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Year : 2011  |  Volume : 54  |  Issue : 4  |  Page : 847-848
Fournier's gangrene with testicular infarction caused by mucormycosis


1 Department of Urology, PGIMER, Chandigarh, Punjab, India
2 Department of Pathology, PGIMER, Chandigarh, Punjab, India

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Date of Web Publication6-Jan-2012
 

How to cite this article:
Kumar S, Pushkarna A, Sharma V, Ganesamoni R, Nada R. Fournier's gangrene with testicular infarction caused by mucormycosis. Indian J Pathol Microbiol 2011;54:847-8

How to cite this URL:
Kumar S, Pushkarna A, Sharma V, Ganesamoni R, Nada R. Fournier's gangrene with testicular infarction caused by mucormycosis. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Apr 24];54:847-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/4/847/91520


Sir,

A 32-year-old-man presented with features of Fournier's gangrene, sepsis, anuria, seizures, and altered sensorium. He did not have any history of local trauma, comorbidity, or immunosupressed state. On examination, he was delirious and hypotensive. His hemoglobin was 6.8 g/ dl, total leukocyte count was 17900/ mm 3 , and serum creatinine was 7.7 mg/dl. After initial stabilization, he underwent surgical debridement. Intraoperatively, the right testis and spermatic cord were found to be gangrenous [Figure 1]a and hence were excised with the gangrenous hemiscrotum. Histopathology showed mucormycosis of the scrotal skin involving the right spermatic cord with vascular thrombosis producing right testicular infarction [Figure 1]b-d. Intraoperative pus culture showed growth of mixed organisms. In the postoperative period, the patient was managed with intravenous broad-spectrum antibiotics and dialysis till improvement of renal function. He was evaluated for systemic mucormycosis including a thorough otorhinolaryngeological evaluation and contrast-enhanced computed tomography of the abdomen, both of which were normal. At 1 month follow-up, patient was doing well and the wound had healed well.
Figure 1: (a) Gross photograph of the testis showing the cut surface showing extensive necrosis with hemorrhage just below the tunica (b) Photomicrograph of scrotal skin showing necrotic areas in the dermis and subcutaneous tissue (hematoxylin and eosin, × 100) (c) Photomicrograph showing broad aseptate fungal profiles with right angle branching (hematoxylin and eosin, × 400). [Inset: Grocott stain highlighting the fungi (Grocott's, × 200)], (d) Photomicrograph of testis showing areas of necrosis and infarcted seminiferous tubules (hematoxylin and eosin, × 200). [Inset: Thrombosed blood vessel in the spermatic cord (hematoxylin and eosin, × 200)]

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Fournier's gangrene due to fungi has been rarely reported in the medical literature. Most commonly Candida albicans and rare cases of Candida glabrata have been reported. [1],[2],[3] To our knowledge, mucormycosis of scrotum and spermatic cord has not been reported in the world literature. Mucoraceae are molds in the environment that become hyphal forms in tissues where they classically invade blood vessels producing thrombosis and tissue necrosis and widespread dissemination through blood stream leading to life-threatening conditions. [4] Depending on where the fungal spores are deposited, mucormycosis may affect the nasal sinuses, lungs, gastrointestinal tract, brain, or skin. Skin infection usually results from traumatic inoculation, for instance with contaminated wooden splints or contaminated medical equipment, such as non-sterile bandages. Rare cases have occurred at catheter sites or insulin injection sites. [4]

Although the administration of appropriate antifungal agents is essential in systemic diseases caused by mucor, they are not essential in treating localized skin infections caused by this agent occurring in immunocompetent individuals infected by trauma, like Fournier's gangrene where prompt and adequate surgical debridement may prove sufficient to affect clinical cure. [4],[5] In our patient also, only surgical debridement and supportive treatment for renal failure cured the patient.

This patient's illness was unique for four reasons:

  • First, the etiologic agent, mucormycosis, has to our knowledge not yet been reported in world literature as a cause of Fournier gangrene.
  • Second, contrary to the classical description, this patient had testicular gangrene which is most likely due to thrombosis of blood vessels of the testis due to involvement of the spermatic cord by the fungus. Mucormycosis should be considered a potential cause of these devastating perineal infections, especially in those with associated testicular gangrene.
  • Third, it reinforces the fact that such invasive fungal infection can occur in immune-competent patients without any underlying predisposing factor.
  • And fourth, it highlights the fact that surgical debridement alone without systemic antifungal therapy may prove sufficient for immunocompetent patients with localized forms of angioinvasive fungal infections.


 
   References Top

1.Johnin K, Nakatoh M, Kadowaki T, Kushima M, Koizumi S, Okada Y. Fournier's gangrene caused by Candida species as the primary organism. Urology 2000;1:153.  Back to cited text no. 1
    
2.Loulergue P, Mahe V, Bougnoux ME, Poiree S, Hot A, Lortholary O. Fournier's gangrene due to Candida glabrata. Med Mycol 2008;46:171-3.  Back to cited text no. 2
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3.Fidel PL, Jr, Vazquez JA, Sobel JD. Candida glabrata: Review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Microbiol Rev 1999;1:80-96.  Back to cited text no. 3
    
4.Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 2005;41:634-53.  Back to cited text no. 4
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5.Padhye AA, Koshi G, Anandi V, Ponniah J, Sitaram V, Jacob M, et al. First case of subcutaneous zygomycosis caused by Saksenaea vasiformis in India. Diagn Microbiol Infect Dis 1988;9:69-77.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Santosh Kumar
Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.91520

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