Fourniers gangrene, Carcinoma of the caecum: an unusual cause of Fourniers gangrene
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INTRODUCTION Fournier’s gangrene is a rapidly progressive necrotizing fasciitis involving the genitalia(1). This disease may be caused by a variety of urological as well as gastrointestinal tract and retroperitoneal diseases(2). We report a case of caecum carcinoma manifesting as Fournier’s gangrene. CASE REPORT A 58-year-old male presented with a history of right lower abdominal pain for one month and rapid scrotal pain and swelling which has spreaded through the abdominal and right flank region in the last 5 days. He did not have any history of a disease which might predispose the patient to Fournier’s gangrene. In his physical examination the significant findings were blood pressure of 90/50mmHg, heart rate of 112/min and temperature of 390C. He was in poor condition. He had a swollen scrotum with a necrotic area in its most dependent portion. The swelling has spread through right lower abdominal quadrant and right flank region. Also there was crepitation on palpation in these regions. The patient underwent urgent debridement. The necrotic scrotal tissue and the fascia in scrotum were all removed. The incision was carried through right inguinal region to the flank region through all fascial and muscular layers. Large amount of pus was drained retroperitoneally. Retroperitoneal region was dissected from adjacent structures without any difficulty. Drains were placed to the retroperitoneal space and the wound was left open. Only E. coli could be isolated. Following operation the patient was in better condition but had persistent right lower abdominal pain. Postoperatively computed tomograpy showed caecum carcinoma (Figure 1) and liver metastasis. The patient was consultated department of general surgery. Right hemicolectomy was not to seen fit by department of general surgery. The patient needed one more debridement in general anesthesia. The first debridement was performed urgent. The second debridement was performed five days later. Following granulation of the edges of scrotal and abdominal wounds(Figure 2) they were closed without the need of grafting. The patient was consultated department of general surgery. Right hemicolectomy was not to seen fit by department of general surgery. The patient was colsultated department of medical and radiation oncology for medical therapies. DISCUSSION Sigmoid and rectal carcinoma associated with Fournier’s gangrene has been reported (3, 4). There has been no other similar case reported in the literature, and thus, although rare, intra-peritoneal causes of infection should be considered in patients with Fournier's gangrene. In our patient there was long term abdominal pain and the involvement of retroperitoneum which are the not usual findings for necrotizing fasciitis. Such findings should alert the clinician that there might be an intraabdominal disease. The ease of retroperitoneal dissection shows that carcinoma has not invaded the retroperitoneal structures. Also there was no fecal contamination in that region. The source of infection might be a small perforation which has been closed spontaneously. The other explanation might be that the microorganisms have reached the region because of lymphatic stasis or bacterial translocation. REFERENCES 1.Veljkovic R, Milosevic P, Stojanovic S. Fournier's gangrene associated with carcinoma of the colon. Med Pregl 51(7-8):351,1998. 2.Gould SW, Banwell P, Glazer G. Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene. Eur J Surg Oncol 23 (4):367-368,1997. 3.Gould SW. Epididymo-orchitis: a rare, fatal, intra-abdominal cause. Ann R Coll Surg Engl 78 (3):230-231,1996. 4.Dewire DM, Bergstein JM. Carcinoma of the sigmoid colon: an unusual cause of Fournier's gangrene. J Urol 147 (3): 711-712,1992.
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