1. January 7, 2009 Huron Valley Hospital Brent Zamzow DO

2.  ER 12/13/08  CC : scrotal pain, b/l leg swelling  HPI : 69  c/o scrotal redness & pain x 1wk. Scrotal swelling on & off for 1yr. B/l leg swelling x 2wks. Rectal pain & fecal urgency attributed to known fistula  PMH : nonrheumatoid arthritis (steroid dependent for 3 years), colitis, rectal fistula, diverticulitis, Bell’s palsy, empyema, chronic anemia, elevated LFTs  PSH : colonoscopy, thoracostomy w/ decortication, cataract, eye muscle surgery  Meds : prednisone, aspirin, motrin prn  Allx : PCN, sulfa

3.  PE  35.9 97/57 103 20  A&O x3, NAD  Scrotal erythema, tender, swollen; b/l thigh & perineum erythema  Rectal fistula w/ stool draining from R buttock  Labs:  WBC 12.9  Hgb 9.6  BUN 37, Cr 1.2  Na 133, K 3.9, Ca 8.0  Scrotal US – skin thickening b/l consistent with scrotal cellulitis, b/l hydrocele, dense & inhomogeneous L epididymis  Consults  Urology – scrotal pain  General Surgery – rectal fistula  GI – bloody diarrhea  Infectious Disease – scrotal cellulitis/rectal fistula

4.  CT – Findings most consistent with Fournier’s gangrene. Gas forming infectious agent with cellulitis in the perineum, scrotum & rectal area. Heterogeneous enhancement of kidneys suggesting pyelonephritis.

6.  Presented to ER 11:51am  Admitted 3:12pm  Urology Consult 6:22pm  CT Scan done 7:25pm  CT Scan read 10:01pm  OR 11:50pm  Urology - I&D perineum & scrotum - Fournier’s  Gen Surgery – Lap assisted transverse loop colostomy, debridement perirectal/perianal abscess

13.  Sepsis  Late Presentation with rectal fistula  Lactic Acidosis - shock/hypoperfusion vs dead bowel  Wound care - wound vac  Chronic Steroids  Malnourished

14.  Mortality avg 20% (7-75%)  Higher if late presentation, DM, alcoholics, colorectal source   Na,  Ca, anemia (  rbc production)