Prognosis

Some researchers and clinicians have advocated the use of scoring systems, such as the Fournier Gangrene Severity Index (FGSI), as a prognostic tool for patient mortality once the disease is confirmed.4 Although its academic merits are without question, the clinical utility of FGSI in early management is debatable.6 FGSI is meant to predict a patient’s likely mortality risk associated with the disease, not to guide clinical decision-making. FGSI analyzes temperature, heart rate, respiratory rate, white blood cell count, hematocrit, serum sodium, serum creatinine, and bicarbonate levels to create a value to predict patient mortality.15 A score from the FGSI >9 is associated with high likelihood of mortality, and a score <9 is associated with a greater likelihood of survival.4,9,13,15

Conclusion

Although rare, FG may be associated with significant risk for morbidity and mortality especially if recognition and treatment are delayed, which is common due to ambiguous history and physical examination findings. Although risks can be reduced significantly with preventive health management of key comorbid conditions, namely those associated with immunodeficiency, disease cannot always be prevented. If FG develops despite these preventive efforts, prompt identification and management, including early antibiotic administration and surgical intervention, are the foundations of mortality reduction and require a high index of suspicion on the part of the examiner.

Mara Kohls, MPAS, PA-C, is a physician assistant with Qualified Emergency Specialists, Inc. and the Department of Emergency Medicine of the University of Cincinnati in Cincinnati, Ohio. Christopher M. Howell, DSc, MSc, MPAS, PA-C, MBA, FAAPA, is an associate professor at Kettering College in Kettering, Ohio, and practices in Indiana and Ohio in addiction and emergency medicine.

References

1. Tarchouli M, Bounaim A, Essarghini M, et al. Analysis of prognostic factors affecting mortality in Fournier’s gangrene: a study of 72 cases. Can Urol Assoc J. 2015;9(11-12):E800-804.

2. Faria SN, Helman A. Deep tissue infection of the perineum: case report and literature review of Fournier gangrene. Can Fam Physician. 2016;62(5):405-407.

3. Sorensen M, Kriegar J. Fournier’s gangrene: epidemiology and outcomes in the general US population. Urol Int. 2016;97(3):249-259.

4. Sen H, Bayrak O, Erturhan S, Borazan E, Koc MN. Is hemoglobin A1c level effective in predicting the prognosis of Fournier gangrene? Urol Ann. 2016;8(3):343-347.

5. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-728.

6. Yim SU, Kim SW, Ahn JH, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratios are more effective than the Fournier’s gangrene severity index for predicting poor prognosis in Fournier’s gangrene. Surg Infect (Larchmt). 2016;17(2):217-223.

7. Norton KS, Johnson L, Perry T, Perry K, Sehon J, Zibari G. Management of Fournier’s gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002;68(8):709-713.

8. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection diagnosis and management. Clin Infect. Dis. 2007;44(5):705-710.

9. Thwaini A, Khan A, Malik A, et al. Fournier’s gangrene and its emergency management. Postgrad Med J. 2006;82(970):516-519.

10. Smith GL, Bunker C, Dinneen M. Fournier’s gangrene. Br J Urol. 1998;81(3):347-355.

11. Chennamsetty A, Khourdaji I, Burks F, Killinger KA. Contemporary diagnosis and management of Fournier’s gangrene. Ther Adv Urol. 2015;7(4):203-215.     

12. Saber A, Bajwa TM. A simplified prognostic scoring system for Fournier’s gangrene. Urol Nephrol Open Access. 2014;1(3):00018.

13. Wróblewska M, Kuzaka B, Borkowski T, Kuzaka P, Kawecki D, Radziszewski P. Fournier’s gangrene–current concepts. Pol J Microbiol. 2014;63(3):267-273.

14. Zaba R, Grzybowski A, Prokop J, Zaba Z, Zaba C. Fournier’s gangrene: historical survey, current status, and case description. Med Sci Monit. 2009;15(2):CS34-CS39.

15. Chia L, Crum-Cianflone NF. Emergence of multi-drug resistant organisms (MDROs) causing Fournier’s gangrene. J Infect. 2018;76(1):38-43.

16. Levenson RB, Singh A, Novelline R. Fournier gangrene: role of imaging. Radiographics. 2008;28:519-528.

17. Sharif HS, Clark D, Aabed M, et al. MR imaging of thoracic and abdominal wall infection: comparison with other imaging procedures. AJR Am J Roentgenol. 1990;154:989-995..

18. Verma S, Sayana A, Kala S, Rai S. Evaluation of the utility of the Fournier’s gangrene severity index in the management of Fournier’s gangrene in North India: a multicentre retrospective study. J Cutan Aesthet Surg. 2012;5(4):273-276.

19. Jeong HJ, Park SC, Seo IY, Rim JS. Prognostic factors in Fournier gangrene. Int J Urol. 2005;12:1041-1044.

20. Nisbet AA, Thompson I. Impact of diabetes mellitus on the presentation and outcomes of Fournier’s gangrene. Urology. 2002;60(5):775-779.

21. Ersoz F, Sari S, Arikan S, et al. Factors affecting mortality in Fournier’s gangrene: experience with fifty-two patients. Singapore Med J. 2012;53:537-540.

22. Lin TY, Ou CH, Tzai TS, et al. Validation and simplification of Fournier’s gangrene severity index. Int J Urol. 2014;21(7):696-701.

23. Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg. 2007;2:19.