AIR ON RADIOGRAPHY OF PERINEAL NECROTIZING FASCIITIS INDICATES TESTIS INVOLVEMENT

Gonadal possession of the vascular supply and anatomical separation from the surrounding fascia generally spare the testes from Fournier's gangrene. To our knowledge the pres- ence of air on plain film of the kidneys, ureters and bladder in the setting of necrotizing fasciitis has not been previously described. We report on a patient with Fournier's gangrene and plain film evidence of testicular involvement. CASE REPORT A 56-year-old white man without diabetes presented else- where with a perianal boil. Initially, he had improvement without clinical evidence of abscess formation but on day 5 of treatment the overall condition began to deteriorate rapidly. Perineal, scrotal and lower abdominal crepitus consistent with Fournier's gangrene was noted. He was intubated for acute respiratory distress syndrome and transferred to our hospital. Before operative debridement radiography of the kidneys, ureter and bladder revealed a vertically oriented curvilinear lucency overlying the left perineal soft tissues and ischial tuberosity consistent with gas in the left vas deferens (see figure). Perineal, scrotal, penile and lower abdominal skin was excised. The left testis was gangrenous and orchi- ectomy was required. A diverting colostomy was performed to protect the wound. Operative wound cultures yielded Escherichia coli and bacteroides. Wounds were treated openly for 6 weeks, and then split thickness mesh skin graft- ing was done. The patient was discharged home 2 weeks later. DISCUSSION The mortality rate associated with Fournier's gangrene is approximately 20 to 45% and higher when associated with perirectal disorders. 1 Prompt diagnosis is critical because of the rapidity with which the process can progress, particu- larly in patients with co-morbid conditions, such as obesity or diabetes. Clinical differentiation from cellulitis may be diffi- cult since the initial signs, including pain, edema and ery- thema, are not distinctive. However, the presence of marked systemic toxicity disproportional with local findings should alert the clinician. Immediate aggressive debridement is es- sential. The skin and subcutaneous tissues should be saucer- ized extensively beyond the areas of involvement to normal fascia. Necrotic fat and fascia should be excised, and the wound should be left open as in our case. Intravenous broad- spectrum antibiotic coverage should also be given because of the mixed nature of these infections, usually consisting of facultative organisms (E. coli, Klebsiella and enterococci) and anaerobes (bacteroides, fusobacterium, clostridium and mi- croaerophilic streptococci). 2 Paty and Smith outlined the pertinent anatomical rela- tions of the fascial planes and infectious spread in the peri-