Fournier Gangrene

King Herod Died of this Rare Disease • Xray of the Week

It is theorized that King Herod, builder of the Second Temple in Jerusalem, died of Fournier gangrene according to Jan Hirschmann, MD in Mystery of Herod's death 'solved'. Roman biographer Flavius Josephus wrote: "He had a fever, though not a raging fever, an intolerable itching of the whole skin, continuous pains in the intestines, tumors of the feet as in dropsy, inflammation of the abdomen, and gangrene of the privy parts."

This 58 year old male diabetic smoker was seen in the Emergency Department with a markedly elevated blood glucose level of 1054 mg/dl (58.6 mmol/l) and crepitus in the perineal region. CT scan was performed demonstrating gas in the scrotum and perineum tracking into the anterior abdominal wall [Figs. 1-2]. Two weeks after presentation, the patient developed a pelvic abscess [Fig. 3].

Figure1. Left image: Axial CT showing gas in the scrotum and perineum.

Right image: Coronal CT showing gas in the scrotum tracking into the anterior abdominal wall.

Figure 2. Axial CT showing gas in the pelvic soft tissues.

Figure 3. Axial CT obtained 2 weeks after initial presentation showing abscess formation in the left pelvic sidewall.

Figure 4. Axial CT obtained after percutaneous CT guided drainage of the abscess in the left pelvic sidewall.

Radiology played a major role in not only diagnosing the disease but also treatment with percutaneous abscess drainage [Fig. 4]. Cultures grew Morganella morgani, Streptococcus agalactiae, Corynebacterium, and his central line later grew Pseudomonas aeruginosa. He required multiple debridements of the inguinal, perineal, and perirectal regions and a colostomy. After 30 days in the hospital, and 10 debridements the patient was discharged to a skilled nursing facility.

Discussion:

Fournier gangrene is an uncommon but life-threatening infection with rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions seen mainly in elderly males. Gangrene is polymicrobial caused by both aerobic and anaerobic bacteria. Most cases are seen in diabetic or immune compromised patients. CT findings include fascial thickening, abscess formation, fat stranding surrounding the affected areas, and subcutaneous emphysema. This is a true surgical emergency and treatment is radical debridement of the necrotic tissue, and broad spectrum intravenous antibiotics. Hyperbaric oxygen therapy (HBOT) has also been shown to be useful. Mortality is between 15-50% depending on the severity at presentation.

References:

1. Levenson RB, Singh AK, and Novelline, RA. Fournier Gangrene: Role of Imaging. RadioGraphics 2008; 28:519 –528

2. Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. 1998;170 (1): 163-168.

3. Uppot RN, Levy HM, Patel PH. Case 54: Fournier gangrene. Radiology. 2003;226 (1): 115-117. doi:10.1148/radiol.2261010714

Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

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