Fournier’s gangrene with corpus spongiosum necrosis following obstructive emphysematous pyelonephritis: An exceptional and severe urological complication

Abstract

Fournier’s gangrene is a grave necrotizing fasciitis that primarily affects the perineum, spreading through the fascias and leading to significant tissue destruction. The involvement of the urethra in necrosis is extremely rare, if not anecdotal.

Emphysematous pyelonephritis, is a urinary infection with a high risk of progression to sepsis. Although both Fournier’s gangrene and obstructive pyelonephritis are independently well-documented, their concurrent presentation is uncommon and poses significant diagnostic and therapeutic challenges.

In this report, we present a rare case of Fournier’s gangrene secondary to emphysematous pyelonephritis, which further led to necrosis of the corpus spongiosum, a scarcely reported complication.

1 Introduction

Fournier’s gangrene is a necrotizing fasciitis that primarily affects the perineum, spreading quickly across fascias and causing considerable tissue loss. This syndrome is usually caused by polymicrobial infections, which are frequently connected with diabetes, immunosuppression, or severe trauma. Obstructive emphysematous pyelonephritis, a urinary infection accompanied by upper urinary tract obstruction and the presence of air bubbles, is a major urological emergency with a high risk of developing into sepsis. Although Fournier’s gangrene and obstructive pyelonephritis are well-documented in isolation, their coexistence is unusual and presents substantial diagnostic and therapeutic problems. In this report, we present a rare instance of Fournier’s gangrene associated with urethral necrosis following an obstructive pyelonephritis, a seldom reported consequence.

2 Case study

80-year-old patient admitted to intensive care for management of anuria and obstructive pyelonephritis complicated by septic shock. The patient has a history of diabetes under oral antidiabetic medication, hypertension under amlodipine, benign prostatic hyperplasia under tamsulosin, and follow-up for renal lithiasis for which he underwent surgery for a staghorn stone in 1995 via right flank incision and for a left renal stone in 2000.

He presented to the emergency department with fever and lumbar pain. The evolution of his clinical condition has been characterized by the onset of confusion, anuria, and sepsis. Upon clinical examination, the patient was found to be confused, with a blood pressure of 70/50 mmHg, a heart rate of 110 bpm, oxygen saturation of 96 %, a temperature of 39°,and respiratory rate of 22 cycles per minute.

The initial lab tests showed white blood cells at 43,200/mm3, Prothrombin Ratio of 67 %, potassium: 6.8 mmol/l, Urea: 2.56 g/l, Creatinine: 55.4mg/l, C-reactive protein test: 250.20mg/l, Platelets: 80,000/mm3, and acidosis.

CT imaging focussed on the kidneys revealed bilateral staghorn calculi in the renal pelvis, causing pelvicalyceal dilatation. An axial cut revealed the presence of air in the upper urinary tract, indicating emphysematous pyelonephritis ( Fig. 1 ). The examination showed a left kidney with a 39mm pyelocaliceal dilatation caused by a 4cm renal calculus (1300UH), right kidney with a 30mm pyelocaliceal dilatation caused by a 25mm renal calculus (1250UH) with perirenal infiltration ( Fig. 1 ). The patient was hospitalized in an intensive care unit with the initiation of antibiotic therapy with carbapenem and amikacin, and the introduction of norepinephrine. The patient benefited from an emergency hemodialysis session and was then admitted to the operating room for the placement of bilateral JJ stents. During the initial cystoscopy, the urethra showed no irregularities.

The immediate evolution was marked by an improvement in potassium levels as well as an improvement in renal function without complete normalization, with a return to normal diuresis, as well as a progressive improvement in CRP reaching a plateau at 140 mg/L and WBC at 18,000mm/3. The cytobacteriological examination of pelvic urine samples revealed the presence of Escherichia coli . Subsequently during his time in reanimation, the onset of urethral ischemia with fasciitis limited to the scrotal area with subcutaneous crepitation was noted. A follow-up imaging, by CT scan, revealed penile periurethral necrosis containing gas bubbles as well as in the scrotal area without further extension ( Fig. 2 ). The patient was taken back to the operating room for debridement and excision of the necrotic scrotal tissues, as well as the necrotic corpus spngiusum and penile urethra. A suprapubic catheter was placed to drain the urine ( Fig. 3 ). Complete normalization of renal function and improvement of its biological inflammatory parameters.