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Case presentation
A 57-year-old man with a history of recently diagnosed diabetes mellitus presented to the ED with 2 weeks of perineal pain and swelling. He was seen at an urgent care centre approximately 1 week prior to presentation, where he was diagnosed with cellulitis and prescribed trimethoprim-sulfamethoxazole. A few days prior to presentation to the ED, the swelling had increased significantly and was now associated with chills, diaphoresis and purulent drainage.
On physical examination, the patient is uncomfortable-appearing with vital signs notable for tachycardia at 104 beats per minute and tachypnoea at 22 breaths per minute; however, he is afebrile at 37.1°C. The penis appears normal without significant tenderness to palpation, however the inferior scrotum and perineum are diffusely swollen and tender to palpation, with erythema tracking superiorly towards the inguinal ring and areas of necrosis with foul-smelling purulent drainage (figure 1).
Photographs showing perineum with areas of necrosis and bloody purulent discharge.
Laboratory workup was notable for a leucocytosis of 14.9×109/Lm, hyponatremia with sodium of 132 mmol/L and blood glucose of 0.556 mmol/L with HbA1c of 11.0. He is acidotic with a pH of 7.28 on venous blood gas and has a lactate of 4.4. Point-of-care ultrasound (POCUS) demonstrates copious subcutaneous emphysema highly concerning for a necrotising infection.
What are the indications for performing POCUS for necrotising fasciitis?
POCUS is an invaluable tool in the diagnosis and management of a number of skin and soft tissue infections (SSTIs) including cellulitis, abscess and necrotising fasciitis. Necrotising fasciitis, colloquially known as ‘flesh-eating’ bacterial infections, are rare, life-threatening infections that result in the death of muscle fascia and subcutaneous tissue. Fournier gangrene is a subset of necrotising fasciitis characterised by an acute necrotic infection of the penis, scrotum or perineum, with reported morbidity and mortality between 15% and 50%.1 Prompt diagnosis and treatment with early surgical intervention is crucial in order to …
Footnotes
Handling editor David Metcalfe
Contributors FC, EN and SG collected the ultrasound images for this case. The report was drafted by FC and revised by EN and SG. All authors contributed to the report and approved the final report.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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