Development of Fournier’s gangrene after chemotherapy for the recurrence of testicular cancer despite the absence of anorectal lesions - A case report

Sep 21, 2026

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Fournier’s gangrene is an aggressive necrotizing soft-tissue infection typically triggered by bacterial invasion, often originating from anorectal or genitourinary lesions. This case report describes a 54-year-old man with recurrent left testicular cancer who developed severe perianal pain and septic shock 12 days into chemotherapy. Dark purple discoloration, severe neutropenia, and CT findings led to diagnosis despite no initial anorectal lesions. Surgical debridement and prolonged intensive care were required for 32 days, with discharge at 391 days and no recurrence during follow-up.

LanguageEnglish

CategoryHealthcare

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Reading Time18 min

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Abstract

Background

Case presentation

Conclusion

Introduction

Etiology and clinical characteristics

Case presentation

® Clinical Case Report Development of Fournier’s gangrene after chemotherapy for the recurrence of testicular cancer despite the absence of anorectal lesions A case report Kenichi Nonaka, MD, PhDa ,* , Kota Kawase, MDb , Kimiaki Takagi, MDb , Yuta Takatsu, MDa , Koji Maniwa, MDc , Chika Takao, MD, PhDa , Minoru Komura, MDc , Yoshinori Mushika, MDc , Noriyuki Takeuchi, MD, PhDc , Toshio Kato, MD, PhDd , Mitsuhiko Kusakabe, MD, PhDc , Mitsutaka Kondo, MD, PhDc | Abstract
Background: Fournier’s gangrene usually occurs when a specific bacterium intrudes into soft tissue, causing a wound or tumor. We encountered a patient with Fournier’s gangrene due to severe myelosuppression after chemotherapy, despite the absence of an initial lesion on the anus and rectum.
Case presentation: A 54-year-old man with a left testicular cancer recurrence had undergone chemotherapy. He hadasymptomatic hepatitis and high hepatitis B virus DNA levels, which were normalized by administering tenofovir alafenamide fumarate. Twelve days after the start of chemotherapy, he complained of severe pain around the anus. The following day, he went into septic shock. Visual inspection showed dark purple skin discoloration on the left side of the anus. Laboratory data revealed severe neutropenia. Computed tomography showed a high density of soft tissue on the left side of the anus and gas bubbles in the left femoral ring. We diagnosed the patient with Fournier’s gangrene due to a severe immunosuppressive state resulting from chemotherapy. We emergently removed necrotic tissue to the fullest extent possible. However, because the patient was in severe sepsis status, careful management in the intensive care unit was required for 32 days. After the first emergency operation, we performed several additional excisions. Finally, 391 days after the initial surgery, the patient was discharged from our hospital. The tumor has not recurred, and he is under outpatient observation in the urology department.
Conclusion: Fournier’s gangrene should be considered in patients who are in a severe myelosuppressive state due to chemotherapy, have normal hepatitis B virus DNA levels but high hepatitis B surface antigen after tenofovir administration, complain of severe pain in the perianal area, and have a dark purple skin discoloration around the anus, despite having no initial anorectal lesions.
Abbreviations: BEP therapy = bleomycin, etoposide, and cisplatin therapy, FGSI = Fournier’s gangrene severity index, HBs = hepatitis B surface, HBV-DNA = hepatitis B virus DNA, ICU = intensive care unit, LRINEC = Laboratory Risk Indicator for Necrotizing Fasciitis, NET = neutrophil extracellular trap | | --- | | Keywords: anorectal, case report, chemotherapy, Fournier’s gangrene, myelosuppression | 1. Introduction Fournier’s gangrene is a necrotizing soft tissue infection that develops mainly in the anorectal or genitourinary region and spreads rapidly to the surrounding genital, perianal, and perineal areas. [1] Fournier first described it in 1883.[2] Fournier’s gangrene occurs when bacteria, including streptococci, staphylococci, clostridia, coliforms, corynebacteria, and Bacteroides,[3] invade soft tissue in a mono- or polymicrobial fashion through an entry point such as a wound (including surgical wounds) or tumor, resulting in soft tissue necrosis and septicemia. With regard to the anorectal region, this infection occurs when hemorrhoidal fistulae are present. [4] Treatment may involve Thiersch operation for rectal prolapse,[5] Funding information is not available. The patient provided written informed consent to publish any potentially identifiable images or data in this article. The authors have no conflicts of interest to disclose. All data generated or analyzed during this study are included in this published article [and its supplementary information files]. a Department of Digestive Surgery, Daiyukai General Hospital, Ichinomiya, Aichi, Japan,

FAQs

How was the patient treated and what was the outcome?

Necrotic tissue was emergently removed, followed by several additional excisions. Because of severe sepsis, the patient required careful intensive care management for 32 days, was discharged 391 days after the initial surgery, and the tumor did not recur during outpatient observation.

What role did hepatitis B status and tenofovir play in the case?

The patient had asymptomatic hepatitis with high hepatitis B virus DNA levels, which were normalized by tenofovir alafenamide fumarate. Even with normalized HBV DNA after tenofovir, the patient still developed Fournier’s gangrene during chemotherapy-related myelosuppression.

Sep 21, 2026

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