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International Journal of Diabetes Mellitus
journal homepage: www.elsevier.com/locate/ijdm
Spontaneous gas gangrene of the scrotum in patient with severe diabetic ketoacidosis
Chu Zhang, Lizhen Ma, Fengying Peng, Yin Wu, Yu Chen, Yuhong Zhan, Xianfeng Zhang ⇑
Department of Endocrinology and Metabolism, Hangzhou Hospital, Nanjing Medical University, China
a r t i c l e
i n f o
a b s t r a c t
A 52-year-old Chinese man presented with severe diabetic ketoacidosis and markedly inﬂated scrotum. Computed tomographic scans of the lower pelvis show extensive gas accumulation and inﬂammatory changes in both sides of the scrotum. Gas gangrene of the scrotum was diagnosed and radical debridement along with other proactive anti-ketoacidosis therapy was performed immediately. Clostridium perfringens was found in cultures of necrotic tissue that veriﬁed the diagnosis and the patient was cured through multiple proactive treatments. Ó 2010 International Journal of Diabetes Mellitus. Published by Elsevier Ltd. All rights reserved.
Article history: Received 26 September 2010 Accepted 30 September 2010
Keywords: Diabetic ketoacidosis Ketosis-prone T2DM Fournier’s gangrene Clostridium perfringens
1. Introduction Spontaneous gas gangrene of the scrotum, also known as Fournier’s gangrene (FG) is an extremely rare but life-threatening skin and soft tissue infective disease in the perineal region . The infection commonly starts as cellulitis adjacent to the portal of entry, and rapidly progresses to extensive tissue necrosis. Without aggressive treatment, the patient will die from sepsis and multiple organ failure . Multiple microbial infections by aerobes and anaerobes are always found in cultures from the wounds, most of which are normal commensals in the perineum and genitalia. Because of the impaired host cellular immunity, these conditional pathogens become virulent, and act synergistically to invade tissue and cause extensive damage . Some comorbid systemic disorders with cellular immunity impairment, including AIDS, diabetes, alcohol abuse, leukemia, chemotherapy and chronic corticosteroid use  are identiﬁed in patients with FG. Diabetic ketoacidosis (DKA) is an acute complication of diabetes, characterized by circulation failure and acidosis. In developing countries, even with improved healthcare systems and reliable insulin supply, mortality and morbidity from DKA remain high
. Although impaired tissue perfusion and defective immune response presented in DKA could be predisposing conditions for FG, there has been no previous report of speciﬁcally pinpointing the DKA with FG. In the present case, we show how a patient with severe DKA and FG recovered through prompt, accurate diagnosis and emergent intervention.
2. Case presentation A 52-year-old previously healthy man was hospitalized on account of poor health. He mainly complained about polydipsia, fever and shortness of breath for 9 days, and a swollen scrotum was found 4 days later. Fever (always) occurred after rigors, and his maximum temperature reached 38.8 °C. The swollen scrotum was accompanied by urodynia, hematuria and dysuria. He had not previously been diagnosed as diabetic, but his father had had type 2 diabetes (T2DM) for 34 years. Upon admission, he was in confusion, with a body temperature of 38.6 °C, systolic blood pressure at 145 mm Hg, pulse at 96/min and breath rate at 24/min. His height was 174 cm, his body weight 82 kg and BMI 27. His skin was dry, and his extremities were cold. The scrotum was found to be swollen almost as big as a football, and was of a dark red colour; there was no tenderness but crepitation could be heard on touching. Laboratory examination revealed DKA and leucocytosis; plasma sugar was 16.95 mmol/L, blood WBCs was 38.2 Â 109/L, plasma beta-hydroxybutyrate was 1898 mmol/L, urine acetone was 3+, urine lencocyte count was 20 per high power lens, pH was 7.06, HCO3À was 4 mmol/L, BE was À28 mmol/L, GAD-Ab, ICA and IAA
Abbreviations: DKA, diabetic ketoacidosis; WBCs, white blood cells; DM, diabetes mellitus; LADA, late onset autoimmune diabetes in adult; MRI, magnetic resonance imaging; CT, computed tomography. ⇑ Corresponding author. Address: Department of Endocrinology and Metabolism, Hangzhou Hospital, Nanjing Medical University, Xueshi Road 4[#], Hangzhou City, Zhejiang Province 310006, China. Tel.: +86 0571 87065701. E-mail address: email@example.com (X. Zhang).
1877-5934/$ - see front matter Ó 2010 International Journal of Diabetes Mellitus. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijdm.2010.09.004
we discontinued his insulin therapy and solely used metformin. Zhang et al. sufﬁcient to allow discontinuation of insulin therapy within a few months of follow-up . and the mortality rate of Fournier’s gangrene is higher in patients with DM . and weak immune response in DM lead to a faster progress of infection and rapid development of systemic sepsis. the patient soon dies after septic shock and multiorgan failure . the organism responsible for classical myonecrotic gas gangrene. the patient in the present case switched his therapy from insulin to oral anti-diabetic glucose 6 months later. and this also supported the diagnosis of ketosis-prone type 2 diabetes. and hyaluronidase. the same pathogen in necrotic tissue.C. diabetes. DKA is an acute complication of DM. third generation cephalosporin or carbapenems for the gram negative organisms. the wound surface was thoroughly rinsed with hydrogen peroxide. In the present case. Actually. or invasive procedures within the urinary tract. but intensiﬁed diabetic management results in signiﬁcant improvement in beta-cell function and insulin sensitivity. such as the age. these are often seen in patients with type 1 DM. characterized by rapid progression of necrotising inﬂammation and by the violent life-threatening course of the disease. Patient recovered consciousness in ﬁrst day of admission. poor tissue perfusion. they produce various exotoxin and enzymes such as a toxin. his blood glucose was well controlled through insulin. For patients of DKA and FG. The usual antibiotic combination includes penicillin or clindamycin for the streptococcal species. Clostridium perfringens. When the patient went back clinic for a routine visit 6 months later. and the infected scrotum was completely healed. such as compromised immunity. without evidence of cutaneous injury or perianal abscess. Doxycycline. Cultures of necrotic tissue and urine from a urethral catheter showed Clostridium perfringens. (B) coronal. 1. He was given tazocin and clindamycin for 4 weeks. 3. The patient in the present case was in his ﬁfties. and become pathogens when predisposing factors are present. the source of infection can be ascribed to the gastrointestinal and genitourinary tract . Without appropriate treatment. clindamycin. As severe DKA developed in such a short time. to cover all possible organisms. and multi broad spectrum antibiotics. Ultrasonography showed a ﬁlled cyst with hydronephrosis in both sides. 1). conventional DKA treatment with ﬂuid replacement and continual insulin infusion were given. DKA and spontaneous gas gangrene of the scrotum was diagnosed. Under normal conditions. with negative GAD-Ab. the signiﬁcance of ﬂuid replacement is even more vital than it is for patient with DKA or FG alone. cefoperazone. and (C) axial CT scan shows an accumulation of gas in the scrotum (white arrow) and extensive inﬂammation of scrotum wall. DM is reported to be present in 20–70% of patients with Fournier’s gangrene . along with other medical intervention like ﬂuid replacement for haemodynamic stabilization. or perianal regions. combined with other characteristics of patient. plus metronidazole for the anaerobes . Once FG is diagnosed. (A) sagittal. genital. The antibiotic sensitivity test also showed that the patient was piperacillin. All these are inconsistent with the diagnosis of type 1 DM or LADA. we proposed that the patient be diagnosed as ketosis-prone T2DM. and metronidazole sensitive. For those idiopathic cases. as urine leucocyte counts was 20 per high power lens and culture of urine from urethral catheter showed Clostridium perfringens. and also being promoted by FG. oﬂoxacin. gas accumulation and the spread of infection. characterized by haemodynamic instability and acidosis. fulminant form of infective necrotizing fasciitis of the perineal. heparinase. pathophysiological states facilitating FG to occur. and his BMI was 27. most possibly. / International Journal of Diabetes Mellitus 2 (2010) 196–198 197 were negative. BMI and negative autoantibody. FG commonly starts as cellulites adjacent to the portal of entry. aggressive debridement of local wounds is warranted. ICA and IAA. his glucose was well controlled thereafter. In the local wounds of patients with FG. gastrointestinal tract. or skin. Another characteristic of ketosis-prone T2DM is that insulin secretion is markedly impaired at presentation. Tazocin and clindamycin were given as empirical antibiotic therapy. temperature dropped back to normal range on the 4th day. which lead to tissue necrosis. collagenase. Clostridium species colonize in gastrointestinal and genitourinary tract. thorough debridement and drainage were performed immediately. When he was discharged from the hospital 4 weeks later. 6000 ml isotonic saline water was given in ﬁrst 24 h. it was the infection of the urinary tract that initiated gas gangrene in the scrotum. . is frequently identiﬁed along with other bacteria in FG . A Lower Pelvis CT scan revealed extensive gas accumulation within the scrotum and inﬂammatory changes to the scrotum wall (Fig. and an antibiotic sensitivity test justiﬁed the empirical antibiotic choice. Hyperbaric oxygen could be used as an adjunctive therapy Fig. as increased tissue glucose. Although such a severe infection like FG could be one factor that causes the initiation and development of DKA. since both DKA and FG are in favor of circulation failure. Discussion FG is a rare.
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