Fournier坏疽临床诊断和综合治疗1例报告及文献复习

doi:10.13481/j.1671-587X.20240430

摘要/Abstract

摘要：

目的探讨Fournier坏疽患者临床表现、诊断和治疗方法，以提高临床医生对该病的认识。方法收集1例Fournier坏疽患者的临床症状、体征、影像学表现和手术结果等临床资料，并复习相关文献，总结Fournier坏疽患者的临床特点、诊断和治疗方法。结果患者，男，42岁，因会阴、阴囊和肛周感染13 d入院。既往史，急性髓系白血病10个月，于当地医院行化疗8个疗程。腹部CT提示，左侧腹股沟区软组织增厚，密度增高浑浊。血常规，白细胞23.99×10⁹ L^-1。创面分泌物培养为大肠埃希菌和阴沟肠杆菌。专科检查，患者阴囊和左臀部近肛门处皮肤坏死，色黑，质硬，坏死皮肤周围溶解，与基底及周围正常皮肤分离，可见少量脓性渗出，无明显异味，创面周围皮肤红肿明显；肛门指诊无出血，未探及窦道。患者入院后当天行急诊清创手术，术后予以换药和多次留置简易负压后行会阴部皮瓣修复及皮肤移植手术，术后患者恢复良好，功能正常，无并发症。结论 Fournier坏疽起病急且进展快，患者临床表现无特异性，感染范围与疾病进展不一致。确诊主要依靠术中探查。反复多次的根治性手术是其主要治疗手段。该病预后较好，复发率低，术后仍需长期随访。

关键词: Fournier坏疽, 坏死性筋膜炎, 负压治疗, 会阴部, 皮肤移植, 皮瓣修复

Abstract:

Objective To discuss the clinical presentations， diagnosis， and treatment methods of the patients with Fournier’s gangrene， and to enhance the clinicians’ awareness of this condition. Methods The clinical data including symptoms， signs， radiological findings， and surgical outcomes of one patient with Fournier’s gangrene were collected.The relevant literatures were reviewed to summarize the clinical characteristics， diagnosis， and treatment methods for this condition. Results The patient， a 42-year-old male， was admitted because of a history of infection around the perineum， scrotum， and perianal area for 13 d. His medical history included acute myeloid leukemia for 10 months， during which the patient underwent eight chemotherapy sessions in the local hospital. The abdominal CT scan results showed thickened， dense， and turbid soft tissue in the left inguinal area. The complete blood count reuslts showed the white blood cell count was 23.99×10⁹ L^-1. The cultures of wound secretions grew the Escherichiacoli and Proteus mirabilis. The examination results showed there was necrosis of the scrotal skin and skin near the anus on the left buttock； the skin was blackened， hard， and demarcated from the surrounding normal skin with slight purulent exudation and no foul smell. The surrounding skin was significantly swollen and red； the rectal examination results showed no bleeding or fistulas. The patient underwent emergency debridement surgery on the admission day， followed by dressing changes， multiple applications of simplified negative pressure， perineal flap reconstruction， and skin grafting. The patient recovered well with normal function and had no complications. Conclusion Fournier gangrene has acute onset and rapid progression， and the clinical manifestations are non-specific. The range of infection is not consistent with the progression of the disease. The diagnosis mainly depends on intraoperative exploration. Repeated radical surgery is the main treatment. The prognosis of this disease is good， and the recurrence rate is low， although long-term follow-up is still necessary after surgery.

Key words: Fournier’s gangrene, Necrotizing fasciitis, Negative pressure treatment, Perineum, Skin transplantation, Flap reconstruction

中图分类号:

R631

孔祥力,石凯,张喜,薛岩,洪雷,张修航. Fournier坏疽临床诊断和综合治疗1例报告及文献复习[J]. 吉林大学学报(医学版), 2024, 50(4): 1144-1149.

Xiangli KONG,Kai SHI,Xi ZHANG,Yan XUE,Lei HONG,Xiuhang ZHANG. Clinical diagnosis and comprehensive treatment of Fournier’s gangrene: A case report and literature review[J]. Journal of Jilin University(Medicine Edition), 2024, 50(4): 1144-1149.

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参考文献 27

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Variable	Value	Score
Hemoglobin	<110 g?L^-1	2
	110-135 g?L^-1	1
	>135 g?L^-1	0
Total white blood cell count	<15×10³ μL^-1	0
	(15-25)×10³ μL^-1	1
	>25×10³ μL^-1	2
Sodium	<135 mmol?L^-1	2
Creatinine	>1.6 mg?dL^-1	2
Glucose	>180 mg?dL^-1	1
C-reactive protein	>150 mg?L^-1	4

Risk category	LRINEC score	Probability for presence of necrotizing fasciitis
Low	≤5	<50%
Medium	6-7	50%-75%
High	≥8	>75%

Variable	High abnormal value				Normal value	Low abnormal value
Variable	+4	+3	+2	+1	Normal value	+1	+2	+3	+4
Temperature（θ/℃）	>40.9	39.0-40.9	-	38.5-38.9	36.0-38.4	34.0-35.9	32.0-33.9	30.0-31.9	<30.0
Heart rate(min^-1)	>179	140-179	110-139	-	70-109	-	55-69	40-54	<40
Respiratory rate(min^-1)	>49	35-49	-	25-34	12-24	10-11	6-9	-	<6.0
Serum sodium[c_B/(mmol?L^-1)]	>179	160-179	155-159	150-154	130-149	-	120-129	111-119	<111
Serum potassium[c_B/(mmol?L^-1)]	>6.9	6.0-6.9	-	5.5-5.9	3.5-5.4	3.0-3.4	2.5-2.9	-	<2.5
Serum creatinine（mg ? dL^-1）	>3.4	2.0-3.4	1.5-1.9	-	0.6-1.4	-	<0.6	-	-
Hematocrit(η/%)	>59.9	-	50.0-59.9	46.0-49.9	30.0-45.9	-	20.0-29.9	-	<20.0
Leukocytes（×10⁹ L^-1）	>39.9	-	20.0-39.9	15.0-19.9	3.0-14.9	-	1.0-2.9	-	<1.0
Serum bicarbonate[c_B/(mmol?L^-1)]	>51.9	41.0-51.9	-	32.0-40.9	22.0-31.9	-	18.0-21.9	15.0-17.9	<15.0