Fournier’s Gangrene Arising from Chronic Ischial Pressure Sore in a Paraplegic Patient: A Case Report

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J Wound Manag Res. 2024;20(3):266-270

Publication date (electronic) : 2024 October 31

doi : https://doi.org/10.22467/jwmr.2024.03090

Jiwoo Jang, Sunkyu Park, Jong-Ho Kim

Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

Corresponding author: Jong-Ho Kim, MD Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea E-mail: kjh6321@naver.com

Received 2024 August 21; Revised 2024 October 4; Accepted 2024 October 6.

Abstract

Introduction

Fournier’s gangrene (FG) is a rare but serious bacterial infection that affects the genital and perianal areas and is associated with high morbidity and mortality rates [1]. The mortality rate of FG can vary depending on the severity of the infection, the age and overall health of the patient, and the promptness and aggressiveness of treatment [2]. Although FG is frequently observed in patients with preexisting medical conditions, such as diabetes or immunodeficiency, it can also arise as a complication of skin injuries, including pressure ulcers [3,4].

A pressure sore, also known as a pressure ulcer, is an injury that occurs when a prolonged period of pressure on the skin causes damage to the underlying tissues. Some studies suggested that grade IV pressure sores, which extend to the muscle and bone level, can be a source of infection and increase the risk of developing FG [3,5]. However, it is rare for severe FG to be caused by direct invasion from this kind of sore.

Here, we report on a 65-year-old male patient with a history of paraplegia and chronic ischial pressure sores who presented to our hospital with FG. We aim to emphasize the importance of recognizing the possibility of FG arising directly from pressure sores and the critical role of early surgical intervention.

The report was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2207/671-072). The patient provided written informed consent for the publication and use of his images.

Case

A 62-year-old male patient presented to the emergency room after 2 weeks of fever, severe swelling in the scrotum and increasing discharge from a pressure sore on the right ischium (Fig. 1). The patient had been in a paraplegic state for 10 years due to compressive myelopathy at the T11–T12 level. He had a grade IV right ischial pressure sore according to the European Pressure Ulcer Advisory Panel classifications. The pressure sore had developed 2 years earlier, and the patient had been managing it through regular dressing changes when he presented to our hospital. Aside from his paraplegia and prolonged ischial sores, the patient did not suffer from diabetes, human immunodeficiency virus infection, chronic alcoholism or other problems that could cause an immunosuppressive state. Blood tests revealed a C-reactive protein level exceeding 40 mg/L coupled with a white blood cell count of 26,000/μL, and the patient had a body temperature of over 38.5 °C. Abdomen computed tomography (CT) imaging revealed extensive foci of gas with complicated fluid in the right scrotum, right coccyx, whole perineal area, and both gluteus maximus muscles (Fig. 2).

Fig. 1.

Photograph taken at the emergency room. (A) A 62-year-old male patient presented to the emergency room with increased discharge from pressure sores. (B) Redness and swelling of the testes are also identified.

Fig. 2.

Abdomen computed tomography (CT) imaging. (A) Abdomen CT demonstrated complex fluid collections with extensive areas of gas in the right coccyx, perineal region, and both gluteus maximus muscles (yellow arrow). (B) The tract between the right testis and pressure ulcer is identified (yellow arrow).

The patient was admitted for prompt surgical debridement and antibiotic treatment. Empirical intravenous antibiotic treatment with a 3rd generation cephalosporin was immediately initiated, and debridement was performed in cooperation with the urology department. The necrotic soft tissue in the scrotum was removed by the urologist, and a tract was found between the ischial sore and scrotum (Fig. 3). Infectious scrotal tissue and swab cultures were obtained and later identified as the Viridans streptococcus group. We performed multiple rounds of massive irrigation and debridement, while keeping the wound open to facilitate drainage. From the day of admission until the last debridement, betadine-soaked gauze dressings were applied daily. Antibiotics were continuously adjusted based on culture and antibiotic susceptibility test results. After a month of regular debridement, daily dressing changes and antibiotic treatment, C-reactive protein levels normalized with negative wound culture results. The wound became clean and had granulated. After confirming that the tract had nearly closed, we planned for reconstruction.

Fig. 3.

The tract between the ischial sore and the scrotum. The silastic drain passes through the tract.

Initially, we planned to use a muscle flap to obliterate the tract. However, with consistent dressings and debridement, the tract nearly closed and the swelling decreased, enabling better tissue mobilization. Consequently, we revised our approach and used a regional fascial flap instead. To avoid leaving any tract or dead space that could lead to future complications, we first closed the scrotal wound, which had shown relatively faster healing. A silastic drain was inserted, and key sutures were placed to facilitate drainage through the ischial wound (Fig. 4). Subsequently, we performed regular dressings through the ischial wound, and observed that granulation tissue had developed without any significant wound problems. Two weeks after the scrotal wound repair, we closed the ischial wound by elevating a fascial local flap around the tract and packing it tightly into the closed tract entrance. The remaining tissues were reconstructed with an advancement flap after proper undermining (Fig. 5). The patient was closely monitored with frequent position changes and wound evaluation, and there were no further wound issues observed for 13 months (Fig. 6).

Fig. 4.

Postoperative photograph after scrotal wound closure. Primary closure was possible due to the substantial reduction in scrotal swelling.

Fig. 5.

Intraoperative photograph of ischial wound closure. (A) Healthy granulation tissue was identified from the ischial side. (B) Postoperative photograph after ischial wound closure.

Fig. 6.

Postoperative photograph taken 13 months after the operation. The wound was well healed and there were no signs of recurrence.

Discussion

We report a case of successful treatment of FG that originated from a preexisting ischial sore. FG is commonly regarded as necrotizing fasciitis of the perirectal, perianal, and genital areas, and is associated with a high mortality rate [1]. Hence, prompt diagnosis and appropriate treatment are imperative. Imaging modalities, such as X-ray, ultrasonography, CT, or magnetic resonance imaging, can aid in the early diagnosis of FG, as well as in assessing the disease’s extent by identifying scrotal wall thickening and the presence of subcutaneous gas [1,6]. It has been reported that prompt surgical intervention and antibiotic therapy can increase the survival rate of FG [7]. Recent studies report on the use of various treatment modalities for pressure sore management, such as negative pressure wound therapy and hyperbaric oxygen therapy, to promote rapid recovery from FG [8,9].

There has been a study indicating that patients who develop pressure sores are at an increased risk of developing FG [3]. This study suggested that the chronic ischial sore served as the primary site of infection, with a direct tract to the scrotum facilitating the spread of bacteria, which allowed the infection to extend from the ischial region to the perineum, leading to severe complications like FG. In our case, a direct connection was established between an ischial sore and the FG site, demonstrating that the open wound of the sore itself could be a direct cause of FG. One important factor in reducing mortality among patients with necrotizing fasciitis is the duration between hospital admission and surgery, as highlighted in prior research [10]. In our patient’s case, early debridement was performed on the testis and ischial sore regions immediately after presentation to the emergency department. Subsequent rounds of extensive irrigation and debridement were carried out, resulting in a favorable outcome.

Studies have shown that a substantial proportion of patients with FG require soft tissue reconstruction via flap surgery rather than simple primary closure [11,12]. In this particular case, the patient underwent multiple debridements. However, as the severe swelling subsided, there was no shortage of skin, and a local fascial flap was deemed adequate for coverage. It highlights the importance of the plastic surgeon’s reconstructive expertise in cases of FG for effective repair of the defect site following multiple debridements.

This case highlights the importance of recognizing the potential for FG to develop as a complication of skin wounds, including pressure sores, particularly in high-risk patients with underlying medical conditions. There is a higher likelihood that the infection stemming from such a tract contributed to the development of FG. Therefore, vigilant observation and education for patients, especially when a prolonged ischial sore with a tract is present, is of significant importance; even more so when it is directed towards the perineum. Early recognition and aggressive treatment, including surgical debridement and antibiotics, can improve outcomes and prevent complications associated with this life-threatening condition. Regular follow-up care and patient education are also crucial in facilitating early diagnosis and minimizing associated risks.

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