A 60 YR OLD MALE WITH FEVER SCROTAL SWELLING AND DEPRESSION

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Chief complaints-

A 60 year old male patient teacher by occupation, was brought to casualty in a drowsy state 2 days ago, fever since 3 days , vomitings since 2 days.

HOPI:

 Patient was apparently asymptomatic 30 years back then he had fever, following which he went to a local hospital where he was given an injection and since then he was feeling that something is happening to him for which one of his relatives took him to a psychiatrist and got treated and was given Tab. Fluoxetine.

H/o giddiness 26 years back for which patient went to a local hospital and got diagnosed with hypertension and was started on Tab. ATEN-AM 50/5 mg OD.

During a routine health check up 20 years back , patient was diagnosed with Diabetes mellitus and started using Tab. Glimi M1 OD

H/o gradual painless diminision of vision 10-15 years back for which the patient consulted an ophthalmologist and was diagnosed with cataract and underwent cataract surgery.

Patient retired 2 years back, and stopped taking DM and HTN medication as he thought he was feeling well 

One month back , his daughter committed suicide for which he got disturbed psychologically and started excess consumption of alcohol.

He complained of itching in the scrotal region 10 days ago following which he developed swelling over the scrotum associated with pus discharge. He took medications without physician consultation.

Patient now presented with h/o fever since 2 days, low grade, intermittent and relieved on medications.

associated with 20 episodes of vomitings since yesterday, non projectile, non bilious non foul smelling, with food particles as content. 

Not associated with pain abdomen, no SOB, associated with generalized weakness.

Past history:-

H/o DM since 20 years and is on Tab. Glimi M1 OD

H/o HTN since 25 years and is on Tab. ATEN- AM 50/5 mg OD

Treatment history-

Personal history: 

Alcoholic since 30 years occasionally consumes 2 pegs per day

Non vegetarian, good appetite, adequate sleep, bowel and bladder movements regular.

GENERAL EXAMINATION:-

Patient is concious, coherent and cooperative

Moderately built and nourished

Delay in obeying commands

Pallor icterus clubbing cyanosis lymphadenopathy pedal edema not seen

Vitals:- 

Temp:- Afebrile

BP:- 100/80 mmhg

PR:- 80 bpm

RR:- 22 cpm

Spo2- :- 99% at room air.

GRBS- 95mg/dl

SYSTEMIC EXAMINATION:- 

CVS- S1, S2 heard, no murmurs

RS - Bilateral air entry present, NVBS heard.

Per abdomen:- Soft, non tender

 Scrotal abscess surrounded by induration is present 

A 3×2 cm necrotic patch over scrotum

Pus discharge +

CNS:- NFND

Surgical referral is done.

Before debridement:

After debridement

Investigations:- 

CBP:- Hb- 10.1 g/dl

TLC- 28,000 cells/mm3

Platelets-3.64

RFT:- 

Urea-101 mg/dl

Creatinine- 1.4 mg/dl

Na- 128 meq/litre

K+ - 4.7 mEq/L

Cl- 90 mEq /L

LFT:-

TB - 4.63

DB -0.17

AST -33

ALT- 16

ALP -333

TP- 6.0

Alb- 2.6

PT- 18

INR -1.3

APTT - 37 secs

BT - 2 mins 30 secs

CT - 5 mins

ECG

Chest x ray-

USG ABDOMEN AND PELVIS:-

Impression:- Grade 1 prostatomegaly

Bilateral renal calculi.

Abg

Acidosis 

Provisional diagnosis:

Diabetic keto acidosis 2° to fournier's gangrene?

Treatment:

1) INJ. MAGNEX FORTE 1.5 gm IV/ BD

2) INJ. CLINDAMYCIN 600 mg IV TID

3) IVF NS @ 150 ml/ hr

4) INJ. HAI 40 units in 39 ml NS IV @6 ml/hr >/< according to GRBS

5) INJ. NORADRENALINE 1 Amp in 49 ml NS @ 6 ml/hr >/< to maintain MAP >/= 65mmhg

6) INJ. PAN 40 MG IV OD

7) INJ. ZOFER 4 mg IV / TID

8) INJ. THIAMINE 1 amp in 100 ml NS IV OD

9) BP/ PR/ Spo2 / GRBS monitoring every hourly

10)Strict input / output charting

Discussion:- 

Fournier’s gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement which usually affects men. It is characterized by progressive necrotising fasciitis.

It is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotising fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens.it is currently recognised to occur at any age and in any gender and with several identifiable aetiological factors. It is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy.