The
medical mystery involved a 69-year-old man with left inguinoscrotal erythema, swelling, and tenderness after colonoscopy, during which he had undergone polypectomy of a moderately dysplastic tubular adenoma of the sigmoid colon. A computed tomographic (CT) scan of the patient's pelvis revealed free air in the left hemiscrotum (1A). Further CT images of the abdomen and pelvis revealed marked diverticular disease affecting the distal colon and widespread gas in the retroperitoneal tissues, spreading along the left renal fascia (1B) and along the left psoas muscle down the left paracolic gutter, extending to the anterior abdominal wall and into the left hemiscrotum. A diagnosis of
Fournier's gangrene secondary to retroperitoneal perforation of the colon during colonoscopy was made.
The patient underwent immediate exploratory laparotomy, during which necrosis of the left retroperitoneal tissues adjacent and caudal to the sigmoid colon was seen. No obvious site of colonic perforation was identified. A Hartmann's procedure was performed. At the end of this procedure, the erythema of the inguinoscrotal region that was present on physical examination at presentation had progressed to obvious gangrene of the scrotum and perineum (C), requiring repeated radical débridement. It is unclear whether the perforation occurred at a diverticulum or the site of the polypectomy.
NEJM Volume 357:2309-2310 November 29,2007 Number 22
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