Foudroyante E. Coli-Sepsis bei Fournierscher Gangrän

Zusammenfassung.

Die Fourniersche Gangrän manifestiert sich meist bei Männern mittleren bis höheren Lebensalters als nekrotisierende Fasciitis des äußeren Genitales. Kennzeichnend sind eine typische Anamnese mit progredienter, schmerzhafter Hodenschwellung und Fieber, ein oft explosionsartiger Beginn, der kaum verwechselbare makroskopische Aspekt und die hohe Mortalität infolge septischer Komplikationen. Der unter Umständen dramatische Verlauf der Erkrankung erfordert ein invasives chirurgisches und intensivmedizinisches Vorgehen. Die Entscheidung hierzu setzt die rasche Diagnose des seltenen Krankheitsbilds voraus. Wir berichten über einen jungen Patienten mit Fournierscher Gangrän, der wenige Stunden nach Aufnahme ins Krankenhaus an einem foudroyant verlaufenden septischen Schock verstarb.

Abstract.

Fournier's gangrene is a necrotising soft-tissue infection of the scrotum and perineal region caused by gram-negative and gram-positive Enterobacteriaceae. The disease is characterised by its unique appearance, its speed of onset, and its high mortality. Case report. A 26-year-old male presented to the emergency room complaining of a painful, tremendously swollen scrotum and penis (Fig. 1) that had developed within the past 24 h. Later, slurred speech, pallor, and hypotension were recognised, leading to the patient's admission to the intensive care unit. Suspecting a severe internal haemorrhage, vigorous volume therapy was started using crystalloids and colloids until blood and fresh frozen plasma were available. One hour later, septic shock was presumed and therapy augmented by IV antibiotics, tracheal intubation, and mechanical ventilation. Despite all efforts, the patients condition deteriorated rapidly and he died a few hours later due to multiple organ failure in septic shock. Postmortem, a perforated external hemorrhoidal node was found to be the primary focus of sepsis. Microbiologic cultures revealed Escherichia coli in blood and tissue samples. Discussion. Fournier's gangrene is a rare disease; nevertheless, its clinical picture has to be recognised immediately in order to provide appropriate treatment in time. It occurs predominantly in males after minor trauma, colorectal or urological disease, and perineal or abdominal surgery. Fournier's gangrene usually begins with itching and pain in the scrotal region followed by swelling and dark-blueish discolouration of the scrotum and penis, occasionally including the lower abdominal wall. Fever and chills are usually present. The illness progresses to severe prostration and septic shock with a mortality of 20% – 50%. Tissue cultures mostly reveal E. coli, gram-positive enterococci, Pseudomonas, Proteus, and various anaerobes. The treatment should include immediate radical surgical debridement, IV administration of broad-spectrum antibiotics, and cardiopulmonary support. Conclusion. The dramatic course of Fournier's gangrene requires early recognition, extensive surgical debridement, as well as intensive care treatment in order to prevent irreversible septic shock.