An atypical microbiology of Fournier gangrene related to
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J Case Rep Images Urol 2021;6:100018Z15FV2021. Ventura et al. 1
www.ijcriurology.com
CASE REPORT PEER REVIEWEDOPEN ACCESS
| OPEN ACCESS
An atypical microbiology of Fournier gangrene related to
Actinomyces spp.
Frank Ventura, Wissam Harmouch, Nicholas Tahmassi,
David Fernandez, Aditya Srinivasan, Joseph Sonstein
ABSTRACT Conclusion: The importance of early detection and
intervention in patients with FG cannot be overstated.
Introduction: Fournier’s gangrene (FG) is a rare This case highlights a rare, likely underreported role of
necrotizing fasciitis affecting the perineum. Symptoms actinomyces in FG with absence of crepitus or necrosis
include tender, edematous scrotal tissue along with fever on physical exam and emphasizes the importance of
and can rapidly disseminate. Though FG is frequently a appropriately debriding and tailoring antibiotics to
polymicrobial infection of Staphylococcus, Escherichia provide effective management.
coli, and Pseudomonas, other pathogens may be
involved. Here, we present a rare case of FG that isolated Keywords: Case report, Fournier gangrene, Infectious dis-
Actinomyces species from its soft tissue culture. ease, Urology
Case Report: A 61-year-old male with a history of
uncontrolled type two diabetes mellitus and hypertension How to cite this article
presented with a 1-week history of scrotal swelling and
Ventura F, Harmouch W, Tahmassi N, Fernandez D,
pain. He developed urge incontinence, fever, and nausea
Srinivasan A, Sonstein J. An atypical microbiology of
several days after symptom onset. Vitals demonstrated
Fournier gangrene related to Actinomyces spp. J Case
fever (100.8F) and the patient had bilateral scrotal swelling
Rep Images Urol 2021;6:100018Z15FV2021.
with erythema and warmth to palpation. Genitourinary
(GU) exam was insignificant for crepitus, necrosis, or
open wounds. Labs showed leukocytosis. Computed Article ID: 100018Z15FV2021
tomography (CT) confirmed the presence of soft tissue
gas in the perineum and scrotum. The patient was started
on empiric antibiotics and underwent emergency scrotal *********
exploration and debridement. Tissue culture at the time
presented with Actinomyces spp. with negative blood doi: 10.5348/100018Z15FV2021CR
cultures. Antibiotics were deescalated to Unasyn. The
patient underwent two additional debridements with
repeat cultures negative for Actinomyces. A partial split
thickness skin graft was performed to reconstruct the INTRODUCTION
scrotum and antibiotics were discontinued.
Fournier’s gangrene (FG) is a rare necrotizing fasciitis
that commonly affects the penoscrotal and perineal
regions locally and may disseminate along fascial layers
Frank Ventura1, Wissam Harmouch1, Nicholas Tahmassi1, to infect the abdominal wall and beyond. Symptoms
David Fernandez1, Aditya Srinivasan2, Joseph Sonstein2 include tender, edematous scrotal soft tissue along with
Affiliations: 1School of Medicine, University of Texas Medical fever eventually progressing to septic shock and death.
Branch, Galveston, Texas, USA; 2Division of Urology, Uni- As FG rapidly disseminates, it is considered a medical
versity of Texas Medical Branch, Galveston, Texas, USA.
emergency that requires urgent surgical debridement
Corresponding Author: Frank Ventura, 606 Ball Street, Gal- and broad-spectrum antibiotics [1, 2]. If left untreated, it
veston, Texas 77550, USA; Email: Flventur@utmb.edu can progress to septic shock and death, with the mortality
rate ranging between 20% and 40% [1, 3]. While many
Received: 18 June 2021
cases are idiopathic, FG can be secondary to trauma or
Accepted: 29 July 2021 infection of the perineum [4]. Though FG is frequently
Published: 09 September 2021 a polymicrobial infection of Escherichia coli, Klebsiella,
Journal of Case Reports and Images in Urology 6, 2021.
J Case Rep Images Urol 2021;6:100018Z15FV2021. Ventura et al. 2
www.ijcriurology.com
Bacteroides, and Clostridia, other pathogens may be involvement given proximity of the infection to the
involved. Here, we present a rare case of FG that isolated anorectal canal. Dissemination in the left gluteal muscle
Actinomyces species from its soft tissue culture. was noted and appropriately debrided. Tissue culture
at the time presented as 2+ mixed organisms and 3+
Actinomyces spp with negative blood cultures. Infectious
CASE REPORT disease deescalated antimicrobrials to Unasyn 3g IV Q6H
to target the specific pathogen. The patient underwent a
A 61-year-old obese male with a history of uncontrolled 2nd debridement two days afterward (Figure 4). Culture
type two diabetes mellitus (T2DM) and hypertension at this time came back 1+ Candida spp, at which point
(HTN) presented with a 1-week history of scrotal swelling the patient was started on micafungin 100 mg IV Q24H.
and pain. He also developed urge incontinence, fever and A 3rd debridement was required before closure.
chills, and nausea several days after the initial symptom A partial split thickness skin graft (STSG) was
onset. Vitals upon ED admission were significant for fever performed by Burn surgery to reconstruct the scrotum
(100.8F) and the patient had bilateral scrotal swelling 14 days postadmission (Figure 5). Burns reperformed
with erythema and warmth on palpation. Physical exam STSG on post-admission day 15 with appropriate closure
was insignificant for obvious crepitus, necrosis, or open (Figure 6). Antibiotics were discontinued at this time and
wounds (Figure 1). Labs showed leukocytosis. Computed the patient was discharged to return to clinic in 1 week for
tomography of the pelvis confirmed the presence of soft follow-up and reassessment of scrotal closure.
tissue gas in the perineum and scrotum (Figure 2).
The patient was started on vancomycin and meropenem
for empiric coverage and brought to the operating room for
emergency scrotal exploration and debridement. Urologic
surgical incision of the left scrotum was created to drain
the loculated regions of purulent material. Gangrenous
tissue of the left scrotum was debrided (Figure 3). The
left spermatic cord and testicle appeared viable and was
preserved. Necrotic tissue disseminated into the right
scrotum and required a right hemiscrotectomy with
preservation of the right spermatic cord and testicle.
General surgery was consulted to evaluate gluteal
Figure 3: Post-debridement #1.
Figure 1: Pre-operative scrotum.
Figure 2: Subcutaneous gas in the scrotum and perineum.
Figure 4: Post-debridement #2.
Journal of Case Reports and Images in Urology 6, 2021.
J Case Rep Images Urol 2021;6:100018Z15FV2021. Ventura et al. 3
www.ijcriurology.com
Table 1: Causative microorganisms of Fournier gangrene
Causative microorganisms in Fournier gangrene
2000 to 2021 in 356 patients
Effective Microorganism N (%)
Gram Positive
Staphylococcus spp. 141 (39.6)
Streptococcus spp. 114 (32.0)
Enterococcus 42 (11.8)
Peptostreptococcus spp. 9 (2.5)
Clostridium spp. 12 (3.4)
Gram Negative
E. coli 176 (49.4)
Pseudomonas spp. 33 (9.3)
Proteus spp. 21 (5.9)
Acinetobacter spp. 18 (5.1)
Klebsiella spp. 7 (2.0)
Enterobacter spp. 9 (2.5)
Bacteroides spp. 75 (21.1)
Figure 5: STSG #1.
Prevotella spp. 49 (13.8)
Cornyabacterium spp. 8 (2.25)
Fungi
Candida spp. 38 (10.7)
female genitourinary tract [10, 11]. As FG is typically seen
in male patients, the less frequent colonization of the male
genitourinary tract may contribute to Actinomyces’ loose
relation to the disease. Furthermore, the identification
of anaerobic organisms is currently challenging. This
difficulty may contribute to the underdiagnosed cases
of FG secondary to actinomyces, and clinicians should
remain wary of these potential pathogens when treating
the disease.
Fournier’s gangrene secondary to Actinomyces
species is a rare finding that has not been well established
Figure 6: STSG #2.
in the literature. Of the few cases, there seems to be an
overlap with our patient’s clinical presentation. In 2014,
a case report was published conveying the findings of
DISCUSSION FG in a 73-year-old male with vascular disease who
presented with inguinal pain [12]. This patient’s physical
Fournier gangrene has been established as a necrotizing exam findings were similar to our patient’s exam as
fasciitis of the penoscrotal and perineal regions caused by both demonstrated perineal edema, skin color changes,
a polymicrobial infection [3, 5]. Classically, it has been but without crepitus. Computed tomography findings
understood that endogenous aerobic and anaerobic were also similar, illustrating a gaseous collection in the
organisms residing in the genitourinary and colorectal subcutaneous tissue; ultimately, confirming the diagnosis
sites are the most common culprits [6, 7]. Staphylococcal, of FG. After cultures were obtained, Actinomyces and
Enterococci, E. coli, Pseudomonas, and Group B Clostridium species were confirmed at the site of infection.
Streptococcus species have been underlined in the past Our 61-year-old patient also showed mild findings of
literature as the most common organisms (Table 1) [5–8]. scrotal/perineal swelling, erythema, and fever. However,
Less likely to be found are anaerobic species, including he lacked the severe findings of crepitus and necrosis,
rare cases of Actinomyces. Actinomyces is an anaerobic which is classically associated with FG. These unique
gram-positive filamentous rod that produces abscesses presentations of mild physical exam findings without
and drains through sinus tracts [9]. Actinomyces spp. are necrosis or crepitus may be related to FG secondary to
also present in the oral mucosa, pharynx, gut, skin, and Actinomyces spp.
Journal of Case Reports and Images in Urology 6, 2021.
J Case Rep Images Urol 2021;6:100018Z15FV2021. Ventura et al. 4
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A second case report was published in 2019 regarding underreported case, role of Actinomyces in FG and
an 84-year-old African American female patient. The emphasizes the importance of physicians appropriately
patient had similar risk factors to our patient such as debriding and tailoring antibiotics to provide effective
obesity, type 2 diabetes mellitus, and hypertension. She management for the patient.
presented with severe right thigh pain and previously
had a bump on her right groin that ruptured in the week
prior. She presented with findings significant for fever REFERENCES
of 38.3°C, physical exam with inner thigh induration,
erythema, edematous, and discolored skin. No bullae 1. Sorensen MD, Krieger JN. Fournier’s gangrene:
or crepitus were noted on exam. Although there was no Epidemiology and outcomes in the general US
crepitus as is typical for a FG physical exam presentation, population. Urol Int 2016;97(3):249–59.
2. Ferretti M, Saji AA, Phillips J. Fournier’s gangrene: A
her CT scan showed diffuse soft tissue gas present in
review and outcome comparison from 2009 to 2016.
the gracilis muscle extending into the perineum, right Adv Wound Care (New Rochelle) 2017;6(9):289–95.
inguinal region, right labia major, and right ischiorectal 3. El-Qushayri AE, Khalaf KM, Dahy A, et al. Fournier’s
fossa confirming a diagnosis of FG [13]. This case of FG gangrene mortality: A 17-year systematic review and
involving Actinomyces infection is of similar presentation meta-analysis. Int J Infect Dis 2020;92:218–25.
to our patient. 4. Montrief T, Long B, Koyfman A, Auerbach J. Fournier
Overall, the presence or absence of crepitus could gangrene: A review for emergency clinicians. J Emerg
be important in making the diagnosis of FG secondary Med 2019;57(4):488–500.
to Actinomyces, however, further research needs to be 5. Yanar H, Taviloglu K, Ertekin C, et al. Fournier’s
gangrene: Risk factors and strategies for management.
done to make this association. Some studies suggest
World J Surg 2006;30(9):1750–4.
Actinomyces does not create an exotoxin that is frequently 6. Chernyadyev SA, Ufimtseva MA, Vishnevskaya IF, et
seen in other pathogens, which may contribute to the al. Fournier’s gangrene: Literature review and clinical
lack of crepitus and necrosis [10]. It may also contribute cases. Urol Int 2018;101(1):91–7.
to a more chronic infection compared to the typical FG 7. Yilmazlar T, Gulcu B, Isik O, Ozturk E. Microbiological
presentation. Due to underreported cases of Actinomyces’ aspects of Fournier’s gangrene. Int J Surg
role in FG, however, the pathogen’s clinical significance is 2017;40:135–8.
yet to be determined. As seen in our case as well as the 8. Tang LM, Su YJ, Lai YC. The evaluation of
report by Tena et al., the patients clinically improved with microbiology and prognosis of Fournier’s gangrene in
past five years. Springerplus 2015;4(1):14.
appropriate antibiotics and repeat debridement.
9. Li J, Li Y, Zhou Y, Wang C, Wu B, Wan J. Actinomyces
It is crucial for clinicians to recognize the early and alimentary tract diseases: A review of its
signs of FG and provide timely management. Without biological functions and pathology. Biomed Res Int
emergent surgical involvement, patients will need 2018;2018:3820215.
more consecutive debridements, the risk of mortality 10. Könönen E, Wade WG. Actinomyces and related
substantially worsens, and complications of septic shock organisms in human infections. Clin Microbiol Rev
and acute renal failure become more likely [14–16]. Not 2015;28(2):419–42.
only is initial debridement essential, but physicians 11. Jeffery-Smith A, Nic-Fhogartaigh C, Millar M. Is the
must pay close attention to the infecting pathogens presence of Actinomyces spp. in blood culture always
significant? J Clin Microbiol 2016;54(4):1137–9.
and their antibiograms. Common pathogens including
12. Tena D, Losa C, Medina-Pascual MJ, Sáez-Nieto JA.
Staphylococci, gram negative bacteria, and beta- Fournier’s gangrene caused by Actinomyces funkei,
hemolytic bacteria should be suspected upon empiric Fusobacterium gonidiaformans and Clostridium
treatment, however, cultures with susceptibilities should hathewayi. Anaerobe 2014;27:14–6.
be obtained to tailor treatment to the offending pathogen. 13. Kus NJ, Kim BJ, Ross HM. A case report of
Due to the severity of the disease and wide variations necrotizing fasciitis with growth of Actinomyces
in offending agents, physicians should stay wary when europaeus and Actinotignum schaalii. J Surg Case
managing FG. Rep 2019;2019(10):rjz286.
14. Kobayashi L, Konstantinidis A, Shackelford S, et al.
Necrotizing soft tissue infections: Delayed surgical
treatment is associated with increased number of
CONCLUSION surgical debridements and morbidity. J Trauma
2011;71(5):1400–5.
The importance of early intervention in patients with 15. Auerbach J, Bornstein K, Ramzy M, Cabrera J,
FG cannot be overstated. While appropriate empiric Montrief T, Long B. Fournier gangrene in the
antibiotic therapy is important, due to the wide range of emergency department: Diagnostic dilemmas,
organisms that may be present, early surgical debridement treatments and current perspectives. Open Access
is crucial in minimizing mortality and maximizing the Emerg Med 2020;12:353–64.
preservation of viable tissue. Alterations to the antibiotic 16. Kranz J, Schlager D, Anheuser P, et al. Desperate
need for better management of Fournier’s gangrene.
regimen may be needed based on tissue cultures for
Cent European J Urol 2018;71(3):360–65.
each individual case. This case highlights a rare, likely
Journal of Case Reports and Images in Urology 6, 2021.
J Case Rep Images Urol 2021;6:100018Z15FV2021. Ventura et al. 5
www.ijcriurology.com
********* version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
Acknowledgments to the accuracy or integrity of any part of the work are
We would like to acknowledge the Division of Urology at appropriately investigated and resolved
University of Texas Medical Branch for their support in Joseph Sonstein – Conception of the work, Acquisition
accomplishing this case report. of data, Analysis of data, Interpretation of data, Revising
the work critically for important intellectual content,
Author Contributions Final approval of the version to be published, Agree to be
Frank Ventura – Conception of the work, Design of the accountable for all aspects of the work in ensuring that
work, Acquisition of data, Analysis of data, Interpretation questions related to the accuracy or integrity of any part
of data, Drafting the work, Revising the work critically of the work are appropriately investigated and resolved
for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all Guarantor of Submission
aspects of the work in ensuring that questions related The corresponding author is the guarantor of submission.
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved Source of Support
Wissam Harmouch – Acquisition of data, Analysis of data, None.
Interpretation of data, Drafting the work, Final approval
of the version to be published, Agree to be accountable for Consent Statement
all aspects of the work in ensuring that questions related Written informed consent was obtained from the patient
to the accuracy or integrity of any part of the work are for publication of this article.
appropriately investigated and resolved
Conflict of Interest
Nicholas Tahmassi – Acquisition of data, Analysis of data, Authors declare no conflict of interest.
Interpretation of data, Drafting the work, Final approval
of the version to be published, Agree to be accountable for Data Availability
all aspects of the work in ensuring that questions related All relevant data are within the paper and its Supporting
to the accuracy or integrity of any part of the work are Information files.
appropriately investigated and resolved
David Fernandez – Acquisition of data, Analysis of data, Copyright
Interpretation of data, Drafting the work, Final approval © 2021 Frank Ventura et al. This article is distributed
of the version to be published, Agree to be accountable for under the terms of Creative Commons Attribution
all aspects of the work in ensuring that questions related License which permits unrestricted use, distribution
to the accuracy or integrity of any part of the work are and reproduction in any medium provided the original
appropriately investigated and resolved author(s) and original publisher are properly credited.
Aditya Srinivasan – Conception of the work, Design of the Please see the copyright policy on the journal website for
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