Endocrine Abstracts

Introduction: Fournier’s gangrene is a rare and serious poly-microbial necrotizing fasciitis of the perineum and external genitalia, characterized by a fulminant evolution and a high morbidity and mortality. Annual incidence is between 1.6 and 3.3 cases/100,000 patients, with type 2 diabetics accounting for 30% to over 50% of cases, and 66% in women.

Observations:

Case 1: 48-year-old female, diabetic for 8 years on Metformin, admitted for diabetic ketosis on Fournier’s gangrene, revealed by a swelling associated with pain in the perianal and gluteal region, rapidly complicated by perianal necrosis extending to the left thigh, evolving for 7 days in a context of fever quantified at 39°c. Biological work-up revealed a frank infectious syndrome with Enterococcus Feacalis on pus sampling.

Case 2: Patient aged 43, admitted for diabetic ketoacidosis inaugurated by Fournier’s gangrene, revealed by an ulcerated lesion in the left perianal area 4 months previously. The lesion was manipulated, and rapidly spread to the left buttock area, evolving in a context of fever at 39.4°c. Biological tests revealed a frank infectious syndrome with Streptococcus Agalactiae in the pus sample. Both patients received triple broad-spectrum probabilistic antibiotic therapy, then adapted to the antibiogram, and underwent immediate broad-spectrum surgical debridement with insulin initiation followed by intensification. The average hospital stay was 20 days. One patient had a favorable outcome after a stay in intensive care, with good progress in directed healing. After stabilization, patients received therapeutic education on the need for hygiene and early consultation in the event of any injury to the perineal region.

Discussion and conclusion: Necrotizing skin and soft-tissue infections are characterized by rapid, deep-seated spread along the fascia and destruction of the skin, hypodermis and muscles. Clinical presentations vary according to the location and extent of lesions, the bacteria involved and predisposing factors linked to the infected subjects. They may be monomicrobial (especially streptococci/staphylococci) or polymicrobial. Fournier’s gangrene most often occurs in an immunocompromised environment: diabetes (40-60% of cases), alcoholism, malnutrition and poor sanitary conditions are frequent predisposing factors, as are immune deficiencies: chemotherapy, AIDS, advanced age. Women are affected much more rarely, and the starting point of the disease is often gynecological. Treatment must be initiated urgently, based on broad-spectrum antibiotic therapy, hemodynamic stabilization measures and, above all, rapid surgical cure by debridement and radical excision of necrotic tissue, in order to reduce the still high mortality rate, as well as aesthetic and functional sequelae.