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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 6  |  Page : 1257-1261
Fournier's gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient


1 First Department of Surgery and Transplant Unit, Evaggelismos General Hospital, Athens, Greece
2 Department of Urology, Evaggelismos General Hospital, Athens, Greece

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Date of Web Publication30-Oct-2015
 

   Abstract 

Fournier's gangrene is not a common cause of morbidity in renal transplant recipients, but, if it occurs, it is difficult to treat because of the immunosuppression and associated increased mortality rate. We describe the case of a male patient who underwent renal transplantation with complicated post-operative course, resulting in cecum perforation (thermal injury due to cautery use during transplantation) requiring exploratory laparotomy and cecostomy. A few days later, he developed Fournier's gangrene and urgent radical surgical debridement of the scrotum was performed, along with aggressive antibiotic regimen and the immunosuppressive treatment was modified. Subsequently, the patient underwent scheduled cecostomy closure (right hemicolectomy), while the scrotum trauma healed with tertiary intention. Epidemiologic characteristics, clinical presentation, diagnostic workup, therapeutic options and morbidity-mortality rates of Fournier's gangrene are reviewed, emphasizing the role of immunosuppression in renal transplant recipients to disease development.

How to cite this article:
Papadimitriou G, Koukoulaki M, Vardas K, Grigorakis A, Vougas V, Drakopoulos S. Fournier's gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient. Saudi J Kidney Dis Transpl 2015;26:1257-61

How to cite this URL:
Papadimitriou G, Koukoulaki M, Vardas K, Grigorakis A, Vougas V, Drakopoulos S. Fournier's gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Dec 10];26:1257-61. Available from: http://www.sjkdt.org/text.asp?2015/26/6/1257/168665

   Introduction Top


Fournier's gangrene is a lethal entity of the perineum and male genitalia if urgent therapeutic intervention is not applied. It is especially prevalent in Africa and Asia, and is suggested that poor socioeconomic status contributes to its development. [1] The overall incidence is estimated to be 1.6/100.000 males. [2] One of the uncommon predisposing factors is immunosuppression of variable etiology (AIDS, HIV, steroid treatment), [3] including immunosuppressive regimens used in renal transplantation. The latter reduce cell-mediated immune response, favoring infection. We present a rare case of Fournier's gangrene in a renal transplant recipient at the early post-operative period caused by iatrogenic perforation of the cecum, which resolved with multiple surgical interventions and antimicrobial treatment along with careful monitoring of immunosuppression.


   Case Report Top


A 56-year-old male patient with end-stage renal disease of unknown cause was admitted to our hospital to receive renal allograft derived from a 20-year-old male deceased donor (died due to traumatic brain injury) with good HLA histocompatibility matching (three common antigens - B51, DR1, DR4). The patient had been undergoing hemodialysis for the past eight years.

The patient had a past medical history of hypertension treated with medication and coronary artery disease. He had undergone quadruple coronary artery bypass grafting 10 months before transplantation with moderate postoperative cardiac function (ejection fraction 55%). Surgical history also included cholelithiasis treated with laparoscopic cholecystectomy nine years earlier and inguinal hernia repair 25 years earlier.

A right anterior extraperitoneal incision was performed, renal graft was transplanted without obvious complications and, after operation, the patient was transferred to the transplant unit of our hospital. Recipient's induction immunosuppression included prednisolone 200 mg on the first post-transplantation day (tapering schema: reduction 25 mg every day), basiliximab (20 mg on Day 0 and on Day 4), mycophenolate mofetil 1 g/day (beginning on Day 1 until Day 3) and cyclosporine (dose according to plasma levels) beginning on Day 1.

On the 5 th post-transplantation day, the patient experienced septic shock with low-grade fever up to 37.8°C, tachycardia up to 120 beats per minute and low systolic blood pressure 80 mm Hg with no response to intravenous fluids infusions. Vasoconstrictors in low dose were initiated. Basic laboratory tests showed normal hematocrit 30.7%, markedly increased white blood count 28,000 × 10 3 /L and C-reactive protein 53.2 mg/dL. Clinical examination revealed fecal content in the surgical drain. The patient was immediately transferred to the operating theater and underwent urgent surgery reusing the previous extraperitoneal incision that revealed perforation of the cecum, most probably due to previous thermal injury, with presence of feces in the extraperitoneal space down to the scrotum. Renal graft was evaluated as viable and an extra midline abdominal incision was made, which did not reveal fecal peritonitis. A cecostomy was performed and two drains were placed, one intraperitoneal and one in the extraperitoneal space. Long incisions of the scrotum were also performed. After operation, the patient was transferred to the intensive care unit where he remained intubated for six days and then returned to the transplant unit. Immunosuppressive regimen was modified and included hydrocortisone at the beginning followed by methylprednisolone until Day 15 when prednisolone per os was commenced. Cyclosporine was started at a low dose on Day 3, keeping low C2 levels (100-200 μg/L) until Day 12 (680 μg/L). Mycophenolate mofetil was not commenced. The post-operative period was complicated by infection of surgical trauma by multiresistant bacteria (Acinetobacter baumannii, Pseudomonas aeruginosa, Providencia stuartii, Klebsiella pneumonia, Enterococcus fecalis, Escherichia coli, Candida albicans, Clostridium sporogenes) and the patient received extended antimicrobial therapy including meropenem, caspofungin, ciprofloxacin, metronidazole, amikacin, tigecycline and colistin in various combinations. Blood and urine cultures were negative. Renal graft function got stabilized on Day 3 (serum creatinine 3.09 mg/dL) with moderate diuresis. The patient was not supported with dialysis during the post-cecostomy period.

On the 13 th post-cecostomy day, he developed a rapidly progressive fasciitis of the scrotum and the diagnosis of Fournier's gangrene was made. The patient underwent urgent radical surgical debridement of the scrotum while both testes were retained [Figure 1]. Immunosuppression regimen with cyclosporine and prednisolone were induced already from the first post-operative day.
Figure 1: Scrotal area after extended surgical debridement (viable testes).

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Uneventful recovery followed and the patient was discharged after three months of hospitalization. At that time, renal graft function was excellent (serum creatinine 0.9 mg/dL, urea 45 mg/dL). The patient was readmitted eight months later for scheduled closure of cecostomy. A right hemicolectomy was performed and the patient was discharged 15 days later. Perineum trauma was closed by tertiary intention, meaning that when contamination was retreated after two months of intensive wound care, surgical suturing was applied [Figure 2]. After two years of follow-up the patient is in good condition. Renal graft function remains excellent (serum creatinine 1.4 mg/dL, urea 56 mg/dL).
Figure 2: Final result of wound healing of scrotal trauma.

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   Discussion Top


Fournier's gangrene is a necrotizing fasciitis that infects regions of the perineum, genitalia and perianal area. Baurienne first described it in 1764. [4] Predisposing factors vary, including chronic alcoholism, prolonged immobilization, obesity and immunosuppression, [1],[5] but diabetes mellitus remains the most frequent. [6] The source of infection is cutaneous, urogenital or colorectal areas, evaluating perianal abscess as the most common etiology in many series. [7] It remains a major challenge, especially in the immunosuppressed patient, with high mortality rates of up to 20-40%. [2] Many scoring systems have been used in order to estimate the severity of the Fournier's gangrene, such as the Fournier Gangrene Severity Index (FGSI) [8] or the Receiver Operating Characteristics (ROC) analysis, [9] but we believe that the most important factors that influence the outcome of Fournier's gangrene in the immunocompromised patient are early recognition and aggressive surgical necrosectomy.

Fournier's gangrene usually presents with scrotal edema, cellulitis and pain, followed by a systemic upset, including fever, sweating and rigors, [10] and the patient rapidly progresses to septic shock. Establishment of diagnosis requires mainly clinician's high index of suspicion. Various multiple imaging modalities can be used, such as bedside ultrasound and emergency computed tomography, [11],[12] which can lead to accurate assessment of disease extent.

In most cases, cultures from the trauma or blood are positive. The synergistic action of both aerobic and anaerobic organisms causes the polymicrobial infection,13 estimating that the most common organisms are Escherichia coli, streptococcal species, Staphylococcus aureus and Pseudomonas aeruginosa.14

Cornerstone of treatment is surgical debridement of the necrotic tissues in order to rid the patient of rapid extension of gangrene, as Meneley introduced in the mid 1920s. [15] Early intervention has an important impact on mortality and is associated with lower rates. [16] Multiple debridement sessions can be necessary and can be up to six or seven. [17],[18] Alternative individualized reconstructive modalities for wound healing and coverage that improve the quality of patient's life can be used, such as Vacuum Assisted Closure (VAC), skin grafting and hyperbaric oxygen therapy. [19],[20]

Fournier's gangrene is no longer a rare disease in urologic-related transplantation patients, but we have not discovered any case report to date of Fournier's gangrene in renal transplant recipients during the early postoperative period due to iatrogenic colon perforation. We treated our patient with urgent radical surgical debridement without delaying diagnosis' establishment with imaging tests. There was no need for multiple debridement sessions, but daily wound care. Post-operatively, we used broad-spectrum antimicrobial regimens relying on wound cultures. In addition, despite the fact that we minimized immunosuppression at the early post-operative period after second operation (cyclosporine was not introduced until Day 3 and keeping low C2 levels until Day 12), giving the opportunity to the patient to fight sepsis, fully knowing that this could be a threat to renal graft, gangrene got developed. Surprisingly, serum creatinine gradually improved at the post-cecostomy period [Figure 3]. Our patient had a prolonged three-month hospitalization, exceeding the mean hospital stay of other reports analyzing Fournier's gangrene (around 20 days), confirming the severity of the disease in a renal transplant patient. Furthermore, we have to note that the obligatory cecostomy, which was performed due to cecum perforation, functioned, possibly as diverting stoma, helping scrotal trauma to be healed. Finally, we could state that the donor's young age and the good HLA histocompatibility matching contributed to the survival of the renal graft.
Figure 3: Serun-creatinine variability related to C2 levels during the hospitalization period after transplantation.

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In conclusion, thanks to the refinements in surgical technique and the impressive progress of immunosuppression, the outcome of renal transplantation can be excellent, but complications can occur even due to iatrogenic errors. Fournier's gangrene in renal transplant recipients should be treated aggressively with cooperation of transplant surgeon, nephrologist, urologist and infectious disease specialist in order to reduce mortality and save the renal graft.

Conflict of interest: None declared.

 
   References Top

1.
Eke N. Fournier's gangrene: A review of 1,726 cases. Br J Surg 2000;87:718-28.  Back to cited text no. 1
    
2.
Sorensen MD, Krieger JN, Rivara FP, et al. Fournier's Gangrene: Population based epidemiology and outcomes. J Urol 2009;181:2120-6.  Back to cited text no. 2
    
3.
Elem B, Ranjan P. Impact of immunodeficiency virus (HIV) on Fournier's gangrene: Observations in Zambia. Ann R Coll Surg Engl 1995; 77:283-6.  Back to cited text no. 3
    
4.
Baurienne H. Sur uneplaie contuse qui s'est terminée par la sphacelé de la scrotum. J Med Chir Pharm 1764;20:251-6.  Back to cited text no. 4
    
5.
Erikoglu M, Tavli S, Turk S. Fournier's gangrene after renal transplantation. Nephrol Dial Transplant 2005;20:449-50.  Back to cited text no. 5
    
6.
Ruiz-Tovar J, Córdoba L, Devesa JM. Prognostic factors in fournier gangrene. Asian J Surg 2012;35:37-41.  Back to cited text no. 6
    
7.
Moslemi MK, Sadighi Gilani MA, Moslemi AA, Arabshahi A. Fournier gangrene presenting in a patient with undiagnosed rectal adenocarcinoma: A case report. Cases J 2009;2:9136.  Back to cited text no. 7
    
8.
Wagner S, Greco F, Hoda MR, Kawan F, Heynemann H, Fornara P. Is intensive multimodality therapy the best treatment for fournier gangrene? Evaluation of clinical outcome and survival rate of 41 patients. Surg Infect (Larchmt) 2011;12:379-83.  Back to cited text no. 8
    
9.
Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier's gangrene: An analysis of 80 patients and a novel scoring system. Tech Coloproctol 2010;14:217-23.  Back to cited text no. 9
    
10.
Sarwar U, Akhtar N. Fournier's gangrene developing secondary to infected hydrocele: A unique clinical scenario. Urol Ann 2012;4:131-4.  Back to cited text no. 10
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11.
You JS, Chung YE, Cho KS, Kim SW, Park I. The emergency computed tomography as important modality for early diagnosis of Fournier gangrene. Am J Emerg Med 2011;29: 959.e1-2.  Back to cited text no. 11
    
12.
Kube E, Stawicki SP, Bahner DP. Ultrasound in the diagnosis of Fournier's gangrene. Int J Crit Illn Inj Sci 2012;2:104-6.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Ferreira PC, Reis JC, Amarante JM, et al. Fournier's gangrene: A review of 43 reconstructive cases. Plast Reconstr Surg 2007;119: 175-84.  Back to cited text no. 13
    
14.
Czymek R, Hildebrand P, Kleemann M, et al. New insights into the epidemiology and etiology of Fournier's gangrene: A review of 33 patients. Infection 2009;37:306-12.  Back to cited text no. 14
    
15.
Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924;9:317-64.  Back to cited text no. 15
    
16.
Sugihara T, Yasunaga H, Horiguchi H, et al. Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: An analysis of 379 cases. BJU Int 2012;110:E1096-100.  Back to cited text no. 16
    
17.
Ullah S, Khan M, Asad Ullah Jan M. Fournier's gangrene: A dreadful disease. Surgeon 2009;7: 138-42.  Back to cited text no. 17
    
18.
Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari GB. Management of Fournier's gangrene: An eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg 2002;68:709-13.  Back to cited text no. 18
    
19.
Assenza M, Cozza V, Sacco E, et al. VAC (Vacuum Assisted Closure) treatment in Fournier's gangrene: Personal experience and literature review. Clin Ter 2011;162:e1-5.  Back to cited text no. 19
    
20.
Ooi A, Chong SJ. Use of adjunctive treatments in improving patient outcome in Fournier's gangrene. Singapore Med J 2011;52:e194-7.  Back to cited text no. 20
    

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Correspondence Address:
Georgios Papadimitriou
First Department of Surgery and Transplant Unit, Evaggelismos General Hospital, Athens
Greece
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DOI: 10.4103/1319-2442.168665

PMID: 26586068

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