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Scand J Infect Dis 36: 610 Á/612, 2004


Fournier's Gangrene after Genital Piercing


From the Departments of 1Infectious Diseases, 2Surgery, Central Hospital, Vaxjo, and 3Department of Infectious Diseases, ¨ ¨ Karolinska Hospital, Stockholm, Sweden

A fulminant case of streptococcal toxic shock syndrome is described. Early surgery was life saving, and the antibiotic regimen should include clindamycin. The value of secondary measures is discussed. High dose intravenous immunoglobulin (IVIG) has shown promising effects in recent publications. Hyperbaric oxygen (HBO) treatment is under evaluation. Piercing of mucosal surfaces might be associated with severe infections. L. Ekelius, Department of Infectious Diseases, Central Hospital Va ¨ , SE-35185 Va ¨, Sweden (Tel. /46 73 98 22 869, ¨xjo ¨xjo e-mail. [email protected])

INTRODUCTION Fournier's gangrene is a fulminant, necrotizing infection that originates from the perineal and genital area and rapidly extends along fascial planes to involve the groins, thighs and abdominal wall (1 Á/3). It is 10 times more common in males than in females. The anatomic constraints are determined by the fascial anatomy of the perineum, external genitalia and abdominal wall. The infection tends to follow the distribution of Scarpas fascia, allowing for extension as far cranial as the clavicles and as far caudal as the fascia lata. A histological hallmark is thrombosis of small subcutaneous arteries with resulting ischaemia, necrosis and gangrene of the fascia. The infection is usually polymicrobial and arises from genitourinary, anorectal and cutaneous sources. Due to non-specific symptoms and paucity of cutaneous findings diagnosis is difficult in the initial stages of the disease. Mortality remains high despite surgery and antibiotic therapy. Group A streptococcal (GAS) infections begin with attachment of fimbria to epithelial cells. The fimbriae are composed of lipoteichoic acid and 1 of over 80 known M proteins, which have important antiphagocytic properties. Particular M proteins are associated with pharyngitis, impetigo, rheumatic fever and glomerulonephritis. M1 and M3 may cause streptococcal toxic shock syndrome. Pyogenic exotoxins (SPE) cause scarlet fever, erysipelas and play, as superantigens, a principle role in triggering deleterious Tlymphocyte overactivation. SPE A and B predominate in invasive disease. The microorganism's hyaluronic acid capsule is similar to human ground substance and may help the bacterium avoid immune detection by molecular mimicry. Streptokinase and hyaluronidase aid rapid spread of the bacterium and streptolysin is cardiotoxic in animals. CASE REPORT

A 39-y-old, previously healthy man presented with penile pain and oedema of the preputium and penis. A y earlier he had performed a self-piercing through the glans penis, in addition to his 3-y-old Prince Albert piercing, i.e. a piercing through the glans penis and urethra (Fig. 1). He was examined under general anaesthesia, the # 2004 Taylor & Francis. ISSN 0036-5548

jewellery was removed and he was admitted mostly for pain relief. The next d he developed fever and the swelling had progressed, with a haematoma of the scrotum. Treatment with cefuroxime was initiated at the intensive care unit (ICU). Blood and wound cultures yielded Streptococcus pyogenes M type 1. Three d after admission there was skin necrosis of the penis and scrotum. (Fig. 2) Signs of worsening sepsis developed with disseminated intravascular coagulation (DIC), deteriorating kidney function (creatinine 633 mm/L), thrombocytopenia ( B/50)/109/L) with petechia, and high fever. Reexamination after transfer to another unit revealed rapid spread of skin necrosis and inflammation over a wide area. The surgeon suspected Fournier's gangrene with necrotising fascitis and the patient was immediately taken to the operating room. Surgery revealed substantial necrosis of the fascia, but the underlying muscle was intact. The necrotic tissue around the penis and scrotum was excised and draining incisions were made from the groins and along the rectus muscle up to the umbilical margin (Fig. 3). The patient needed assisted ventilation postoperatively and the antibiotics were changed to bensylpenicillin and clindamycin with addition of ciprofloxacin to cover Gram-negative bacteria. Inotropic drugs and hyperbaric oxygen treatment (HBO) was initiated after another revision. Further revisions and skin transplantations were performed at a university hospital. He was discharged 43 days after admission. He had total amnesia for one week after the first operation.

DISCUSSION The age of the patient, clinical history and lack of an alternative explanation suggest that the urethral mucosa barrier penetration of the penile piercing could be the port of entrance for the streptococci and thus the source of the gangrene and fasciitis. The patient explained that his daughter had kicked him during sleep. It may be that a microtrauma with mucous membrane disruption, due to the piercing jewellery, could permit microorganisms to enter deeper tissues. Previous experience indicate that urethral damage is a risk factor in 77% of cases of fasciitis of the male genital tract (4). The average case fatality rate due to Fournier's gangrene is 16% in a metaanalysis of over 1729 cases (2). Early operative debridement of all necrotic tissue is crucial and improves the rate of survival (5). Radical surgery is necessary, since necrosis of the fascia and loss of circulation imply that

DOI: 10.1080/00365540410017086

Scand J Infect Dis 36

Case Reports


Fig. 3. The necrotic tissue was excised and draining incisions were made during the first operation.

Fig. 1. Illustration sketches the piercing jewellery placement of the patient.

antibiotics do not reach the infected site. The involved body surface area (BSA) was found to be an important prognostic variable with a significant impact on outcome (3). Patients

Fig. 2. 3 d after admission there was skin necrosis of the penis and scrotum. The widespread involvement of the skin is clearly visible.

with an involved BSA of 5% or greater are at a particularly high risk of dying. If the muscle is also affected, chances for survival are small. GAS myositis has a case fatality rate of 80 Á/100% (6). Fournier's gangrene is especially prevalent in patients with diabetes mellitus, which is seen in 20% of the cases (2). Other observed predisposing conditions are alcoholism and immunosuppression, where prognosis is especially poor. The aetiology is often polymicrobial, including Gramnegative bacilli, Gram-positive cocci as well as anaerobes. GAS is the most common cause of monomicrobial necrotizing fasciitis (5). Streptococcal septicaemia with associated necrotizing fasciitis is a rapidly progressive disorder with 30 Á/60% of the patients dying within 72 Á/96 h (7). Dual treatment with bensylpenicillin and clindamycin gives the patient the best chance of survival. Single drug penicillin was shown to be ineffective in experimental streptococcal infections (7 Á/9). This is thought to be due to the inoculum effect (Eagle effect), where bacteria quickly reach a stationary phase. In this phase, penicillin-binding proteins (PBPs) are not expressed. The role of clindamycin is multifactorial. It suppresses the production of bacterial toxins and other proteins, facilitates phagocytosis by inhibiting M protein synthesis and also may suppress monocyte synthesis of TNF-alpha (10). Some reports have suggested that IVIG is useful for treating streptococcal toxic shock syndrome (11), possibly because of its ability to neutralize bacterial exotoxins. Recent work has further substantiated this positive effect, but due to limited data and high cost, IVIG has not yet reached the status of established treatment (12, 13). The value of HBO


Case Reports

Scand J Infect Dis 36

addition in the treatment of Fournier's gangrene is controversial (2, 3). The habits of piercing continue to grow in the modern society with much focus on body apparition, and hence the medical consequences are likely to increase (14). Besides early local reactions like bleeding, allergy, scars, keloids, abscess formation and chondritis, late systemic infections, as described in this report, may occur. A review of the medical literature about serious infectious complications associated with piercing yielded 1 case with brain abscess (15), several cases of endocarditis (16 Á/24) and 2 cases of septicaemia (25, 26). Transmission of HIV (27), hepatitis (28, 29), tuberculosis, leprosy and tetanus (14, 28) has also been described. To our knowledge, this is the first report of Fournier's gangrene as a complication to piercing. Medical risks and consequences of piercing, especially of mucosal surfaces, should not be underestimated. ACKNOWLEDGEMENTS

We wish to thank the patient for extensive cooperation. We also thank Tommy Wandel for the illustration and Jan Michael Breider ¨ for photographs. The excellent working facilities at the Research and Development Centre of Kronoberg County Council are acknowledged.


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10. D. Stevens, The flesh eating bacterium: what's next?, J Inf Dis 179 (1999) 366 Á/74. 11. R Kaul, A McGreer, A Norrby-Teglund, M Kotb, B Schwartz, K O'Rourke, et al., Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome: a comparative observational study, Clin Inf Dis 28 (1999) 800 Á/7. 12. Darenberg, J, Ihendyane N, Sjolin J, Aufwerber E, Haidl S, ¨ Follin P, et al. and the StreptIg Study Group. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Inf Dis 2003; 37: 333 Á/40. 13. A Norrby-Teglund, N Ihendyane, J. Darenberg, Intravenous immunoglobulin adjunctive therapy in sepsis, with special emphasis on severe invasive group A streptococcal infections, Scand J Infect Dis 35 (2003) 683 Á/9. 14. A. Stirn, Body piercing: medical consequences and psychological motivations, Lancet 361 (2003) 1205 Á/1215. 15. R Martinello, E. Cooney, Cerebellar brain abscess associated with tongue piercing, Clin Inf Dis 36 (2003) 32 Á/4. 16. J Friedel, J Stehlik, M Desai, J. Granato, Infective endocarditis after oral body piercing, Cardiol Rev. 11 (2003) 252 Á/5. 17. J Weinberg, R. Blackwood, Case report of Staphylococcus endocarditis after navel piercing, Pediatr Infect Dis J. 22 (2003) 94 Á/6. 18. B. Goldrick, Endocarditis associated with body piercing, Am J Nurs. 103 (2003) 26 Á/7. 19. H Akhondi, A. Rahimi, Haemophilus aphrophilus endocarditis after tongue piercing, Emerg Infect Dis. 8 (2002) 850 Á/1. 20. P Harding, M Yerkey, G Deye, D. Storey, Methicillin resistant Staphylococcus aureus (MRSA) endocarditis secondary to tongue piercing, J Miss State Med Assoc. 43 (2002) 109. 21. H Tronel, H Chaudemanche, N Pechier, L Doutrelant, B. Hoen, Endocarditis due to Neisseria after tongue piercing, Clin Microbiol Infect. 7 (2001) 275 Á/6. 22. C Ochsenfahrt, R Friedel, A Hannekum, B. Schumacher, Endocarditis after nipple piercing in a patient with a bicuspid aortic valve, Ann Thorac Surg. 71 (2001) 1365 Á/6. 23. I Ramage, N Wilson, R. Thomson, Fashion victim: infective endocarditis after nipple piercing, Arch Dis Child 77 (1997) 187. 24. M Battin, L Fong, J. Monro, Gerbode ventricular septal defect following endocarditis, Eur J Cardiothorac Surg. 5 (1991) 613 Á/ 4. 25. V McCarthy, W. Peoples, Toxic shock syndrome after ear piercing, Pediatr Infect Dis J. 7 (1988) 741 Á/2. 26. Shulman, B. Ear piercing and sepsis. Clin Pediatr (Phila.) 1973; 12: 27A. 27. D Pugatch, M Mileno, J. Rich, Possible transmission of human immunodeficiency virus type 1 from body piercing, Clin Inf Dis 26 (1998) 768 Á/9. 28. S Tweeten, L. Rickman, Infectious complications of body piercing, Clin Inf Dis 26 (1998) 735 Á/40. 29. K Roy, D Goldberg, A Taylor, P. Mills, Investigating the source of hepatitis C virus infection among individuals whose route of infection is undefined: a study of 10 cases, Scand J Infect Dis 35 (2003) 326 Á/328.

Submitted March 9, 2004; accepted May 24, 2004



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