Solitary Candida albicans Infection Causing Fournier Gangrene and Review of Fungal Etiologies

Polymicrobial bacterial infections are commonly found in cases of Fournier gangrene (FG), although fungal growth may occur occasionally. Solitary fungal organisms causing FG have rarely been reported. The authors describe a case of an elderly man with a history of diabetes who presented with a necrotizing scrotal and perineal soft tissue infection. He underwent emergent surgical debridement with findings of diffuse urethral stricture disease and urinary extravasation requiring suprapubic tube placement. Candida albicans was found to be the single causative organism on culture, and the patient recovered well following antifungal treatment. Fungal infections should be considered as rare causes of necrotizing fasciitis and antifungal treatment considered in at-risk immunodeficient individuals.Key words: Fournier gangrene, Fournier’s Gangrene Severity Index, Candida albicansFournier gangrene (FG) is a rare, rapidly progressive, necrotizing infection of the perineum and genital area that was first described in 1883 by Jean Alfred Fournier in five young male patients.¹ The infectious flora causing necrotizing fasciitis are typically polymicrobial, involving aerobic and anaerobic bacteria derived from gastrointestinal, genitourinary, and cutaneous sources.^2,3 Certain predisposing conditions increase the risk of developing FG, including diabetes, chronic kidney disease, immunosuppression, local trauma, urethral stricture, or genitourinary infections.^4–6It is essential to diagnose FG early and treat it emergently because the infection can quickly progress, with mortality rates of 7.5% to 50% cited in various series.^7,8 Aggressive management involves hemodynamic stabilization, broad spectrum antibiotics to empirically cover all potential organisms, and wide surgical debridement.^3–5 Early surgical debridement with excision of all nonviable tissue is the most important component of treatment. Multiple surgical debridements are often required, as the areas of cutaneous involvement may not indicate the full extent of subcutaneous disease.⁵Rapid initiation of broad spectrum antibiotic coverage is also necessary to stabilize the presenting patient with FG before and after surgical management. The infection is generally caused by three or more microorganisms, most commonly Escherichia coli, Proteus, Enterococcus, and anaerobes.⁴ Fungal etiologies of necrotizing infections are rare but have been increasingly reported in the literature.^9–12 Candida species are commonly part of the normal flora in the gastrointestinal and genitourinary tracts of humans but may cause acute disease in the setting of compromised host immunity. This report describes a case of primary C albicans necrotizing fasciitis of the genitalia and reviews the literature regarding fungal FG to determine possible predisposing factors.