Man with scrotal pain and swelling

A 45-year-old male with type 2 diabetes presented to the emergency department (ED) with 1 week of testicular swelling. Despite receiving multiple antibiotics for cellulitis at another ED 3 days prior, he experienced increasing pain, swelling, fever, diaphoresis, and perineal desquamation accompanied by serosanguinous discharge. Initial vital signs were stable. Physical examination revealed scrotal swelling and erythema, two draining perianal lesions, and significant tenderness to touch without crepitus. Laboratory findings included leukocytosis, hyponatremia, hyperglycemia, and elevated inflammatory markers. Point-of-care-ultrasound (POCUS) performed in the ED confirmed scrotal edema (Figure 1, Video S1) and a phlegmonous perineal area concerning for abscess formation without subcutaneous emphysema (SE) (Figure 2, Video S2). Computed tomography (CT) imaging corroborated POCUS findings.

Given failed outpatient antibiotics, markedly elevated inflammatory markers, and POCUS findings, necrotizing soft tissue infection was suspected. The patient received intravenous broad-spectrum antibiotics and underwent surgical debridement.

Fournier gangrene (FG) is a necrotizing infection of the perineum that can rapidly extend to surrounding structures.^1-3 Mortality with treatment ranges from 22% to 40%.^2-5 Risk factors include obesity, alcoholism, diabetes, male gender, and so on.¹ SE is regarded as a classic imaging finding. Yet in one systematic review of diagnostic POCUS in necrotizing fasciitis, SE was the least sensitive (6.3%) compared to fluid accumulation (85.4%), thickened fascia (66.7%), and cobblestoning (16.7%).⁶ In this case, POCUS, in conjunction with clinical and laboratory findings, was a valuable component in diagnosis of FG, identifying a soft tissue region indicative of evolving infection requiring surgical intervention.

The authors declare no conflicts of interest.