Aerobic and anaerobic bacteria such as Clostridium perfringens. It can also result from infections caused by group A streptococcus (GAS), as well as other pathogens such as Staphylococcus aureus and Vibrio vulnificus.[3] 

alcoholicdiabetic, and malnourished, while another ten percent had been immunosuppressed through chemotherapysteroids, or malignancy.[6]

Fournier gangrene is a recognized side effect of SGLT2 inhibitors (canagliflozin dapagliflozin, and empagliflozin),[7][8] which increase the excretion of glucose in the urine.[citation needed]

Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the external genitalia or perineum.









It commonly occurs in older men, but it can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised.

It was first described by Baurienne in 1764 and is named after a French venereologistJean Alfred Fournier, following five cases he presented in clinical lectures in 1883.[2]


 Fournier gangrene is a urological emergency requiring intravenous antibiotics and debridement (surgical removal) of dead tissue.[2] In addition to surgery and antibiotics, hyperbaric oxygen therapy may be useful and acts to inhibit the growth of and kill the anaerobic bacteria.[9]


Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.

In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure. These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.

Infection in the kidneys may spread to the bloodstream—a serious condition called sepsis—though this is also uncommon.



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A 40–year-old male patient with type 2 diabetes, taking a “flozin” (SGLT2 inhibitor), calls your office because he is having difficulty urinating and quite a bit of pain in the perineal area. He has not felt well for several days and was running a low-grade fever.

Examination reveals an obese male who is waddling into the office because of pain in his scrotal area. Vitals: blood pressure 150/100 mm Hg, pulse 112 bpm, respirations 20 bpm, and temperature 39.0°C. Other significant findings include a swollen scrotum that is dusky red, exquisitely tender to touch, and without crepitus. You do not have extended laboratory access in your office, but a urine dipstick is negative for blood and leukocyte esterase. His blood sugar, which is usually fairly well controlled, is elevated at 320 mg/dL.

Your next step for this patient will be which of the following?

The correct answer is B.

 This presentation likely represents Fournier gangrene (and remember that SGLT2 inhibitors, such as this patient is on, increase the risk of Fournier). The erythematous, swollen scrotum with pain out of proportion to examination and associated signs of fever, tachycardia, and elevated blood sugar make Fournier gangrene the most likely diagnosis. While crepitus is common with Fournier gangrene due to presence of gas-forming anaerobic bacteria, its absence does not rule out gangrene. Without early surgical debridement and IV antibiotics, infection can progress rapidly to sepsis and multiorgan failure. Therefore, “B,” emergent surgical referral, is the best option for this patient. Antibiotics, particularly oral (options “A” and “B”), are inappropriate as a sole therapy. Broad-spectrum IV antibiotics may be part of initial management, but “D” is incorrect because the patient emergently needs surgical debridement to remove the necrotic tissue.


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Fournier gangrene is caused by infection with:

The correct answer is C. You answered C.


Which of the following statements regarding nonalcoholic fatty liver disease (NAFLD) is true?

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The correct answer is D. You answered A.

The answer is D. (Chap. 364) Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in many parts of the world, including the United States. Population-based abdominal imaging studies have demonstrated fatty liver in at least 25% of American adults. Because the vast majority of these subjects deny hazardous levels of alcohol consumption (defined as greater than one drink per day in women or two drinks per day in men), they are considered to have NAFLD.

NAFLD is strongly associated with overweight/obesity and insulin resistance. However, it can also occur in lean individuals and is particularly common in those with a paucity of adipose depots (i.e., lipodystrophy). Ethnic/racial factors also appear to influence liver fat accumulation; the documented prevalence of NAFLD is lowest in African Americans (~25%), highest in Americans of Hispanic ancestry (~50%), and intermediate in American whites (~33%).


A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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The correct answer is A. You answered A.

Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.


Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The correct answer is A. You answered A.

The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.



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