Case Presentation: A 78-year-old man with history of severe obesity, prostate cancer and urethral strictures requiring chronic indwelling Foley catheter, presented to the emergency room with decreased urine output. He also reported worsening scrotal pain and swelling. He had presented 9 days prior with scrotal pain and swelling after his Foley catheter fell out. He also had fever and urinary overflow incontinence. At that time, abdominal CT and scrotal ultrasound had revealed right scrotal edema without gas or fluid collection. Urine culture showed multiple organisms suggestive of contamination. He was diagnosed with scrotal cellulitis and was discharged on ciprofloxacin and cephalexin. At the time of his representation, a repeat abdominal CT showed improving edema but development of subcutaneous gas that was concerning for Fournier’s gangrene. He subsequently underwent surgical debridement; operative findings confirmed an obliterated urethra with necrosis of the penis and cavitation in the suprapubic and right inguinal areas. A urine sample for culture was collected percutaneously in addition to a sample of the glans penis and scrotal tissue. Both of these samples grew Candida albicans. The patient was started on micafungin and subsequently was discharged on fluconazole.
Discussion: Fournier gangrene is a rapidly spreading necrotizing infection of the perineum and genital area. Certain predisposing conditions increase the risk of Fournier’s gangrene, including diabetes mellitus, chronic kidney disease, immunosuppression, urethral strictures and genitourinary infections. The infection in this condition is typically polymicrobial, with aerobic and anaerobic bacteria derived from gastrointestinal, genitourinary and cutaneous sources. Treatment usually consists of prompt surgical debridement and institution of broad-spectrum antibiotics to empirically cover all potential organisms. Fungal etiologies are rare but increasingly reported. Given the high rates of both morbidity and mortality associated with Fournier’s gangrene, it is prudent to think of adding empiric antifungals to initial antibiotic regimens in patients with risk factors for fungal infection. Previous reviews have suggested that chronic retention, prior fungal infection, urethral stricture with urinary extravasation and immunocompromised state as some potential situations when this should be considered.
Conclusions: Fungal etiologies of Fournier’s gangrene are now being increasingly recognized. Given the high morbidity and mortality associated with this condition, adding empiric antifungals to the initial antibiotic regimen for at-risk patients should be considered.