A Case of Atypical Acute Limb Ischemia and Concurrent Fournier's Gangrene

Fournier's gangrene is a severe necrotizing soft tissue infection involving the perineal, perianal, and genital areas, where early and aggressive surgical debridement is the key determinant for survival. Acute limb ischemia (ALI) occurs when vascular compromise threatens a limb, often requiring revascularization or amputation. A synergistic pathophysiological effect between Fournier's gangrene and ALI can be appreciated as infection promotes microthrombi, which leads to vessel occlusion, exacerbating the soft-tissue gangrene and local ischemia. Thus, fulminant Fournier's gangrene promotes a hypercoagulable state, which may result in ALI. A 63-year-old African American male with hypertension, hyperlipidemia, and a 35-pack-year smoking history presented with left lower extremity pain, scrotal swelling, and absent pedal pulses. Color Doppler showed an occlusion proximal to the left popliteal artery, and CT confirmed Fournier's gangrene extending to the presacral area. The patient was taken emergently to the operating room for an attempt at reperfusion of the left lower extremity. This was unsuccessful due to the extent of vascular disease. Extensive surgical debridement of the genitals and perineum was also performed. Subsequent trips to the operating room for further debridement were required. Ultimately, a left above-knee amputation was performed. Despite source control of his infection, the patient suffered an aspiration event on hospital day seven, which led to hypercarbic respiratory failure and cardiac arrest. This resulted in a poor neurologic outcome, from which he did not recover. The patient was transitioned to comfort measures and expired on hospital day 20. The rarity of concurrent Fournier's gangrene and ALI presents a unique clinical question, as one must decide which problem should be treated first on the operating table. This complex management decision requires a multidisciplinary approach accounting for the clinical severity of both disease processes.