|Year : 2018 | Volume
| Issue : 3 | Page : 174-176
Neonatal Fournier's gangrene
Aditya Pratap Singh, Arun Kumar Gupta, Rajlaxmi Pardeshi, Dileep Garg
Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
|Date of Web Publication||2-Aug-2018|
Dr. Aditya Pratap Singh
Near the Mali Hostel, Main Bali Road, Falna, Pali, Rajasthan
Source of Support: None, Conflict of Interest: None
Necrotizing fasciitis of the perineum and external genitalia is a life-threatening infective gangrene. Primarily, it is seen in adults but it may be seen at any ages. It is rare in neonates and infants. Early surgical debridement with appropriate antibiotics and aggressive supportive care gives good results. It is a preventable condition to some extent. We are reporting here a case of Fournier's gangrene in a 25-day-old male neonate who was treated aggressively with broad-spectrum antibiotics and early surgical debridement. Even though no obvious precipitating cause was identified, hygiene was thought to be the inciting factor.
Keywords: Fournier's gangrene, hygiene, neonate
|How to cite this article:|
Singh AP, Gupta AK, Pardeshi R, Garg D. Neonatal Fournier's gangrene. J Clin Neonatol 2018;7:174-6
Fournier's gangrene is more common in adults and peak incidence occurs between 20 and 50 years of age and is extremely rare in children. Only around 80 cases of necrotizing fasciitis have been reported in the literature., Fournier's gangrene is a serious and aggressive form of infective necrotizing fasciitis involving the perineal region and genitalia due to polymicrobial infection.
Parent of a 25-day-old male child presented to us with the complaints of progressively increasing scrotal swelling with discoloration of the scrotal skin and penile discoloration for the past 8 days. On local examination, both the scrotal skin was red, edematous, and gangrenous patch over the penis [Figure 1]. The baby did not have a history of fever. Birth history did not reveal any abnormality, and the patient's birth weight was 2.5 kg. There was no history of any type of surgical intervention and injury to the perineum or lower abdomen, catheterization, insect bite, or other predisposing conditions. On general examination, baby hygiene was poor, and the perineum was normal. Other systemic examinations were within normal limits.
Investigations revealed a leukocyte count of 21,000/mm3 with 75% neutrophils. Hemoglobin was 10.0 mg/100 mL, blood urea was 45 mg/100 mL, and serum creatinine was 1.5 mg/100 mL. Serum electrolytes were normal. An ultrasonography of the scrotum demonstrated thickened fascial planes with edema. Chest X-ray was normal.
The baby was vigorously resuscitated with intravenous fluids and broad-spectrum antibiotics, which covered both aerobic and anaerobic organisms, in addition to other supportive measures. Surgical debridement was undertaken under general anesthesia with endotracheal intubation, and all devitalized and necrotic tissues were excised, and scrotal incision and drainage were done bilateral [Figure 2]. The dressing protocol was continued in the postoperative period. Wound swab showed growth of Staphylococcus aureus, and antibiotics were continued according to the sensitivity report. The blood culture report was negative. Antibiotics and other supportive treatments along with regular dressing were continued in the postoperative period which led to a fairly rapid contraction of the wound. The patient's parents were properly counseled during the postoperative period regarding the maintenance of proper hygiene and its importance.
The source of infection is perineal and genital skin infection, anorectal or urogenital trauma including perineal or pelvic injury, omphalitis, localized abscess, diaper rash, insect bite, and circumcision.,,
The bacteria act synergistically to produce enzymes such as collagenase and hyaluronidase that invade the fascial planes which lead to vascular thrombosis with subsequent gangrene of the overlying skin. Bacteria further proliferate in these devitalized tissues. Infection from the superficial perineal fascia may spread to the penis and scrotum or to the anterior abdominal wall or vice versa. In our case, the infection was involved scrotum and penis initially. Testicular involvement is rare as it has a blood supply independent of the affected area as evident in our case.
The necrotizing process commonly originates from an infection in the anorectum, the urogenital tract, or the skin of the genitalia. The reported etiological factors in the pediatric age group include omphalitis, strangulated hernia, prematurity, diaper rash, varicella infection, circumcision, and perineal skin abscesses. Other causes in children include trauma, insect bites, surgeries or invasive procedures in the perineal region, urethral instrumentation, burns, and systemic infections. In children, the causative organisms usually are streptococci, staphylococci, and anaerobes. In our case, there was no identifiable cause precipitating the condition. The only obvious feature was poor general hygiene. Usually, the diagnosis is clinical, even though a plain X-ray of the region may demonstrate gas in the subcutaneous and other tissue planes. Ultrasound may differentiate it from an intrascrotal pathology.
The management of this condition is controversial. Some surgeons recommend immediate exploration, whereas others prefer conservative management.
Although the initial literature advocates early aggressive surgical debridement of Fournier's gangrene wounds, a recent report shows a successful outcome with a more conservative and selective surgical debridement. We recommend more than one antibiotic coverage, including one specifically targeted toward S. aureus. Both Enterococcus and S. aureus have been implicated as the causative organisms of Fournier's gangrene in previous reports. Our patient also responded to this aggressive modality of treatment. Hyperbaric oxygen has shown some promising results in the management of this condition. This therapy needs to be balanced with the stability of the patient.
Mortality as reported by different authors ranged from 3% to 45% and was due to severe sepsis, coagulopathy, and renal failure. A high index of suspicion and prompt diagnosis along with surgical debridement and a multidisciplinary approach are the mainstays of management in children with Fournier's gangrene. Hygiene has a role to play in Fournier's gangrene.
Since this patient had poor hygiene and no obvious inciting factors were found, we have concluded that poor hygiene can be a cause of neonatal Fournier's gangrene. Proper health education regarding good hygiene of a neonate to the parents can probably prevent neonatal Fournier's gangrene.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Dr. Neelam Dogra, Anaesthesiologist, Senior professor, SMS Medical college, Jaipur.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]