Introduction

Fournier gangrene is an uncommon but aggressive type of necrotizing fasciitis involving the perineal, perianal, genital, and scrotal regions. The infection rapidly spreads through the superficial and deep fascial planes, causing extensive inflammation, tissue necrosis, sepsis, and substantial morbidity. Despite treatment, it carries a mortality rate approaching 40% [1]. Many conditions that impair host immunity are associated with Fournier gangrene, including diabetes mellitus, chronic alcohol use disorder (AUD), human immunodeficiency virus (HIV) infection, immunosuppression, and malignancy [2]. Fournier gangrene is typically a polymicrobial infection involving a combination of aerobic and anaerobic bacteria. Frequently isolated aerobic pathogens include Escherichia coli, Klebsiella, Proteus, Staphylococcus, and _Streptococcus _species. Common anaerobic organisms include Bacteroides, Clostridium, and _Peptostreptococcus _species [3]. The pathologic process may begin with infection or local tissue injury, including urinary tract infection, perineal abscess, cellulitis, recent instrumentation or surgery involving the genital or perineal region, or minor skin trauma. The interaction between aerobic and anaerobic organisms leads to the release of destructive enzymes, collagenases, and endotoxins that damage surrounding tissue and blood vessels. This process causes obliterative endarteritis and microvascular thrombosis, resulting in tissue ischemia, gangrene, and rapid extension of infection [1].

Because Fournier gangrene can quickly progress to fulminant infection, prompt diagnosis and source control are essential. Computed tomography (CT) is the most specific imaging technique for determining the extent of infection and can assist the surgical team in planning debridement. Radiography and ultrasonography may also contribute to diagnosis [4]. Treatment includes broad-spectrum antimicrobial therapy and urgent surgical debridement, with negative-pressure wound therapy, vacuum-assisted closure, or hyperbaric oxygen therapy used in selected cases [4]. Classic manifestations include perineal pain, swelling, erythema, crepitus, skin discoloration, and systemic toxicity, although localizing symptoms or findings may be subtle early in the disease course. Syncope as the presenting complaint without a documented perineal or genital complaint is unusual and may initially direct attention toward neurologic or cardiac causes. Chronic alcohol use may further increase susceptibility through impaired immune function, nutritional compromise, hepatic dysfunction, and impaired wound healing [5,6]. We report a patient with AUD who presented after syncope and was subsequently found on CT to have Fournier gangrene. The educational value of this case lies in considering an occult perineal source in septic patients with relevant risk factors even when localizing complaints are absent.