1 General Surgery and Renal Transplantation Unit and 2 Nephrology, Selcuk University Meram Medical Faculty, Konya, Turkey
Correspondence and offprint requests to: Mehmet Erikoglu, General Surgery and Renal Transplantation Unit, Selcuk University Meram Medical Faculty, Konya, Turkey. Email: merikoglu{at}hotmail.com
Keywords: Fournier's gangrene; immunosuppressive treatment; penile implantation; renal transplantation
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Introduction |
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This syndrome is seen very rarely after renal transplantation. We present herein a case occurring in a renal transplant patient who accumulated several risk factors.
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Case |
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This condition was evaluated as Fournier's gangrene and treated with wide surgical debridation (Figure 1). There was no need for faecal diversion by colostomy, because the anal region was intact. The wound was followed up by repeated debridation and frequent wound dressings. Enterobacter, Enterococcus and Klebsiella were found in the wound culture. A combination antibiotic regimen of vancomycin, piperacillintazobactam and imipenem was instituted following the antibiogram results. Diabetes mellitus was controlled by insulin treatment. There was significant wound improvement after 1 month of intensive wound care. The wound was closed by primary suture after controlling of the infection (Figure 2). After the infection had been controlled, serum creatinine and BUN levels returned to normal values.
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Discussion |
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We discovered only one case report to date of Fournier's gangrene after penile prosthetic implantation in a renal transplant patient [3], but no reports to date of Fournier's gangrene developing after renal transplantation in a patient with a penile prosthetic implant. Walther et al. [3] reported one case of Fournier's gangrene associated with prosthetic penile implant after renal transplantation and in this case the penile implant was thought to be a predisposing factor. They suggested extreme caution before proceeding with a prosthetic operation in a transplant patient.
Diabetes mellitus, chronic renal failure, hepatic failure, immunosuppression (bone marrow transplantation, steroid treatment and AIDS), malignancy and morbid obesity are among the predisposing factors. The presence of these factors will affect the extent of the gangrene and morbidity [1,2]. The most frequent systemic illness associated with Fournier's gangrene is diabetes mellitus and is seen in 1060% of cases. Susceptibility to Fournier's gangrene in patients with diabetes mellitus may be explained by defective phagocytosis, decreased cellular immunity and microvascular disease with resultant ischaemia [2,5]. Small [6] reported that the rate of infection after penile prosthesis implantation in diabetic patients was six times greater than in non-diabetic patients. We believe that the prosthetic penile implant, diabetes mellitus, transplant surgery and immunosuppressive treatment were predisposing factors in the development of Fournier's gangrene in our patient.
The most commonly isolated agent is Escherichia coli [7]. Walther et al. [3] found microaerophilic Streptococcus and Staphylococcus in the cultures of their patient. Mixed bacteria (Enterobacter cloacae, Enterococcus faecalis and Klebsiella pneumoniae) were detected in our case. The normal level of white blood cells, which is an infection parameter, was thought to be due to immunosuppressive treatment. Generally, the mortality rate in patients with Fournier's gangrene is 18.6% while the mortality rate in diabetic patients is 33%; in non-diabetic patients this rate is 14.7%. The mortality rate will increase in conditions where diagnosis and treatment are delayed [8].
Since a satisfactory psychological benefit has been achieved by the use of penile prosthetic implantation as the primary therapeutic modality, even in the higher risk diabetic population [9], it is likely that the need for renal transplantation following penile prothesis operations will continue to confront transplant surgeons.
Because a penile prosthesis is a foreign body, we think that it may lead to stasis, mechanical trauma and damage to genital tissue blood supply. In addition, the presence of diabetes in an immunosuppressed patient with a penile prosthesis increases the risk of contracting Fournier's gangrene.
We believe that in diabetic patients with a penile prosthesis, careful selection is necessary before these patients can be considered as candidates for renal transplant surgery to avoid the possibility of developing Fournier's gangrene.
Conflict of interest statement. None declared.
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References |
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