggressively, and often results in systemic complications such as shock, multiple organ failure, and sepsis [12]. The mortality rate amongst individuals who develop septic shock approaches 90% [5]. This emphasizes the critical importance of early intervention.
Management of FG requires a multidisciplinary approach. Initial resuscitation with fluid therapy and stabilization of cardiopulmonary function are essential for patients presenting with septic shock. Prompt surgical debridement of devitalized tissue, combined with broad-spectrum antibiotic therapy, remains the cornerstone of treatment. Antibiotic regimens should be tailored based on microbial culture and sensitivity results. The complete removal of necrotic tissue is essential to halt the progression of the infection and mitigate the systemic effects caused by the toxins produced by the bacteria [13]. Multiple debridement sessions may be required to ensure adequate local control of the infection. The patient in this study was referred to our hospital when the initial medical treatment failed to alleviate her symptoms. This case underscores the necessity for timely diagnosis and intervention in necrotizing soft tissue infections. Prompt diagnosis and treatment are essential for patient survival. However, multidisciplinary care is crucial for the effective management of comorbid conditions, and for educating patients on optimal management and complication prevention for their condition. In summary, this case highlights the need for heightened awareness of atypical presentations of FG in female patients.
Notes
Author Contributions
Conceptualization: MSC and SKC. Formal analysis: JHS. Investigation: all authors. Methodology: MSC. Project administration: MSC. Supervision: MSC. Validation: MSC. Visualization: MSC. Writing-original draft: JHS. Writing-review & editing: all authors. All authors read and approved the final manuscript.
Conflict of Interest
The authors declare no conflicts of interest.
Funding
This research received no specific grant from any funding agency.
Ethical Statement
This case report was approved by the Institutional Review Board of our hospital (no.: 2025-02-001). The requirement for informed consent was waived by the Institutional Review Board.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.