Case Presentation: A 21-year old man presented with one day of scrotal swelling and pain. He developed sharp, throbbing pain after unprotected sex with a male partner a day prior. The pain had worsened over the last few hours. He was afebrile, normotensive and tachycardic. His scrotum was enlarged (> 25 centimeters) with well-demarcated erythema and central ecchymosis (Figure 1). The remainder of his examination was unremarkable.
A testicular ultrasound revealed soft tissue edema without vascular compromise or torsion. A bedside incision revealed clean non-friable tissue, and drained 250 milliliters of serosanguinous fluid. Labs revealed leukocytosis and lactic academia.
Intravenous fluid resuscitation and broad-spectrum antibiotics were initiated with concern for sepsis and scrotal cellulitis. His scrotal edema, leukocytosis, and lactic acidosis initially improved. However, the next day he developed septic shock, prompting emergency surgical management. Intraoperatively, his scrotum had necrotic tissue consistent with Fournier’s gangrene, requiring debridement and near complete removal of the scrotum. The next day, cultures from the incision and drainage grew Group C streptococcus. Upon further questioning, patient reported that he self-injected two liters of normal saline into his scrotum two days prior for cosmetic effect. The patient was discharged on amoxicillin-clavulanic acid and clindamycin with plan for eventual grafting. He was counseled on the risks of saline injection.
Discussion: Hospitalists frequently manage skin and soft tissue infections, ranging from uncomplicated cellulitis to deeper-space infections [e.g. necrotizing fasciitis (NF), pyomyositis]. Fournier’s gangrene is a rare type of NF involving the perineum. NF can spread as quickly as one inch per hour along the fascial planes in absence of skin changes due to the continuity of the scrotal fascia with the fascia of the perineum and abdomen. Most (52-88%) of affected men have a pre-disposing condition such as diabetes, obesity, immunosuppression, or alcoholism. Necrotizing infections are typically polymicrobial; our patient did not have the traditional risk factors and had the less common mono-bacterial NF type 2 associated with toxic shock syndrome (Table 1). In addition, his infection was due to group C streptococci, an uncommon cause of NF.
This atypical presentation was likely due to the preceding saline infusion. The improving scrotal edema due to the resorption of injected saline provided false reassurance and confounded the physical exam.
Saline infusion into body parts, including the scrotum, labia, breasts, and subcutaneously for augmentation is increasingly seen in certain sexual subcultures. Sometimes, “infusion centers” in tattoo parlors perform this procedure. However, most individuals self-inject at home using internet-purchased kits thus increasing the risk of complications. Known complications of saline infusion include cellulitis and subcutaneous emphysema. This is the first case report to our knowledge describing Fournier’s gangrene as a consequence of scrotal inflation.
Conclusions: Hospitalists should be aware of high-risk sexual behaviors that may predispose immune-competent adults to necrotizing skin and soft infections of the genitals and perineum.
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