Abstract
Fournier’s gangrene is a rare, rapidly progressive, fulminant form of infective necrotising fasciitis of the genital, perianal and perineal regions. We present a case of Fournier’s gangrene of the penis complicating acute genital ulceration and recurrent paraphimosis that was secondary to contemporaneous COVID-19 and Mpox infection in an otherwise healthy 41-year-old man. It is important for clinicians to be aware of Fournier’s gangrene, as early detection remains the cornerstone of effective tissue and indeed life conserving management.
Introduction
The last few years has seen the emergence of new and evolving global health problems that will continue to pose significant health challenges. Coronavirus disease 2019 (COVID-19) is a systemic disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On March 11, 2020, COVID-19 was defined as a pandemic by the World Health Organization (WHO). More recently Mpox, a viral disease caused by the monkeypox virus (MPXV), was declared by the WHO as a Public Health Emergency of International Concern (PHEIC) due to an escalating global outbreak occurring especially among men who have sex with men (MSM). Limited information is available concerning the health outcomes of co-infection between COVID-19 and Mpox. We report a case of Fournier’s gangrene of the penis in a male patient co-infected with COVID-19 and Mpox.
Case Report
A 41-year-old MSM was referred to Urology with a second episode of paraphimosis. The patient had initially presented four days earlier to his local accident and emergency department with distal penile ulceration and paraphimosis that had been manually reduced. For the preceding two weeks he had been unwell with cough and fevers up to 37.9°C and had tested positive for COVID-19 on a lateral flow test (LFT). On examination, there was an oedematous foreskin with ulceration of the ventral aspect of the penis (Figure 1(a)). He was lateral flow (LFT) and polymerase chain reaction (PCR) positive for COVID-19. C-reactive protein was elevated to 87.0 mg/L (0-5.0 mg/L). A penile block and manual reduction of the paraphimosis were performed, and the patient admitted for observation overnight. He was subsequently taken to theatre the next day for a dorsal and ventral slit plus stab incision of the prepuce after the paraphimosis recurred for a third time. He was discharged two days later. However, he re-presented after four days with increasing oedema and bruise-like skin discolouration to the glans and foreskin. Well-circumscribed pustules with surrounding erythematous rim were also noted on the right hand and left index finger. The patient reported unprotected intercourse with a man approximately three weeks prior to lesion onset; there was no history of recent international travel, and the patient was not taking HIV pre-exposure prophylaxis (PrEP). A swab was taken from the right-hand lesion. Intravenous clindamycin and piperacillin-tazobactam were commenced. The skin swab returned positive for MPXV. Oral tecovirimat daily was started. The patient reported worsening penile pain and increasing difficulties with passing urine over 48-hours, and a dry necrotic area on the foreskin, concerning for Fournier’s gangrene, was noted to be enlarging (Figure 1(b)). There was no crepitus. The patient remained systemically and biochemically well. Serology for HIV and syphilis was negative. He returned to theatre for circumcision and debridement and excision of necrotic tissue (Figure 1(c)). Histology showed extensive surface ulceration with congestion, florid acute and chronic inflammation and microabscess formation as well as focal haemorrhage and necrosis of the lamina propria. Tissue culture grew a moderate growth of Enterobacter cloacae complex and Corynebacterium jeikeium. The patient was discharged six days later on a seven-day course of oral ciprofloxacin 500 mg BD. The penis has healed with atrophic scarring (Figure 1(d)). (A) Oedematous and erythematous foreskin with shallow ulceration of the ventral aspect of the penis leading to paraphimosis; (B) Increasing oedema to the glans and foreskin with dry black eschar and a well-circumscribed pustule with surrounding erythematous rim to the base of the right thumb; (C) Day 1 post circumcision and debridement and excision of necrotic tissue; (D) Seven months after initial presentation showing atrophic scarring to the glans penis.
Discussion
We present a case of Fournier’s gangrene (FG) of the penis complicating acute genital ulceration and recurrent paraphimosis that was secondary to contemporaneous COVID-19 and Mpox infection in an otherwise healthy 41-year-old man. Cumulative evidence and experience suggest COVID-19 can be responsible for balanoposthitis, but the generalized inflammatory hypercoagulable state that results in macro- and microvascular thrombosis and acro-ischaemic events can cause penile ulceration, Mondor’s disease and priapism.1–3 MPXV is a novel cause of balanoposthitis and genital ulceration. Penile oedema, phimosis and paraphimosis (sometimes necessitating circumcision) have been encountered, as has significant penile scarring.4–6 FG is a rare form of polymicrobial, necrotising fasciitis affecting the genital, perianal and perineal regions. Male sex, and states of impaired micro-circulation and immunosuppression, are accepted risk factors for development. Initial symptoms and signs of FG may be indistinct, but there can be rapid clinical fulmination to overwhelming sepsis with a relatively high mortality rate of up to 70%. It is important for clinicians to be aware of FG, because early detection and decisive effective intervention are key to life saving and tissue-preserving outcomes. 7 A multidisciplinary approach with input from sexual health services is crucial for the best management of patients who present with acute genital ulceration. The literature on concomitant MPV and COVID infection is scanty. 8 To the best of our knowledge frank FG has not been reported with MPXV; three cases associated with COVID-19 have been published affecting the male (buttock, scrotum, scrotum/perineum/suprapubic),9–11 but not the penis.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
