Abstract and Introduction
Abstract
Introduction: The efficacy of surgical intervention for perianal infection in patients with hematologic malignancy is not well-established.
Objective: This article presents a case series of perianal infection progressing to Fournier's gangrene (FG) in patients with hematologic malignancy to guide physicians, because to the author's knowledge, there were no randomized or prospective studies presenting the management strategies reported herein. It was hypothesized that surgery might reduce mortality and morbidity in patients with inflammation spreading beyond the perianal region, in patients with abscess formation, and in those who show no improvement with medical therapy.
Materials and Methods: The data of 4 adults with hematologic malignancy who developed perianal infection progressing to FG between January 2010 and December 2018 were reviewed retrospectively. Patients younger than 18 years and patients without hematologic malignancies or FG were excluded. The primary outcome was mortality. The secondary outcome was irreversible organ damage.
Results: Four male patients with a mean age of 36.75 years ± 13.1 standard deviation (range, 23–52 years) reported fever and dull anal pain during treatment for hematologic malignancy. A broad-spectrum antibiotic regimen was administered as initial empiric therapy at onset of fever and was de-escalated based on the culture results and clinical response. However, FG arose in all cases approximately 8.75 days ± 6.94 (range, 3–17 days) after onset of anal pain. All patients underwent surgical debridement, and diverting ostomy was performed in 3 cases. One patient died of overwhelming sepsis (25%), and 1 patient required orchiectomy (25%).
Conclusions: Clinical suspicion of FG may be effective in reducing mortality in patients with hematologic malignancy, especially in cases with fever accompanied by anal pain. Surgical intervention may improve the prognosis for patients with inflammation spreading beyond the perianal region, patients with abscess formation, those who show no improvement in medical therapy, and those who develop FG. Diverting ostomy may improve survival in patients with FG.
Introduction
Perianal infections have a wide spectrum of clinical manifestations that range from local cellulitis to sepsis. Historically, the incidence of such infection was underestimated, as often patients were thought to have another proctologic disease or their data were improperly recorded. Although imaging is performed in select cases, typically the diagnosis is based on anamnesis and physical examination. Perianal infection arises in 7.3% to 9% of patients with acute leukemia, and diagnosis is a clinical challenge.[1–3] In patients at high risk of neutropenia, a rectal examination cannot be performed because of the need to prevent passage of intestinal microorganisms from the damaged mucosa into the surrounding tissue.
Moreover, since the inflammatory response is suppressed owing to neutropenia, the absence of pus causes false-negative results on digital examination. Delayed diagnosis and resulting lack of treatment may result in progression of perianal infection to Fournier's gangrene (FG), a form of necrotizing fasciitis of the perineal, perianal, and genital region that originates from genitourinary, colorectal, and dermal diseases.[4] Although FG bears the name of J. A. Fournier, FG was first reported by Baurienne[5] in 1764. Mortality resulting from FG is primarily dependent on the timing of medical care and the extent of the infection; delay in treatment and inadequate surgical debridement are factors that contribute to morbidity (including amputation and organ failure) and mortality.[6]
In patients with hematologic malignancy, perianal infection presents diagnostic challenges and therapeutic controversy. The efficacy of surgical intervention is not well established. Although the findings reported herein represent a case series without a comparator, they may be of value to physicians because as of this writing and to the author's knowledge, no randomized or prospective studies have been done on the management of perianal infection in patients with hematologic malignancy. It was hypothesized that surgical treatment might reduce mortality and morbidity in cases in which inflammation extended beyond the perianal region, in cases with abscess formation, and in cases that showed no improvement with medical therapy. It was also supposed that a diverting ostomy might improve survival rates in the setting of FG.
Wounds. 2022;34(1):31-35. © 2022 HMP Communications, LLC
