A Week After Shaving, She Developed Rare Flesh

She shaved her perineal area, then applied a topical herbal substance provided by an alternative practitioner -- but a week later, the 40-year-old woman developed aggressive necrotizing fasciitis. What ensued was a 12-week hospitalization for surgical debridement and numerous wound therapy interventions, Ali Bassi, MD, MSc, and Futoon Alsaleh, MD, of King Saud University in Riyadh, Saudi Arabia, reported in the American Journal of Case Reports. They noted that this type of infection predominantly affects males and immunocompromised individuals. While she was obese, the patient had a functioning immune system. "This case highlights that Fournier gangrene [an aggressive form of necrotizing fasciitis that affects the perineum and external genitalia] can occur following minor perineal manipulation in women without immunodeficiency," they wrote. About 30% of Fournier gangrene cases occur in otherwise healthy individuals, but have a mortality rate of about 40%, the authors wrote. When it occurs in women "it may be initially misdiagnosed as a gynecologic condition which can delay definitive management." The shaving and application of the herbal topical occurred a week before the patient presented with progressive left labial pain and swelling, vomiting and lower abdominal pain. In an email to MedPage Today, Bassi said the patient did not identify the herbal substance that she used. However, he and Alsaleh "believe that the combination of perineal shaving, which disrupts the skin barrier, and the subsequent application of a non-sterile topical preparation may have created a portal of entry for polymicrobial infection." Both the shaving and the herbal topical substance should be considered as possible contributing factors to the necrotizing fasciitis rather than the proven causes, he emphasized. The patient's "history of shaving and using non-medical topical preparations suggests possible contamination from unsterilized instruments or herbal compounds, creating conditions favorable for polymicrobial invasion," they wrote. Numerous steps were taken to treat the patient after CT imaging, including negative-pressure wound therapy, serial dressing changes, and more surgical debridement under anesthesia for 5 of the 12 weeks, according to the report. A discovered anal fistula was treated with a fistulotomy, although it was unclear if it was a source of the infection or a complication. Wound cultures revealed E. coli, Klebsiella pneumoniae, and Enterobacter cloacae, which were treated with a variety of antibiotics. Meropenem was administered after the initial broad-spectrum antibiotics were discontinued, and the patient was ultimately stepped down to amoxicillin-clavulanate. Bassi told MedPage Today the patient has recovered and regained good function, but "was left with mild cosmetic deformity from the extensive tissue loss." The patient received nutritional counseling focused on high-protein supplementation and was referred to rehabilitation services for gait disturbances due to perineal scarring, the report stated. Scar revision surgery was planned for a year later. "Obesity may mask early clinical signs and contribute to diagnostic delay," the authors wrote. They advised that early recognition should result in "prompt imaging, aggressive surgical debridement and multidisciplinary management." The most important lesson from this case, Bassi told MedPage Today, is that Fournier gangrene is a clinical diagnosis, not a demographic diagnosis. Clinicians should consider it whenever patients present with rapidly progressive perineal pain and swelling, regardless of sex or immune status."