To the Editor: The medical mystery in the October 4 issue1 involveda 69-year-old man with left inguinoscrotal erythema, swelling,and tenderness after colonoscopy, during which he had undergonepolypectomy of a moderately dysplastic tubular adenoma of thesigmoid colon. A computed tomographic (CT) scan of the patient'spelvis revealed free air in the left hemiscrotum (Figure 1A).Further CT images of the abdomen and pelvis revealed markeddiverticular disease affecting the distal colon and widespreadgas in the retroperitoneal tissues, spreading along the leftrenal fascia (Figure 1B) and along the left psoas muscle downthe left paracolic gutter, extending to the anterior abdominalwall and into the left hemiscrotum. A diagnosis of Fournier'sgangrene secondary to retroperitoneal perforation of the colonduring colonoscopy was made.
Figure 1. Fournier's Gangrene Associated with Retroperitoneal Perforation of the Colon.
An axial view of a CT scan of the patient's pelvis shows free air in the left hemiscrotum (Panel A, arrow). An axial view shows diverticular disease affecting the distal colon and widespread gas in the retroperitoneal tissues, spreading along the left renal fascia (Panel B, arrows) and extending into the left hemiscrotum, causing gangrene of the scrotum and perineum (Panel C).
The patient underwent immediate exploratory laparotomy, duringwhich necrosis of the left retroperitoneal tissues adjacentand caudal to the sigmoid colon was seen. No obvious site ofcolonic perforation was identified. A Hartmann's procedure wasperformed. At the end of this procedure, the erythema of theinguinoscrotal region that was present on physical examinationat presentation had progressed to obvious gangrene of the scrotumand perineum (Figure 1C), requiring repeated radical débridement.It is unclear whether the perforation occurred at a diverticulumor the site of the polypectomy.
Marc A. Gladman, Ph.D. Shukri K. Shami, M.S., F.R.C.S. Queen's Hospital Essex RM7 0AG, United Kingdom
Editor's note: We received 740 responses to this medical mystery,from 63 countries. Sixty percent of the respondents were practicingphysicians, 20% were physicians in training, 13% were medicalstudents, and 7% were other readers. This medical mystery generateda variety of responses, most of which reflected the differentcomponents leading to the diagnosis of Fournier's gangrene.Overall, 40% of the respondents diagnosed an underlying colonicperforation as a complication of the colonoscopy procedure;10% correctly identified the presence of air in retroperitonealtissues; 4% and 18% of respondents suggested the presence ofabscess and hernia, respectively; and 8% of respondents specificallydiagnosed Fournier's gangrene. The remaining respondents (20%)suggested various other diagnoses, including a neoplasm andhematomas.
References
Gladman MA, Shami SS. Medical mystery -- an unusual complication of colonoscopy. N Engl J Med 2007;357:1431-1431. [Free Full Text]
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