Epidemiological study on Fournier syndrome in a tertiary hospital in Jundiaí-SP from October 2016 to October 2018 / Estudo epidemiológico sobre síndrome de Fournier em um hospital terciario de Jundiaí-SP de Outubro de 2016 a Outubro de 2018

Abstract Introduction: Fournier's gangrene is a polymicrobial infection caused by aerobic and anaerobic microorganisms, which determine a fast and progressive necrotizing fasciitis, compromising mainly the perineal region and the genital region, being able to evolve to sepsis, multiple organ failure and death. Treatment consists of early surgical diagnosis and debridement, associated with broad-spectrum antibiotic therapy and hyperbaric oxygen therapy. Objective: Compare the most prevalent epidemiological data of patients with Fournier's Syndrome with the data examined in the literature in order to evaluate the incidence in the analyzed service, treatment form and evolution of the patients with the disease. Materials and methods: Observational transversal study from the medical records of patients diagnosed with the disease at the São Vicente de Paulo Charity Hospital in Jundiaí, SP, from October 2016 to October 2018. Results: 23 patients with Fournier's Syndrome, all included in the study, and were analyzed. The most prevalent epidemiological data on the disease, such as age, sex, association with other comorbidities, treatment performed, mortality and early surgical procedure, had obtained a similar data as compared as the medical literature that was in studied. Conclusion: Despite the recognized severity of Fournier's Syndrome, early diagnosis combined with extensive surgical debridement, broad-spectrum antibiotic therapy and measures and oxygen therapy when available are important measures to contain the rapid progression of the disease, thus decreasing its levels of mortality.

Resumo Introdução: A Gangrena de Fournier é uma infecção polimicrobiana ocasionada por microrganismos aeróbios e anaeróbios, que determinam uma fascite necrosante rápida e progressiva, comprometendo principalmente a região do períneo e a região genital, podendo evoluir para sepse, falência de múltiplos órgãos e óbito. O tratamento consiste no diagnóstico e desbridamento cirúrgico precoce, associado à antibioticoterapia de largo espectro e oxigenoterapia hiperbárica. Objetivo: Comparar dados epidemiológicos mais prevalentes dos pacientes diagnosticados com Síndrome de Fournier com os dados já descritos na literatura a fim de avaliar a incidência no serviço em questão analisado, forma de tratamento e evolução dos pacientes com a doença. Materiais e métodos: Estudo transversal observacional a partir da análise de prontuários de pacientes diagnosticados com a doença no Hospital de Caridade São Vicente de Paulo de Jundiaí-SP, no período entre Outubro de 2016 a Outubro de 2018. Resultados: Foram analisados 23 pacientes com diagnóstico de Síndrome de Fournier, todos incluídos na pesquisa. Avaliado os dados epidemiológicos mais prevalentes na doença, como faixa etária, sexo, associação com outras comorbidades, tratamento realizado, mortalidade decorrente da doença, período médio de internação, uso de antibioticoterapia e necessidade de procedimento cirúrgico, obtendo-se dados semelhantes com os já descritos na literatura médica. Conclusão: Apesar da reconhecida gravidade da Síndrome de Fournier, o diagnóstico precoce aliado ao desbridamento cirúrgico extenso, antibioticoterapia de amplo espectro e medidas e oxigenioterapia quando disponível são medidas importantes na contenção da rápida progressão da doença, diminuindo assim seus níveis de mortalidade.

Hemivulvectomía radical por gangrena de fournier en mujer con antecedente de radioterapia pélvica / Radical hemivulvectomy due to Fournier's gangrene in a woman with a history of pelvic radiotherapy

RESUMEN La Gangrena de Fournier es una infección necrotizante que afecta al área genitourinaria, perineal y perianal. Se trata de una infección muy grave con una rápida evolución a estadios avanzados y una elevada tasa de morbimortalidad asociada. Sin embargo, con frecuencia tiende a ser infradiagnosticada. Es vital en su manejo un diagnóstico basado en la sospecha clínica e inicio del tratamiento quirúrgico precoz con desbridamiento y exéresis de los tejidos afectos. Además, es crucial la asociación de antibioterapia de amplio espectro y el apoyo nutricional de soporte en el pronóstico de dicha entidad. En este artículo se revisa un caso clínico de Gangrena de Fournier, en una paciente con antecedentes de osteítis púbica y cistitis derivadas del tratamiento mediante radioterapia pélvica, diagnosticado y tratado con una hemivulvectomía radical, antibioterapia y lavados quirúrgicos en nuestro Hospital.

ABSTRACT The Fournier's Gangrene is a necrotizing infection which is located in the perineal area. It´s a severe infection, which involves a quick evolution to advanced stages where a high morbimortality rate is associated. However, it often tends to be underdiagnosed in early stages. The most important in the diagnosis is a high clinical suspicion and subsequent surgical treatment which is base on a desbridalment and exeresis of the affected tissues. In addition, the association of broad-spectrum antibiotic therapy and nutritional support are crucial. This report reviews a clinical case of Fournier's Gangrene, in a patient with a history of radiation induced cystitis and pubic osteitis after pelvic radiotherapy, diagnosed and treated with a radical hemivulvectomy, antibiotic therapy and lavages in our Hospital.

Use of photodynamic inactivation for in vitro reduction of prevalent bacteria in Fournier's Gangrene

ABSTRACT Fournier's Gangrene (FG) is an infectious disease caused by several synergic microbes, with high morbidity and mortality rates; therefore, the search for new less invasive and mutilating treatments, with faster recovery, has been proposed. Surgical intervention, the use of several systemic and topic antibiotics, and hyperbaric oxygen therapy are currently the best approach for the treatment of these patients. The use of Photodynamic Inactivation (PDI) aims to lower morbidity and mortality, by reducing bacterial microbiota and speeding wound healing. In the present study, viable bacteria were separated in four groups: Group L-/F- (no irradiation with red laser and absence of methylene blue photosensitizer), Group L-/F+ (no irradiation with red laser and presence of methylene blue), Group L+/F- (irradiation with red laser and absence of methylene blue) and L+/F+ (irradiation with red laser associated to methylene blue). In all groups, exposure time to treatment was 5, 10 and 15 minutes. The concentration of methylene blue photosensitizer was 0.1mg/L, and the dose of red laser (660nm wave length) was 176.9mW/cm2. Following irradiation, the reduction of number of bacteria was evaluated, and the results were expressed in colony forming units (CFU) and as exponential reduction. As the main results, in the L+/F+ group, there were no Clostridium perfringens and Staphylococcus aureus CFUs and there was a reduction of Escherichia coli that was not observed in the other groups.

Terapêutica cirúrgica na síndrome de Fournier: relato de caso / Surgical therapy in Fournier syndrome: case report

Síndrome de Fournier ou Gangrena de Fournier é uma fasceíte necrotizante que acomete região perineal, perianal e genital, ocasionada por uma infecção polimicrobiana sinergística de bactérias aeróbicas e anaeróbicas, com predomínio em homens em média aos 50 anos. A enfermidade é caracterizada por uma endarteríte obliterante causando trombose vascular subcutânea e necrose de tecidos. Microrganismos distintos aparecem como patógenos nas culturas dos pacientes com essa enfermidade. O quadro clínico pode se manifestar com dor, eritema e edema, cianose e crepitação em bolsa escrotal e períneo associada ou não a febre e calafrios. Diagnóstico e intervenção precoce, com antibioticoterapia de largo espectro e drenagem ampla, permitiu melhores resultados nestes doentes. A mortalidade permanece elevada quando o diagnóstico é tardio e o tratamento operatório retardado. O objetivo do artigo é relatar um caso de Síndrome de Fournier em um paciente de 52 anos e discutir a melhor abordagem cirúrgica e seus impactos no sucesso terapêutico nesta enfermidade.

Fournier syndrome or Fournier's gangrene is a necrotizing fasciitis that affects the perineal, perianal and genital region, caused by a polymicrobial infection of aerobic and anaerobic synergistic bacteria predominantly in men, on average at age 50. The disease is characterized by obliterative endarteritis causing subcutaneous vascular thrombosis and tissue necrosis. Different microorganisms appear as patogens in cultures of patients with this disease. The clinical picture may manifest as pain, redness and swelling, cianosis and crepitus in the scrotum and perineum with or without fever and chills. Early diagnosis and intervention with broad spectrum antibiotics and ample drainage contributed to a better outcome for these patients. Mortality remains high when diagnosis is late and the surgical procedure postponed. The aim of this paper is to report a case of Fournier syndrome in a 52 year old patient, discuss the best surgical approach and its impact on therapeutic success in this disease.

Fascitis necrotizante perineal: Gangrena de Fournier / Perineal necrotizing fasciitis: Fournier's gangrene

La gangrena de Fournier o fascitis necrotizante perineal es una entidad infecciosa que afecta las fascias perineales y/o sus dependencias. Es prevalente en hombres de la 5ta o 6tadécada de su vida, y es más común en diabéticos, obesos, enolistas o inmunodeprimidos. El sostén metabólico, la antibioticoterapia, eldebridamiento de tejidos necróticos y la reparación de tejidos son los pilares del tratamiento. Reporte de casos: En el presente artículo presentamos unarevisión bibliográfica de esta enfermedad, y presentamos 3 casos dediferente resolución en nuestro hospital, a modo de ejemplo, con susrespectivos registros fotográficos. Discusión: La fascitis necrotizante perineal es una grave entidad infecciosa que requiere diagnóstico temprano, tratamiento oportuno multidisciplinario y reconstrucción de tejidos según el caso, para lo cual existen varias opciones...

Fournier's gangrene or perineal necrotizing fasciitis is an infectious entity affecting perineal fascias and / or its dependencies. It is more prevalent in men in the 5th or 6thdecade of life and is more common in diabetics, obese, alcoholics or immunodeppressed. Metabolic support, antibiotic therapy, debridement of necrotic tissue and tissue repair arethekey of treatment. Cases Report: In this article we present a literature review of the disease and present 3 cases of different resolution in ourhospital, as examples, with their photographic records. Discussion: The perineal necrotizing fasciitis is aseriousinfectious entity that requires early diagnosis, early multidisciplinary treatment and tissue reconstruction according to case, for which there are several options...

Etiological factors and treatment outcome of genital and perineal necrotizing fascitis [Fournier's gangrene]

To analyze clinical and laboratory parameters in patients with Fournier's gangrene [FG] and to assess factors that determine mortality. A retrospective review of 82 patients with FG from January 2007 to December 2011 was made. They were divided into two groups: those who survived [survivors] and those who did not [non survivors]. We analyzed clinical and laboratory data. The mortality rate remained 36.6% [30/82 patients]. Increased heart and respiratory rates, elevated serum creatinine, pre-existing kidney disease, and higher extent of affected body surface were associated with higher mortality. Severe sepsis on admission and hypotension < 90 mm Hg] were also predictive for higher mortality. The median FG severity index [FGSI] score was higher in non survivors [22 vs 12, p < 0.0001]. Besides standard clinical and laboratory parameters included in the FGSI calculation, higher extent of affected body surface area and presence of hypotension on admission were positively associated with mortality. Early clinical identification and prompt aggressive treatment are essential for reducing mortality and morbidity in patients

Diagnosis and treatment of Fournier's gangrene: two cases and literature review

Fournier's gangrene [FG] is a rapid progressive disease with high mortality and is caused by polymicrobial infection. FG usually begins with infection and affects fascias in [the perianal and] perineal regions as well as the abdominal wall and other organs. Although this disease has been recognized for many years, there are only a few cases reported in the world and few from China. Here, we report our success in the diagnosis and treatment of two cases of FG, one of which had severe necrotic sing fasciitis spreading to the abdominal wall, perianal, and perineal regions. We have discussed the pathogenesis, diagnosis, and treatment of FG

Gangrena de Fournier / Fournier’s gangrene

La Gangrena de Fournier es una enfermedad infecciosa caracterizada por una fascitis necrotizante de evolución fulminante que afecta a la región perineal, genital o perianal, presentando una rápida progresión y alta letalidad, siendo la etiología identificable en un 95 por ciento de los casos. La enfermedad ha sido descrita en ambos géneros, con edad promedio de presentación de 40 años y una mayor prevalencia en hombres, con una relación 10:1. La variedad de manifestaciones clínicas dificulta el diagnóstico, el que es fundamentalmente clínico. El tratamiento debe ser oportuno y agresivo, contemplando tres pilares fundamentales: manejo hidroelectrolítico y nutricional, antiobioterapia de amplio espectro y desbridamiento quirúrgico amplio. En este artículo presentamos una revisión sistemática actualizada de la literatura acerca de esta interesante entidad patológica, con especial énfasis en la epidemiología, etiología, presentación clínica, diagnóstico y tratamiento.

Síndrome de Fournier: análise dos fatores de mortalidade / Analysis of mortality in Fournier's gangrene

A fascite necrótica perineal (Síndrome de Fournier) é infecção grave dos tecidos moles, de etiologia não totalmente esclarecida, porém associada a procedimentos urológicos, proctológicos ou ginecológicos, além de diabetes melito, alcoolismo, desnutrição grave e outros estados de imunodepressão. Trata-se de situação grave, exigindo antibioticoterapia de amplo espectro, desbridamentos cirúrgicos e por vezes derivação do trânsito fecal e/ou urinário. OBJETIVO: Avaliar os fatores relacionados com mortalidade. CASUÍSTICA: Foram avaliados retrospectivamente 43 doentes (39 masculinos) com média de idade de 54,8 anos, no período de 1998 a 2005, na Santa Casa de São Paulo. MÉTODO: foram analisados sexo, idade, sinais e sintomas, tempo de evolução e de internação, doenças associadas, sepse, broncopneumonia, exames laboratoriais, área comprometida, cirurgias realizadas, índice fisiológico Apache II e causa de óbito. RESULTADOS: Sobreviveram 33 doentes e houve 10 (23,2 por cento) óbitos. A letalidade relacionou-se a pacientes mais velhos, tempo de evolução longo, internações curtas, índice fisiológico Apache II elevado, sepse e broncopneumonia . Não houve relação com sexo, diabetes melito, desnutrição, culturas e antibioticoterapia, local de início, extensão da necrose, número de desbridamentos, bem como com colostomias e cistostomias. CONCLUSÃO: a letalidade relaciona-se à disseminação da infecção e retardo do tratamento. Não é relacionada com diabete nem cirurgias como colostomia ou cistostomia.

BACKGROUND: Necrotizing fasciitis is a severe infection of soft tissues, and when it affects the perineum it is called Fournier's gangrene. Some controversy exists over the origin of the disease, but all studies identified correlations between infection and proctologic, urologic, gynecologic origin procedures or trauma. In addition, many other causes are commonly associated, such as diabetes mellitus, abuse of ethanol, malnutrition and immunodepression. It is a severe situation, and diagnosis and surgical therapeutics are emergency procedures, and antibiotics and operations are usually required. OBJECTIVE: Evaluation of conditions related to the causes of death. METHOD: Since 1998 to 2005 in Santa Casa de São Paulo Hospital has 43 Fournier's gangrene patients (39 male) age averege 54,8 years and this study analysed their gender, symptoms, evolution of the disease, associated diseases, medical and surgical procedures, sepsis, lung infection, extension of infection, number of debridements, Apache II physiologic index and causes of death. RESULTS: The survivors was 33 pacients and overall mortality of 10 subjects (23.2 percent), was related to age, delay of treatment, Apache II index and occurence of sepsis and pneumonia. No correlations were found with gender, diabetes mellitus, weight loss, bacteriology, place of begining and extension of lesions, number of debridments or colostomy and cistostomy. CONCLUSIONS: Mortality is related to treatment delay and sepsis. There is no statistical evidence of any relation with diabetes, colostomy or cistostomy.

Infecciones severas del periné luego de radioterapia en cáncer de recto / Severe perineal infections due to radiotherapy in rectal cancer

Introducción: Las infecciones severas del periné constituyen un conjunto de infecciones entre las que se destaca la gangrena de Fournier o sinérgica. Es una fascitis necrotizante del periné y área genital, de etiología polimicrobiana. El foco puede estar localizado en el tubo digestivo distal, el tracto genitourinario o la piel. Objetivo: Analizar los hallazgos clínicos, imagenológicos y factores de riesgo y conducta terapéutica en pacientes con infecciones del periné luego de radioterapia por cáncer de recto. Diseño: Análisis retrospectivo. Revisión de la literatura. Métodos: Revisión de bases MEDLINE, LILACS, AMA, AAC y SACP. Pacientes: 3 casos en 15 días. Resultados: Caso 1: masculino, 46 años; cáncer de recto en tratamiento adyuvante. Al finalizar radioterapia presenta celulitis perineal y absceso profundo por perforación adyacente del tumor rectal. Laparotomía, colostomía definitiva por tumor localmente avanzado y drenaje de absceso y celulitis. Egreso. Falleció por progresión de su enfermedad de base. Caso 2: masculino, 40 años. Tumor de recto irresecable por metástasis hepática en tratamiento con radioterapia paliativa por sangrado persistente, presentó gangrena de Fournier por perforación del tumor. Drenaje del foco séptico. Evoluciona con insuficiencia respiratoria progresiva, disfagia y hemorragia digestiva. Óbito. Caso 3: masculino, 33 años. Tumor de recto localizado, de diagnóstico reciente, en tratamiento neoadyuvante con radio y quimioterapia. Durante la radioterapia presentó gangrena de Fournier por perforación de recto retroperitoneal. Evolucionó con sepsis a pesar del tratamiento. Óbito. Discusión y conclusiones: El manejo se basa en el debridamiento quirúrgico, drenaje y curaciones programadas, asociados a antibióticos de amplio espectro y sostén de los parámetros vitales. El diagnóstico precoz es fundamental... (TRUNCADO)

Introduction: Perineal severe infections are unfrequent and the most common presentation is Fournier's Disease. This disease compromise genital and perineal areas with necrosis of the muscular fascia and does not involve the muscle. Primary focus can come from digestive tract, urinary tract of skin. Objective: To analyze clinical, radiological, risk factors and treatment of Founier’s Disease in patients with rectal cancer and external radiotherapy. Design: Retrospective serie. Literature review. Patients: 3 cases in last 15 days. Results: Case 1: male, 46y, rectal cancer and adyuvant radiotherapy. During treatment, rectal lateral abscess appeared as consequence of rectal perforation. Laparotomy, definitive colostomy and drainage were performed. He died because of neoplastic disease. Case 2: male, 40y. Rectal tumor with hepatic metastasis was under palliative radiotherapy due to low rectal bleeding. Fournier's Disease was diagnosed due to tumor perforation. In spite of surgical treatment, he developed pulmonary insuficiency, disfagia and digestive bleeding and died. Case 3: male, 33y. Lower rectal tumor in neoadyuvant protocol of radiotherapy. Fournier's Disease was presented during this period due to rectal perforation to retroperitoneum. He presented sepsis and died. Discussion and conclusions: Early surgical debridement, elective and periodic surgical wound care and broad spectrum antibiotics should be applied. Early diagnosis is mandatory. Mortality is nearly 20 per cent. Perforated rectal tumor associated with radiotherapy in males younger than 50y presented as Fournier's Disease is first reported.

A aplicabilidade da hidrofibra com prata em lesão provocada pela Síndrome de Fournier: relato de experiência / The applicability of hydrofiber with silver in wound caused by Fournier

Esta pesquisa foi desenvolvida em um Hospital Estadual, localizado na cidade de São Paulo. Neste trabalho, buscou-se relatar a experiência dos enfermeiros no tratamento de um cliente internado em uma UTI com Síndrome de Founier e descrever os efeitos do produto (Hidrofibra com Prata) na aceleração do processo de cicatrização. Apesar da amostra estudada ser pequena, observou-se uma excelente resposta dos pacientes ao tratamento, principalmente na retirada do tecido desvitalizado. Ressalta-se a importância de o enfermeiro conhecer melhor os prudutos disponíveis no mercado, ter conhecimento mais profundo do processo de cicatrização, dos fatores que nele interferem. Assim, o profissional de enfermagem poderá melhor intervir, valendo-se tanto de sues conhecimentos técnicos, quanto científicos.

Sistema de aspiración-tracción en el tratamiento de la fasciitis necrotizante del periné / Negative pressure wound therapy for the treatment of perineal necrotizing fasciitis

Introducción: Se discuten 5 pacientes tratados en nuestra institución. Además del aseo quirúrgico con desbridamiento inicial y terapia antibiótica, utilizamos el sistema de aspiración-tracción (SAT) como parte de su tratamiento. Pacientes y métodos: El SAT fue manufacturado artesanalmente con material disponible en el hospital. Después de que el diagnóstico de fasciitis necrotizante del periné fue establecido, todos los pacientes fueron sometidos a aseo quirúrgico y desbridamiento del tejido necrótico. La herida fue cubierta con el SAT quedando a presión negativa bajo aspiración central. Tiempo después, cuando la herida se encontraba limpia y no se requerían de otros aseos quirúrgicos o curaciones bajo anestesia en pabellón, los pacientes fueron sometidos a curaciones locales. En el momento que se logró buen tejido de granulación, se dejó de utilizar el SAT y se continuó con curaciones planas. Cuando la herida empezó a contraerse, aproximamos los bordes con puntos separados de Nylon y dejamos que cerrara por segunda intención. Conclusión: El uso del SAT constituye otra opción válida para el manejo de la herida que deja el aseo quirúrgico y desbridamiento de la gangrena perineal, además provee un mejor manejo de la herida con mayor comodidad para el paciente.

lntroduction: We discuss five patients treated at our institution. Besides the initial surgical debridement and antibiotic therapy, we used the negative-pressure wound therapy (NPVVT) as part of their treatment. Patients and methods: The NPVVT device was constructed with off-the-shelf components. After the diagnosis of perineal necrotizing fasciitis was established, all patients underwent surgical debridement of necrotic tissue. The wound was closed with the NPVVT system and left under negative-pressure central aspiration. After the wound was clean and no more surgical debridements were necessary, patients underwent local treatment. When they achieved granulation tissue, simple dressings were used. When the wound was contracting, we approximated the edges with an interrupted suture of Nylon, and allowed to heal by second intention. Conclusion: The use of NPWT stands as another valid option to manage the wound left after surgical debridement of the perineal gangrene and provides better and more comfortable management of the wound.

Fournier gangrene following iatrogenic urethral trauma

To assess outcome of 17 patients with Fournier gangrene due to iatrogenic urethral trauma after aggressive treatment. Record of patients with Fournier gangrene due to iatrogenic urethral trauma was reviewed retrospectively between Jan 2000 to Dec 2007 in Department of Urology Services Hospital, Lahore. Etiology, duration of injury, extent of involvement, management, hospital stay and course of rehabilitation were evaluated. Seventeen patients were identified. Mean age of the patients was 43.5 years. Mode of urethral injury included traumatic catheterization [9 cases], traumatic bougienage [6 cases] and urological endoscopy [2 cases]. Mean time interval between injury and presentation in the hospital was 7.14 days [range 1-30 days]. All patients were treated with broad spectrum antibiotics, suprapubic cystostomy and multiple sessions of debridement [mean 3.07]. Mean hospital stay was 21.3 days and mean time taken for rehabilitation of urethra and skin cover was 16.5 weeks. Optical urethrotomy was required in 11 patients, end to end urethral anastomosis in four and perineal urethrostomy in one patient. Bilateral orchiectomy was done in two and penectomy in one patient. Five patients required skin grafting. Urethral trauma due to transurethral manipulations may lead to Fournier gangrene. Patients usually present late in our set up. Multidisciplinary approach towards management including aggressive repeated sessions of debridement can improve survival. Rehabilitation takes a long course. Measures should be taken to prevent iatrogenic urethral injury

Gangrena de Fournier / Fournier's gangrene

A Gangrena de Fournier é uma grave infecção polimicrobiana que evolui com fasciitenecrotizante, comprometendo principalmente as regiões genital, perineal e perianal. Caracteriza-se por rápida evolução e pode complicar com sepse, falência de múltiplos órgãos e óbito. Abase do tratamento é o diagnóstico precoce e o desbridamento agressivo. Antibioticoterapia deamplo espectro, oxigenoterapia hiperbárica e cuidados locais são medidas complementares.

Fournier´s gangrene is a serious infectious disease caused by multiplemicroorganisms leading to a necrotizing fasciitis of the genitals and perineum. With a rapid andprogressive evolution can complicate with sepsis, multiple organ failure and death. Treatment ismainly based in early diagnosis and aggressive and extensive debridment, broadspectrumantibiotics, hyperbaric oxygen therapy, and local wound care are coadjuvants.

Fournier's Gangrene Secondary to Appendicectomy

Background: Fournier's gangrene is predominantly an infectious process involving the superficial and deep fascial planes in the perineal area. Aim: To highlight the existence of a potential space between the Scarpa's and Camper's fascia which allows for spread of infection from an infected appendicectomy wound to the scrotum. Case report: A 33-year-old male presented in the accident and Emergency department of Living Word Mission Hospital with a few days history of painful scrotum with desquamation of the epithelium of the scrotal skin. He gave a history of an appendicectomy for a ruptured appendix carried out 8 days earlier at another hospital. Examination revealed a dehisced appendicectomy wound and a de-epithelialized distal scrotal skin. A diagnosis of Fournier's gangrene was made. He was commenced on potent antibiotics and had debridement of the scrotal wound. The wound improved with healthy granulation tissue and it was then covered with a split skin graft. Lesson: When the appendix is found to be ruptured at operation; potent antibiotics are required to forestall the spread of the infection in the peritoneum or along the fascial planes causing necrotising fasciitis

Fournier gangrene. Approaches to diagnosis and treatment

To investigate the factors associated with patients with Fournier's gangrene, and to clarify the effect of diabetes mellitus [DM] as a comorbid disease on morbidity and mortality of patients with Fournier's gangrene. Twenty-six Fournier's gangrene patients who were admitted to the Emergency Department of Ankara Numune Teaching and Research Hospital, Ankara, Turkey from 1997 to 2003 were examined retrospectively. The mean age of the patients was 52.8 years. There were 8 female [30.8%] and 18 male [69.2%] patients. The etiological causes were as follows: diseases of the perianal region, history of operations, trauma and injections. Major comorbid disease states were diabetes mellitus [DM] and hypertension. The lesions in Fournier's gangrene were most commonly located in the perineum and genital region. Female patients with diabetes mellitus had significantly unusual extensive involvement, especially abdominal wall involvement. The most frequently isolated pathogen was Escherichia coli, while staphylococcal infection was most commonly seen in the presence of DM. Colostomy was performed on 53.8% of the patients, and cystostomy on 7.6% of the patients. Average time of staying at the hospital was 25 days with a mortality rate of 34.6%. Patients with DM had high mortality rates and stayed longer at the hospital than the non-diabetic patients. In addition to early diagnosis, early and aggressive debridement and administration of multiple wide spectrum antibiotics chosen for the causative agent are the golden standard for decreasing the mortality and morbidity. Diabetes mellitus has been found to be an important factor to increase mortality rates of patients with Fournier's gangrene

Fournier Gangrene: a series of 12 patients

Fournier gangrene is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia, the perineum, or the abdominal wall that is associated with high morbidity and mortality. In this series, we describe 12 patients with Fournier gangrene who had presented to our medical center. Twelve men had been diagnosed with Fournier gangrene in Shohada-e- Tajrish hospital between March 2002 and September 2005. Their medical records were reviewed and the Fournier Gangrene Severity Index scores before and after the treatment were determined. Fifty percent of the patients were diabetic and their mean age was 58.2 ' 17.8 years. The mean delay between the onset of the disease and the admission was 4.9 days and the mortality rate was 16.6%. The median Fournier Gangrene Severity Index scores before the admission and at the time of discharge were 4.5 [range, 0 to 11] and 0 [range, 0 to 9], respectively [P = .005]. One of the patients who died had the scores of 11 and 9, respectively. Split-thickness skin graft was performed for 5 patients [41.7%]. In Fournier gangrene, a rapid diagnosis and emergent surgical intervention is crucial. The Fournier Gangrene Severity Index seems to be an excellent tool for outcome prediction

Complex wounds / Feridas complexas

Complex wound is the term used more recently to group those well-known difficult wounds, either chronic or acute, that challenge medical and nursing teams. They defy cure using conventional and simple "dressings" therapy and currently have a major socioeconomic impact. The purpose of this review is to bring these wounds to the attention of the health-care community, suggesting that they should be treated by multidisciplinary teams in specialized hospital centers. In most cases, surgical treatment is unavoidable, because the extent of skin and subcutaneous tissue loss requires reconstruction with grafts and flaps. New technologies, such as the negative pressure device, should be introduced. A brief review is provided of the major groups of complex wounds-diabetic wounds, pressure sores, chronic venous ulcers, post-infection soft-tissue gangrenes, and ulcers resulting from vasculitis.

Ferida complexa é uma nova definição para identificar aquelas feridas crônicas e algumas agudas já bem conhecidas e que desafiam equipes médicas e de enfermagem. São difíceis de serem resolvidas usando tratamentos convencionais e simples curativos. Têm atualmente grande impacto sócio-econômico. Esta revisão procura atrair atenção da comunidade de profissionais de saúde para estas feridas, sugerindo que devam ser tratadas por equipe multidisciplinar em centro hospitalar especializado. Na maioria dos casos o tratamento cirúrgico deve ser indicado, uma vez que a perda de pele e tecido subcutâneo é extensa, necessitando de reconstrução com enxertos e retalhos. Nova tecnologia, como uso da terapia por pressão negativa foi introduzido. Breves comentários sobre os principais grupos de feridas complexas: pé diabético, úlceras por pressão, úlceras venosas, síndrome de Fournier e vasculites.