January 7, 2009Huron Valley Hospital

Brent Zamzow DO

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

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

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.

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

12/8 12/912/10

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What Happened?

Sepsis Late Presentation with rectal fistula Lactic Acidosis - shock/hypoperfusion vs

dead bowel Wound care - wound vac Chronic Steroids Malnourished

Fournier’s

Mortality avg 20% (7-75%) Higher if late presentation, DM, alcoholics,

colorectal source Na, Ca, anemia (rbc production)

End