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Diabetes Case Report Extensive Fournier’s Gangrene in a Patient with Type 2 Diabetes René Rodríguez-Gutiérrez, MD, 1,2 Gloria Gonzalez-Saldivar, MD, 2 Jose Gerardo Gonzalez-Gonzalez, MD, PhD 2 and Margo S Hudson, MD 3 1. Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, US; 2. Endocrinology Division, University Hospital “Dr José E González” Universidad Autonoma de Nuevo León, Monterrey, México; 3. Division of Endocrinology, Hypertension and Diabetes, Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts, US Abstract Necrotizing fasciitis is one of the best-known soft tissue infections. Fournier’s gangrene is a type of necrotizing fasciitis of the genital, perianal, and perineal regions caused by the infection of multiple anerobic/aerobic microorganisms. We present the case of a 47-year-old man with a history of uncontrolled type 2 diabetes who presented to the emergency room with intense abdominal pain and signs of severe sepsis. A prompt diagnosis of a necrotizing fasciitis of the perineum (Fournier’s gangrene) was made and immediately broad-spectrum antibiotics, intravenous fluids, and surgical debridement were administered. The patient had an impressive response to treatment with resolution sepsis and was discharged 4 weeks after a skin graft of the abdominal and perineal areas. Fournier’s gangrene remains a life-threatening and many times fulminant disease in which a high grade of suspicion is needed for its diagnosis and rapid and assertive treatment for its survival. Keywords Fournier’s gangrene, necrotizing fasciitis, type 2 diabetes Disclosure: René Rodríguez-Gutiérrez, MD, Gloria Gonzalez-Saldivar, MD, José Gerardo Gonzalez-Gonzalez, MD, PhD, and Margo S Hudson, MD, have no conflicts of interest to declare. No funding was received for the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Compliance with Ethics: Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available upon request for review by the editor of this journal. Received: August 18, 2015 Accepted: October 13, 2015 Citation: US Endocrinology 2015;11(2):83–4 Correspondence: René Rodríguez-Gutiérrez, MD, Knowledge, Evaluation and Research Unit , Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, US. E: rodriguezgutierrez.rene@mayo.edu Necrotizing fasciitis is a soft tissue infections in addition to cellulitis and myositis, which is classified as being either type 1 or type 2. 1 In type 1 necrotizing fasciitis, the infection is caused by multiple microorganisms that involve at least one anaerobic species (e.g. Peptostreptococcous, Clostridium, or Bacteroides) in combination with one or more members of Enterobacteriaceae and one or more facultative anaerobic Streptococci. 1,2 Classically, these types of infections are characterized by fulminant tissue destruction, with sepsis, consequent toxic systemic signs, and a high mortality rate (20–40 %). 3,4 Herein we present the case of an extensive Fournier’s gangrene in a patient with type 2 diabetes. Case Presentation Fournier’s gangrene is a type of necrotizing fasciitis (usually type 1) of the genital, perianal, and perineal regions than can rapidly extent to the lower extremities or abdomen. 3–4 The most commonly reported etiology is an anal/perineal abscess in patients with underlying uncontrolled diabetes, but has also been described to be secondary to thrombosed hemorrhoids or strangulated inguinal hernia. 3–5 Many of the cases remain of unknown etiology and the postoperative period has been described as one of the most common settings of its presentation in patients with diabetes. 3–5 It A 47-year-old man with a history of uncontrolled type 2 diabetes, hypertension, and coronary artery disease presented to the emergency department with malaise, myalgia, fever, and an intense abdominal pain (9/10). On physical examination, heart rate was 115 beats per minute, blood pressure 95/50, respiratory rate 21 per minute, and temperature 39.1ºC. Lower abdomen was swollen, erythematous, and tender. On the perineum there was a 2 x 2 cm necrotic patch surrounded by violaceous tissue (probably due to a furuncle). There was no subjacent gastrointestinal or urological pathology. Plasma glucose was 375 mg/dl with normal blood gases and negative serum and urine ketones. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was 7; high suspicion for necrotizing fasciitis (C-reactive protein >150 mg/L, white blood cell count 20 per mm 3 , hemoglobin 12.5 g/dL, sodium 136 mEq/L, creatinine 1.4 mg/dL, and glucose >180 mg/dL). A diagnosis of a necrotizing fasciitis of the perineum represents a diagnostic challenge and given the usually high mortality associated with this condition, a prompt diagnosis, and an aggressive broad-spectrum antibiotic regimen and surgical treatment are mandatory. (Fournier’s gangrene) with severe sepsis was made. Management with intravenous (IV) fluids, aerobic/anaerobic broad-spectrum antibiotics (imipenem/cilastin 500 mg IV every 6 hours and vancomycin 1g IV every TOU CH MED ICA L MEDIA 83