Fournier's gangrene after renal transplantation

Mehmet Erikoglu1, Sakir Tavli1 and Suleyman Turk2

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



   Introduction
 Top
 Introduction
 Case
 Discussion
 References
 
Fournier's gangrene is a rapidly progressive and potentially lethal disease that affects the perineum and male genitalia. Treatment consists of supportive care, surgical debridation and antibiotic therapy. Even with the use of broad-spectrum antibiotics and the development of asepsis and antiseptic measures in the operating theatre as well as modern surgical techniques and intensive care units, there is still a high mortality rate for Fournier's gangrene [1,2]. Erectile impotence is a common problem in male patients with renal failure. The management of erectile impotence with prosthetic implants in renal transplant patients may lead to life-threatening infection [3].

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.



   Case
 Top
 Introduction
 Case
 Discussion
 References
 
A 33-year-old male was admitted to our organ transplantation unit for live donor renal transplantation. His medical history revealed he had had a penile prosthetic implantation 2 years earlier to correct erectile dysfunction and 15 years earlier he had undergone right nephrectomy for renal calculi. He also had a history of diabetes mellitus. The patient was in chronic renal failure for 2 years and had undergone peritoneal dialysis for 1 year. At the onset of the infection, he was maintained on standard immunosuppression (30 mg prednisone, 300 mg cyclosporin and 2 g mycophenolate mofetil daily) as well as insulin for diabetes mellitus. In the second month after transplantation, the patient presented complaining of high fever, swelling and pain and tenderness in the scrotum. A physical examination revealed necrosis, oedema, hyperaemia and a malodorous discharge from the right scrotum. However, the testis seemed to be normal. There was scrotal crepitation on palpation. The patient's white blood cell count was 10 000/mm3, the level of C-reactive protein was 18 mg/l (normal: 0–5 mg/l), serum creatinine was 2.7 mg/dl and blood urea nitrogen (BUN) was 108 mg/dl. The blood level of cyclosporin was 225.2 ng/ml (normal: 130–528 ng/ml) at the time the infection occurred.

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, piperacillin–tazobactam 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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Fig. 1. The appearance of the wound after surgical debridement.

 


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Fig. 2. The appearance of the wound after healing.

 


   Discussion
 Top
 Introduction
 Case
 Discussion
 References
 
Fournier's gangrene is a fulminant aerobic and anaerobic necrotizing infection starting from the perineal and genital regions and spreading rapidly over the fascial planes into the inguinal area, thigh and abdominal wall [4]. In the pre-antibiotic era the disease was commonly fatal and today it still carries a significant risk of morbidity and death [1,2].

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 10–60% 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.



   References
 Top
 Introduction
 Case
 Discussion
 References
 

  1. Vick R, Carson CC, III. Fournier's disease. Urol Clin North Am 1999; 26: 841–849[ISI][Medline]
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  3. Walther PJ, Andriani RT, Maggio MI, Carson CC, III. Fournier's gangrene: a complication of penile prosthetic implantation in a renal transplant patient. J Urol 1987; 137: 299–300[ISI][Medline]
  4. Dahm P, Roland FH, Vaslef SN et al. Outcome analysis in patients with primary necrotizing fasciitis of the male genitalia. Urology 2000; 56: 31–35[CrossRef][ISI][Medline]
  5. Jean-Charles N, Sadler MA. Necrotizing perineal fasciitis in two paraplegic nursing-home residents: CT imaging findings. Abdom Imaging 2001; 26: 443–446[CrossRef][ISI][Medline]
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  7. Kiliç A, Aksoy Y, Kiliç L. Fournier's gangrene: etiology, treatment and complications. Ann Pl Surg 2001; 47: 523–527[ISI]
  8. McGeehan DF, Asmal AB, Angorn IB. Fournier's gangrene. S Afr Med J 1984; 66: 734–737[ISI][Medline]
  9. Beaser RS, van der Hoek C, Jacobson AM, Flood TM, Desautels RE. Experience with penile protheses in the treatment of impotence in diabetic men. JAMA 1982; 248: 943–948[Abstract]
Received for publication: 29. 7.04
Accepted in revised form: 12.11.04





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