Research Day

Fournier's Gangrene as the Presenting Sign for Perforated Rectal Cancer: A Rare Presentation of a Highly Fatal Pathology.

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INTRODUCTION: Fournier’s Gangrene is a necrotizing fasciitis of the perineum and perianal regions. Infection is typically polymicrobial with both anaerobes and aerobes present. Sources of infection typically initiate from the skin, urinary tract or anorectal tract. This case report describes the sixth case in the literature of perforated rectal carcinoma presenting as Fournier’s gangrene. Co-occurrence of these conditions is rare, but potentially fatal, thus increasing physician awareness of the various presentations of rectal carcinoma is essential to improve patient outcomes.

CASE PRESENTATION: A 63-year-old male presented to the emergency department with a one-month history of perineal pain and erythema. He had seen his primary care physician multiple times and was diagnosed with cellulitis and treated with topical antibiotics. He presented with hemodynamic instability with elevations in white blood cell count, BUN, creatinine, lactic acid, and creatinine kinase. CT scan of the abdomen and pelvis revealed extensive subcutaneous air in the right lower abdominal wall and perineum extending through the right inguinal canal and involving the right testicle. He was taken emergently to the operating room for extensive radical debridement of necrotic tissue and a right orchiectomy. The operation ended prematurely with plans for further debridement due to worsening hemodynamic instability requiring multiple vasopressors. The patient was stabilized and returned to the operating room 18 hours later, where a diverting end sigmoid colostomy was performed. Debridement of the perineum during that operation revealed a necrotic and perforated rectum for which the patient underwent an abdominoperineal resection(APR) 24 hours later. Patient had a complicated hospital stay with multiple further debridement of his right lower extremity extending from his abdominal wall into the popliteal fossa. In addition, he developed multiple organ failure and on post-operatively day eleven from his index procedure he expired. Final pathology from the APR revealed an 8.2 x 5.4 cm perforated rectal mass consistent with a moderately differentiated adenocarcinoma extending through the muscularis propria into the subserosal tissues. 2/18 lymph nodes were positive for adenocarcinoma. 

CONCLUSION: Fournier’s gangrene is a severe infection of the perineum requiring emergency radical surgical debridement and broad-spectrum antibiotics. It has high morbidity and mortality rates with studies reporting an average of 20% mortality rate. Although, it is an emergent surgical condition it is imperative for both primary care physicians and surgeons alike to be cognizant of this condition, as timing of diagnosis and early operative debridement has been shown to have improve outcomes.

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