Case 3 - Quiz

Photo Quiz
Painful Scrotal Swelling

Vibhuti Ansar, MD, and Kihae Shin, DO, Piedmont Columbus Regional Hospital, Columbus, Georgia
A 44-year-old man presented with worsening

scrotal swelling that began two weeks prior. He FIGURE 1
also had sharp, constant pain that radiated to
both legs (left more than right) and his buttocks.
He rated it as 10 out of 10 on a pain scale. The
pain worsened with urination and was mini-
mally relieved by over-the-counter ibuprofen. He
had never had a similar episode and had no inju-
ries. His sexual history was significant for mul-
tiple male partners since 21 years of age. He had
untreated HIV infection, which was diagnosed in
2007. He had no other significant medical history.
Physical examination revealed diffuse scrotal
edema and tenderness and multiple black blisters
on the scrotum and perianal area (Figure 1). The
lesions were warm to the touch and erythema-
tous. He had no penile tenderness or discharge.
His white blood cell count was 16.82 per µL
(0.02 × 109 per L) with an absolute CD4 cell
count of 506 per µL (0.50 × 109 per L).
Question
Based on the patient’s history and physical
examination findings, which one of the follow-
ing is the most likely diagnosis?
l A. Gas gangrene.
l B. Kaposi sarcoma.
l C. Necrotizing fasciitis.
l D. Pyoderma gangrenosum.
l E. Pyomyositis.
See the following page for discussion.
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PHOTO QUIZ
Discussion
The answer is C:necrotizing fasciitis, known SUMMARY TABLE
as Fournier gangrene when affecting the
perineum or genital regions. Fournier gan- Condition Characteristics
grene is a rare life-threatening necrotizing fas-
Gas gangrene Tissue infection caused by Clostridium perfringens;
ciitis caused by a polybacterial infection of the less painful than necrotizing fasciitis
muscle fascia and overlying subcutaneous fat,
which has a relatively poor blood supply. Nec- Kaposi sarcoma Vascular tumor associated with HIV infection;dark
brown or reddish lesions;uncommon with CD4
rotizing fasciitis usually presents as erythema,
counts greater than 200 per µL (0.20 × 109 per L);
severe tenderness, fever, crepitus, and skin bul- rarely affects the scrotum
lae or necrosis. However, systemic symptoms
such as fever may be absent, as in this patient.1 Necrotizing Polybacterial infection of the muscle fascia and over-
fasciitis lying subcutaneous fat;erythema, severe tenderness,
Necrotizing fasciitis is an emergency requir-
fever, crepitus, and skin bullae or necrosis;systemic
ing surgical debridement. Broad-spectrum symptoms may be absent
antibiotics should be started empirically.
Diagnosis is established by surgical explo- Pyoderma Inflammatory and ulcerative skin disorder usually
gangrenosum associated with other conditions, such as inflam-
ration and tissue biopsy. The mortality rate
matory bowel disease, hematologic disorders, and
is high (20% to 88%) even with treatment, arthritis
and the condition can progress rapidly if not
treated appropriately.2 Pyomyositis Skeletal muscle abscess caused by Staphylococcus
aureus;less severe systemic symptoms than necro-
Gas gangrene is a tissue infection caused
tizing fasciitis
by Clostridium perfringens, a gram-positive
rod bacterium. Although necrotizing fasciitis
and gangrene both may lead to gas formation
in the tissues, gas gangrene is more common following tissue). Pyomyositis has less severe systemic symptoms than
traumatic injuries. Gas gangrene usually causes less pain necrotizing fasciitis and does not require emergent surgery.6
than necrotizing fasciitis.3 Treatment of gas gangrene may
Address correspondence to Vibhuti Ansar, MD, at vibhuti.ansar@
require amputation. piedmont.org. Reprints are not available from the authors.
Kaposi sarcoma is a vascular tumor associated with HIV
infection. The skin lesions are dark brown or reddish and References
may look similar to the bullae of necrotizing fasciitis. Kaposi 1. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med.
sarcoma does not usually occur with CD4 counts greater 2017;377(23):2253-2265.
than 200 per µL (0.20 × 109 per L). Lesions may occur on 2. Kranz J, Schlager D, Anheuser P, et al. Desperate need for better man-
agement of Fournier’s gangrene. Cent European J Urol. 2018;71(3):
multiple areas, but scrotal lesions are rare.4 360-365.
Pyoderma gangrenosum is an inflammatory and ulcer- 3. Tikorn DJ, Citak M, Fehmer T, et al. Characteristics and differences
ative skin disorder. It may be challenging to distinguish in necrotizing fasciitis and gas forming myonecrosis:a series of 36
from necrotizing fasciitis because it causes similar skin patients. Scand J Surg. 2012;101(1):51-55.
4. Yenice MG, Varnalı E, Şeker KG, et al. Scrotal Kaposi’s sarcoma in HIV-
lesions, which quickly progress to ulcers. Most cases are negative patient:a case report and review of the literature. Turk J Urol.
associated with other diseases, such as inflammatory bowel 2018;4 4(2):182-184.
disease, hematologic disorders, and arthritis.5 5. Bisarya K, Azzopardi S, Lye G, et al. Necrotizing fasciitis versus pyo-
Pyomyositis is a skeletal muscle abscess caused by Staph- derma gangrenosum:securing the correct diagnosis! A case report and
literature review. Eplasty. 2011;1 1:e24.
ylococcus aureus. Magnetic resonance imaging can distin-
6. Seok JH, Jee WH, Chun KA, et al. Necrotizing fasciitis versus pyomyosi-
guish it from necrotizing fasciitis because of the type of tis:discrimination with using MR imaging. Korean J Radiol. 2009;10(2):
tissue involved (muscle as opposed to fascia and adipose 121-128. ■
436 American Family Physician www.aafp.org/afp Volume 100, Number 7 ◆ October 1, 2019

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Painful Scrotal Swelling

A 44-year-old man presented with worsening

See the following page for discussion.

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