British Journal of Radiology (2003) 76, 841-842
© 2003 British Institute of Radiology
doi: 10.1259/bjr/20796813
All that glistens isn't gold (so do be sure the surgeon's told!)
S P Harden, FRCS, FRCR and
T S Creasy, FRCS(Ed), FRCR
Department of Radiology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset BH7 7DW, UK
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Introduction
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A 50 year-old man presented with a 3 day history of increasing pain and swelling of the left side of the scrotum. He had chicken pox and some of the vesicles had started to ulcerate. There was no other relevant medical history. An ultrasound of the scrotum was performed (Figure 1
). What is the diagnosis?
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Figure 1. Longitudinal ultrasound scan of the left hemiscrotum, (a) at the level of the epididymal head and (b) centred on the body of the testis.
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Answer
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Ultrasound showed multiple small echogenic foci in the scrotal subcutaneous tissues with dirty posterior acoustic shadowing (Figure 1
) which is the typical appearance of subcutaneous gas. There was marked associated scrotal wall oedema. The left testis and epididymis were morphologically normal with normal vascularity on colour Doppler imaging. The right hemiscrotum was normal. A pelvic radiograph was performed (Figure 2) confirming the presence of extensive scrotal soft tissue gas with a typical honeycomb appearance which extended into the left inguinal region. A large round gas collection more inferiorly represented a scrotal wall abscess. The imaging features are those of Fournier's gangrene [1].
Fournier's gangrene is a form of necrotizing fasciitis that involves the perineo-scrotal region. It occurs most commonly in men aged 50–70 years and there is often comorbidity with 40–60% of patients being diabetic [2]. It usually develops from a perineal or genitourinary infection, but can arise following local trauma with secondary infection of the wound. The infection is aggressive and spreads rapidly, with the rate of fascial necrosis reported to be up to 2–3 cm h-1 [3]. Thrombosis of subcutaneous and skin blood vessels occurs producing gangrene but the extent of fascial necrosis is usually far greater than the amount of visible gangrene would suggest. Multiple organisms are cultured in each case, with the most common being Klebsiella, Streptococcus, Proteus and Staphylococcus.
The mortality rate of Fournier's gangrene is significant and may be as high as 33%. This mortality rate increases with delay in diagnosis or treatment. A delay of 24 h before radical debridement increases mortality by 11.5% and a delay of 6 days carries a mortality rate of 76% [3]. Thus it is vital that the diagnosis is made promptly to permit surgical intervention to be instituted as quickly as possible. While the diagnosis is often made clinically, ultrasound may be able to identify evolving Fournier's gangrene before it becomes clinically obvious, as in this case. With the diagnosis established, CT has been used to help to determine the initiating focus of infection where an intrapelvic or intra-abdominal source is suspected and it has also been used in cases where there is extensive infection and necrosis to help plan surgical debridement [4].
There are very few reported cases of Fournier's gangrene related to varicella infection [5, 6]. Secondary infection following ulceration or scratching of a scrotal vesicle may occur, but the exact pathogenesis is not known.
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Footnotes
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The authors have no financial interest in the article and no funding has been obtained. 
Received for publication March 3, 2003.
Accepted for publication March 20, 2003.
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References
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- Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol 1998;170:163–8.[Free Full Text]
- Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotising fasciitis: the use of frozen section biopsy. N Engl J Med 1984;310:1689–93.[Abstract]
- Paty R, Smith AD. Gangrene and Fournier's gangrene. Urol Clin North Am 1992;19:149–62.[Medline]
- Tisnado J, Amendola MA, Walsh JW, Jordan RL, Turner MA, Krempa J. Computed tomography of the perineum. AJR Am J Roentgenol 1981;136:475–81.[Abstract/Free Full Text]
- Clayton MD, Fowler JE Jr, Sharifi R, et al. Causes, presentation and survival of 57 patients with necrotising fasciitis of the male genitalia. Surg Gynaecol Obstet 1990;170:49–55.
- Guneren E, Keskin M, Uysal OA, Ariturk E, Kalayci AG. Fournier's gangrene as a complication of varicella in a 15 month-old boy. J Pediatr Surg 2002;37:1632–3.[CrossRef][Medline]
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