Case Studies

Chapter 11 Case 2

A 47-year-old insulin-dependent type II diabetic man attends A+E with a 5-day history of right gradual-onset scrotal pain and swelling. He is apyrexial but tachycardic at 117 bpm and his blood pressure is 110/65 mmHg. On examination the right hemiscrotum is extremely swollen and approaching three times the size of the contralateral side. Most of the skin is indurated and erythematous, but there is an area 2 cm in diameter which is necrotic and on applying pressure, there is a ‘crackling’ sensation.

• 1. What is the likely diagnosis?

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  Correct answer:

  Fournier’s gangrene (necrotic fasciitis of the perineum).

• 2. What features in this history are concerning?

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  Correct answer:

  The ‘crackling’ is tissue emphysema – gas forming within the tissue due to the infection.
  Tissue necrosis.
  Tachycardia and hypotension – these are not specific to this condition, but do suggest developing sepsis.

• 3. What key risk factor for this condition does this patient have?

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  Correct answer:

  Diabetes mellitus

• 4. The patient’s GP thinks that he has suffered a testicular torsion. Is the GP correct?

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  Correct answer:

  No. Untreated testicular torsion can result in Fournier’s gangrene, but the onset of pain would have been sudden.