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CASE 22.1

A 40 year old male patient with type 2 diabetes calls your office because he is having difficulty urinating and quite a bit of pain in the perineal area. He has not felt well for several days and was running a low-grade fever. He went to his chiropractor 2 days ago when he only had pain and swelling in the scrotum and the chiropractor adjusted his … well, we won't go there …. He is now noting that his temperature is higher (he doesn't have a thermometer and is reading his temperature via his old mood ring from the 90s). You suggest that he presents to your office.

Examination reveals an obese male who is waddling into the office because of pain in his scrotal area. Vitals: blood pressure 150/100 mm Hg, pulse 112 bpm, respirations 20 bpm, and temperature 39.0°C. Other significant findings include a swollen scrotum that is bright red, exquisitely tender to touch, and without crepitus. You do not have extended laboratory access in your office, but a urine dipstick is negative for blood and leukocyte esterase. His blood sugar, which is usually fairly well controlled, is elevated at 320 mg/dL.

Question 22.1.1 Your next step for this patient will be which of the following?

A) Start the patient on cephalexin (Keflex) for methicillin-sensitive Staphylococcus aureus and Streptococcus coverage and follow-up with the patient in the morning

B) Emergent surgical referral

C) Begin trimethoprim/sulfamethoxazole (Bactrim) for methicillin-resistant S. aureus (MRSA) coverage and follow-up with the patient in the morning

D) Admit the patient and start him on IV vancomycin, piperacillin/tazobactam, and metronidazole for coverage of MRSA, Streptococcus, Pseudomonas, anaerobes

Answer 22.1.1 The correct answer is "B." This likely represents Fournier gangrene. The erythematous, swollen scrotum with pain out of proportion to examination and associated signs of fever, tachycardia, and elevated blood sugar make Fournier gangrene the most likely diagnosis. While crepitus is common with Fournier gangrene due to presence of gas-forming anaerobic bacteria, its absence is not sensitive enough to rule out gangrene. Without early surgical debridement and IV antibiotics, infection can progress rapidly causing sepsis and multiorgan failure. Therefore, "B," emergent surgical referral is the best option for this patient. Antibiotics, particularly oral (options "A" and "B"), are inappropriate as a sole therapy. "D" has the right intent with broad-spectrum coverage but is incorrect because the patient needs adjunct surgical debridement to remove the necrotic tissue.

Question 22.1.2 Fournier gangrene can best be described as:

A) Necrotizing fasciitis

B) Necrotizing cellulitis


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