Group C streptococcal sepsis complicating Fournier gangrene.

Abstract: Fournier gangrene is a life-threatening necrotizing fasciitis of the perineal-scrotal area that occurs in diabetic males. Patients typically present with systemic toxicity and significant inflammatory changes in the scrotum and perineum. Most cases of Fournier gangrene are polymicrobic and require urgent surgical debridement and broad-spectrum antibiotic therapy. We describe a case of Fournier gangrene in a young diabetic man that was associated with group C streptococcal bacteremia, an association previously unreported in the literature to our knowledge.

Key Words: Fournier gangrene, necrotizing fasciitis, group C streptococci, diabetes mellitus

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Diabetic patients who present with fever should undergo a meticulous search for obvious occult infection, since infection-related morbidity and mortality is often significant in this patient population. Although diabetics may present with common infectious processes similar to patients without diabetes, several unusual infections peculiar to diabetic patients must be considered in the appropriate setting, such as mucormycosis, malignant otitis externa, and necrotizing fasciitis. (1) A specific type of necrotizing fasciitis involving the perineum known as Fournier gangrene classically afflicts diabetic males with poor glycemic control. (2) This infection spreads rapidly throughout the perineal and scrotal tissues and may begin in a perirectal abscess. Reported below is the case of a young male with type 2 diabetes mellitus who presented with Fournier gangrene and sepsis due to group C streptococci.

Case Report

A 40-year-old male with type 2 diabetes mellitus presented to the emergency department with a 2-day history of fever, chills, malaise, anorexia, and severe pain in the rectal area accompanied by scrotal pain and swelling. Due to significant prostration and severe perirectal and scrotal discomfort, the patient was confined to bed for 2 days before admission. He noted that his blood glucose readings were significantly higher than usual, with values approaching 400 mg/dL. The patient reported no recent perineal trauma or anal intercourse.

The patient had a history of hypertension and took lisinopril, hydrochlorothiazide, metformin, and pioglitazone daily. The patient was a nonsmoker and did not consume alcohol. Vital signs were as follows: temperature, 102[degrees]F; pulse, 116; respirations, 26; and blood pressure, 118/58 mm Hg. Physical examination revealed a toxic-appearing obese male in moderate distress secondary to pain as well as tachycardia and dry mucous membranes. The abdomen was nontender, without distention. However, examination of the anal area revealed a large, fluctuant, tender, erythematous mass. The perineum and scrotum were markedly swollen, erythematous, and tender. Laboratory findings included a serum glucose level of 359 mg/dL, anion gap of 17; total leukocyte count of 10,200 cells/[mm.sup.3] with 20% band forms; and an arterial pH of 7.41.

A diagnosis of Fournier gangrene was made, and the patient was admitted to the intensive care unit. Two sets of blood cultures were obtained, and volume resuscitation with crystalloid was begun. An insulin infusion and piperacillin-tazobactam were administered. Dopamine was necessary for several hours due to hypotension. A surgical consultant took the patient to surgery for debridement. After surgery, the patient's hemodynamic status and pain improved. Blood cultures and surgically obtained tissue from the scrotum both yielded group C streptococci in pure culture. He required two more debridements but improved on a daily basis with defervescence and a sense of well-being. He was discharged home on piperacillin-tazobactam with a wound care regimen and directions for optimal glycemic control.

Discussion

Febrile diabetic patients can present a formidable challenge and must be assessed in a timely and thorough manner. Common bacterial infections frequently occur in the diabetic host and include community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections. However, diabetics may on occasion develop unusual bacterial infections that are unique to this patient population (Table 1). Reasons for an increased risk of bacterial infections in diabetic patients include hyperglycemic defects in phagocyte and T-lymphocyte function and vascular disease, which may lead to poor arterial flow to tissues. (1) Neutrophils from patients with hyperglycemia and ketonemia may exhibit altered chemotaxis and phagocytosis: adding insulin in vitro to diabetic neutrophils improves bactericidal activity. (3)

Fournier gangrene is a type of necrotizing fasciitis that involves the perineal and scrotal soft tissue and often begins in the perirectal area. (2,5) Significant involvement of the deep tissues (eg, muscle, adipose, fascia) can occur with rapid spread to the abdominal wall and occasionally, the lower extremities: (4,5) The majority of cases occur in diabeties, often with poor glycemic control. As such, any diabetic man with fever or pain in the pelvis, rectum, perineum, or scrotum should be carefully assessed for the presence of Fournier gangrene. Treatment of Fournier gangrene centers around prompt surgical debridement and inspection of the rectal area for an abscess that may have commenced the infection. Multiple surgeries may be needed to debride ongoing tissue necrosis and to place skin grafts in some patients. Some authorities advocate hyperbaric oxygen therapy. (4,5) Most cases of Fournier gangrene are polymicrobic in nature, resulting from infection with coliforms, streptococci, and anaerobes. As such, prompt administration of broad-spectrum antibiotics is necessary (eg, piperacillin-tazobactam).

Group C streptococci are commonly isolated from animals and include the species Streptococcus equisimilis, Streptococcus zooepidemicus, Streptococcus dysgalactiae, and Streptococcus equi. (6) However, most microbiology laboratories do not speciate and report clinical isolates simply as group C streptococci based on the Lancefield grouping system. (7) Reported infections due to group C streptococci include bacteremia, endocarditis, peritonitis, soft tissue infections, pleuropulmonary infections, head and neck infections, septic arthritis, urinary tract infections, endovascular infections, and intra-abdominal infections. (6-13) Patients with underlying fluid collections or abscesses require surgical or needle-directed drainage for optimal outcome, although antibiotics alone are adequate for some infections. (6,7) Group C streptococci are susceptible to [beta]-lactam agents (eg, penicillins and cephalosporins) as well as vancomycin. (6) Resistance to tetracyclines, erythromyein, and sulfonamides is not unusual and [beta]-lactam agents are considered first-line therapy. (11,14,15) Vancomycin should be used in patients with severe [beta]-lactam hypersensitivity or allergy. (6) We did not find any reported cases of Fournier gangrene with associated group C streptococcal bacteremia and suspect this is an uncommon occurrence.

Conclusion

Fournier gangrene is a life-threatening necrotizing soft tissue infection that afflicts diabetic men and progresses rapidly if not diagnosed and treated in a timely manner. Prompt administration of antibiotics and surgical debridement (with or without hyperbaric oxygen) are the mainstays of therapy. Most cases of Fournier gangrene are polymicrobic in nature; however, clinicians should consider group C streptococci as a cause of Fournier gangrene and consider the diagnosis in any diabetic male with bacteremia and perineal, scrotal, or rectal pain.

References

1. Stevens DL. Infections of the skin, muscle, and soft tissues. In: Braunwald E, Fauci A, Kasper DL, eds. Harrison's Principles of InternalMedicine. New York, McGraw-Hill, 2001, 5th ed, pp 821-825.

2. Marinella MA. Necrotizing fasciitis. In: Frequently Overlooked Diagnoses in Acute Care. Philadelphia, Hanley and Belfus, 2003, pp 69-73.

3. Mims CA, Nash A, Stephen J. Attachment to and entry of microorganisms into the body. In: Mims' Pathogenesis of Infectious Disease. London, Academic Press, 2001, 5th ed, pp 10-66.

4. Clayton MD, Folwer JE, Sharifi, et al. Causes, presentation, and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynecol Obstet 1990;70:49.

5. Schneider RE. Male genital problems. In: Tintinalli JE, Kelen GK, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. New York, McGraw-Hill, 2000, 5th ed, pp 631-640.

6. Bradley SF, Gordon JJ, Baumgartner DD, et al. Group C streptococcal baeteremia: analysis of 88 cases. Clin Infect Dis 1991;13:270.

7. Salata RA, Lerner PI, Shlaes DM, et al. Infections due to Lancefield group C streptococci. Medicine (Baltimore) 1989;68:225.

8. Layon J, McCulley D. Subdural empyema and group C Streptococcus. South Med J 1985;78:64.

9. Hamilton ME, Gibson RS. Group C. streptococcal arthritis. NY State J Med 1980;80:1746.

10. Barson WJ. Group C streptococcal osteomyelitis. J Pediatr Orthop 1986;6:346.

11. Ghoneim ATM, Cooke EM. Serious infections caused by group C streptococci. J Clin Pathol 1980;33:188.

12. Brown J, Savage D. Group C streptococcal endocarditis. South Med J 1980;73:86.

13. Benjamin JT, Perriello VA. Pharyngitis due to group C hemolytic streptococci in children. J Pediatr 1976;89:254.

14. Barnham M, Cole G, Efstratiou A, et al. Characterization of Streptococcus zooepidemicus from human and selected animal infections. Epidemiol Infect 1987;98:171.

15. Barnham M, Kerby J, Chandler RS, et al. Group C streptococci in human infection: a study of 308 isolates with clinical correlations. Epidemiol Infect 1989;102:379.

Mark A. Marinella, MD, FACP, CNSP, FACN, FACGS

From Wright State University School of Medicine, Dayton, OH.

Reprint requests to Dr. Mark Marinella, 33 West Rahn Road, #101, Dayton, OH 45429. Email: [e-mail]

Accepted August 29, 2003.

RELATED ARTICLE: Key Points

* Diabetic patients may present with infections unique to this population, which include rhinocerebral mucormycosis, emphysematous cholecystitis, malignant otitis externa, and Fournier gangrene.

* Fournier gangrene is a form of necrotizing fasciitis involving the perineum and scrotum that affects diabetic men with poor glycemic control.

* Typical signs and symptoms of Fournier gangrene include perirectal, perineal, and scrotal pain and swelling, as well as fever.

* Most cases of Fournier gangrene are polymicrobic, but isolating group C streptococci should not dissuade the clinician from the diagnosis.

* Infections due to group C streptococci should be treated with a [beta]-lactam agent and if a drainable focus is present, surgery or percutaneous drainage should be performed.

Table. Infections unique to patients with diabetes mellitus

Emphy sematous cholecystitis
Emphy sematous cystitis
Emphysematous pyelonephritis
Fournier gangrene
Mafignant otitis externa
Rhinocerebral mucormycosis