Fournier's gangrene": an uncommon differential diagnosis and complication of "Bartholin abscess

Document Type : Case report


1 Assistant professor, Department of Obstetrics and Gynecology, Women's Health Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Fellowship of Gynecologic Oncology; Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

3 Anesthesiologist, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

4 Resident, Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.


Introduction: Necrotizing Fasciitis is one type of necrotizing soft tissue infections involving fascia and overlying subcutaneous fat, it has fast development and results in fulminant tissue destruction, toxicity, sepsis and high mortality. "Fournier's gangrene" is another name for "Necrotizing fasciitis of perineum". Signs and symptoms are seveer pain, swelling, erythema and induration of major labia that spreads rapidly to the anterior abdominal wall and gluteal region. Clinical manifestations of early stage of "Fournier's gangrene" are similar to "Bartholine abscess". Since Bartholin abscess is common and "Fournier's gangrene" is rare, gynecologist, usually does not consider this diagnosis.
Case presentation: A 52 year – old woman with fever and pain, erythema and swelling of valva was admitted to the hospital. Initially, her diagnosis was bartholine abscess and drainage and marsupialization was done to her. Since fever continued, pain and mal- odor discharge didn’t improve, erythema and swelling progressed to mons of pubis and RLQ[S1] , thus with diagnosis of Fournier's gangrene, she underwent surgical exploration and debridement together with broad spectrum antibiotic therapy; she discharged two weeks later with good condition and no fever.
Conclusion: Since early stages of "fournier's gangrene" can be mistaken with "Batholine abscess", gynecologist should consider fournier's gangrene in women with underlying medical conditions such as diabetes and immunodeficiency with urogenital infection."Fourneir's gangrene" is a surgical emergency, therefore early diagnosis and treatment can prevent morbidity and mortality.


  1. Chiders BJ, Doyondy LD, Nachreiner R, Rogers FR, Childers ER, Oberg KC. Necroziting fasciit: a fourteen year retrospective study of 163 consecutive patients. Am Surg 2002; 68(2):109-16.
  2. Fournier JA. Gangrene foudroyante de la verge. Med Prat 1883; 4:589-97.
  3. Wolach MD, MacDermott JP, Stone AP, deVere White RW. Treatment and complications of Fournier’s gangrene. Br J Urol 1989; 64(3):310-4.
  4. Asci R, Sarikaya S, Buzukalpelli R, Yilmaz AF, Yildiz S. Fournier’s gangrene: risk assessment and enzymatic debridment with lyophilized collagenase application. Eur Urol 1998; 34(5):411-18.
  5. Clayton MD, Fowler JE Jr, Sharifi R, Pearl BK. Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynacol Obstet 1990; 170(1):49-55.
  6. Morris MW Jr, Aru M, Gaugler A, Morris RF, Vanderlan WB. Necrotizing fasciitis of the perineum associated with a bartholin abscess. Surg infect (Larchmt) 2014; 15(2):131-3.
  7. Kdous M, Hachicha R, Iraqui Y, Jacob D, Piquet PM, Truc JB. Necrotizing fasciitis of the perineum secondary to a surgical treatment of Bartholin's gland abscess. Gynecol Obstet Fertil 2005; 33(11):887-90.
  8. Kohagura K, Sesoko S, Tozawa M, Iseki K, Tokuyama K, Fukiyama K. A female case of Fournier's gangrene in a patient with lupus nephritis. Nihan Jinzo Gakkai Shi 1998; 40(5):354-8.
  9. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 2003; 85-A(8):1454-60.
  10. Darenberg J, Luca-Harari B, Jasir A, Sandgren A, Pettersson H, Schalén C, et al. Molecular and clinical characteristics of invasive group A streptococcal infection in Sweden. Clin Infect Dis 2007; 45(4):450-4.
  11. Stevens DL, Tanner MH, Winship J, Swarts R, Ries KM, Schlievert PM, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989; 321(1):1-7.
  12. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 1997; 103(1):18-24.
  13. Das DK, Baker MG, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over the period 1990 to 2006. J Infect 2011; 63(6):429-33.
  14. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis 2007; 44(5):705-10.
  15. Smusckiewicz P, Trojunowgka I, Tomezak H. Late diagnosed necrotizing fasciit as a cause of multiorgan dysfunction syndrome: a case report. Cases J 2008; 1(1):125.
  16. McLellan E, Suvarna K, Townsend R. Fatal necrotizing fasciitis caused by Haemophilus influenzae serotype f. J Med Microbiol 2008; 57(Pt 2):249-51.
  17. Stumvoll M, Fritsche A. Necrotizing fasciitis caused by unencapsulated Haemophilus influenzae. Clin Infect Dis 1997; 25(2):327.
  18. Hau V, Ho CO. Necrotising fasciitis caused by Vibrio vulnificus in the lower limb following exposure to seafood on the hand. Hong Kong Med J 2011; 17(4):335-7.
  19. Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 2005; 352(14):1445-53.
  20. Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ 2005; 330(7495):830-3.
  21. Beaudoin AL, Torso L, Richards K, Said M, Van Beneden C, Longenberger A, et al. Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation. JAMA Intern Med 2014; 174(7):1136-42.
  22. Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 1987; 206(5):661-5.
  23. Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis 1995; 1(3):69-78.
  24. Laucks SS 2nd. Fournier's gangrene. Surg Clin North Am 1994; 74(6):1339-52.
  25. Stephens BJ, Lathrop JC, Rice WT, Gruenberg JC. Fournier's gangrene: historic (1764-1978) versus contemporary (1979-1988) differences in etiology and clinical importance. Am Surg 1993; 59(3):149-54.
  26. Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital Fournier's gangrene: experience with 38 patients. Urology 1996; 47(5):734-9.
  27. Eneli I, Davies HD. Epidemiology and outcome of necrotizing fasciitis in children: an active surveillance study of the Canadian Paediatric Surveillance Program. J Pediatr 2007; 151(1):79-84.
  28. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59(2):147-59.
  29. Marechal R, Taccone F. Diagnosis and treatment of an unusual cause of sepsis in a diabetic patient: a Fournier’s gangrene. Acta Clin Belgica 2005; 60(1):17-21.
  30. Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988; 158(1):23-8.
  31. Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis 1995; 20(Suppl 2):S154-7.
  32. Capelli-Schellpfeffer M, Gerber GS. The use of hyperbaric oxygen in urology. J Urol 1999; 162(3 Pt 1):647-54.
  33. Efem SE. Recent advances in the management of Fournier’s gangrene: preliminary observations. Surgery 1993; 113(2):200-4.
  34. Efem SE. Clinical observations on the wound healing properties of honey. Br J Surg 1988; 75(7):679-81.
  35. Huang KF, Hung MH, Lin YS, Lu CL, Liu C, Chen CC, et al. Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution. J Trauma 2011; 71(2):467-73.
  36. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg 2000; 87(6):718-28.