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A black perineal skin lesion: a sign of Fournier gangrene

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An 84-year-old man was found to be hypotensive before receiving his regularly scheduled dialysis treatment and was referred to our emergency department. He reported slight fatigue but did not have any pain. On arrival, his blood pressure was 58/13 mm Hg and his heart rate was 102 beats/min. He had a normal respiratory rate and was afebrile. He had a score of 15 on the Glasgow Coma Scale (E4, V5, M6). The only potential source of infection that we identified was a small, black skin lesion near the anus, with induration and slight tenderness (Figure 1A). Based on his clinical presentation, we diagnosed perineal fasciitis, also known as Fournier gangrene. We administered intravenous fluids and vasopressor support, and urgently consulted surgery. After stabilization, a computed tomography scan showed subcutaneous free air behind the rectum (Figure 1B).

<a href=”https://www.cmaj.ca/content/cmaj/195/28/E957/F1.large.jpg?width=800&height=600&carousel=1″ title=”(A) Black perineal lesion near the anus at initial presentation of an 84-year-old man with Fournier gangrene. An area of induration with slight tenderness is indicated by the dashed line. (B) Computed tomography scan of the perineal lesion, showing free air in the subcutaneous space behind the rectum (yellow arrowhead).” class=”highwire-fragment fragment-images colorbox-load” rel=”gallery-fragment-images-1554836957″ data-figure-caption=”

(A) Black perineal lesion near the anus at initial presentation of an 84-year-old man with Fournier gangrene. An area of induration with slight tenderness is indicated by the dashed line. (B) Computed tomography scan of the perineal lesion, showing free air in the subcutaneous space behind the rectum (yellow arrowhead).

” data-icon-position data-hide-link-title=”0″>Figure 1:

Figure 1:

(A) Black perineal lesion near the anus at initial presentation of an 84-year-old man with Fournier gangrene. An area of induration with slight tenderness is indicated by the dashed line. (B) Computed tomography scan of the perineal lesion, showing free air in the subcutaneous space behind the rectum (yellow arrowhead).

Imaging did not delay definitive management; we transferred the patient to the operating room for emergent surgical débridement. The blackened skin, subcutaneous tissue and lower rectum were necrotic, with sparing of the perineal muscle. A full-thickness perforation from necrosis in the lower rectum was identified, and a partial rectal resection with colostomy was performed. We treated the patient with meropenem and vancomycin, and he remained in the intensive care unit for 7 days postoperatively. He was discharged after 2 months of rehabilitation.

Even in well-resourced settings, the mortality associated with Fournier gangrene has been reported to be 7%–20%.1,2 Patients with suspected Fournier gangrene require appropriate resuscitation, aggressive surgical débridement and critical care management that should not be delayed by diagnostic testing.1,2 Hypotension and hemorrhagic bullae are highly specific for Fournier gangrene, but occur late in the disease course.3 Diagnosing Fournier gangrene in its early stage can be challenging. In this case, although the patient did not report pain, we detected black discoloration of the skin in the perineal area. When assessing patients with an unknown cause of shock, careful physical examination is necessary, and Fournier gangrene should be considered if perineal black skin lesions are present.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • The authors have obtained patient consent.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

 

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Tips for shopping for Medicare Advantage plans

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Shopping season for Medicare coverage is about to begin. With it comes the annual onslaught of TV ads and choices to consider.

People eligible for the federal government’s Medicare program will have from Oct. 15 to Dec. 7 to sign up for 2025 Medicare Advantage plans, which are privately run versions of the program. They also can add a prescription drug plan to traditional Medicare coverage.

Many people on Medicare Advantage plans will probably have to find new coverage as major insurers cut costs and pull back from markets. Industry experts also predict some price increases for Medicare prescription drug plans.

Shoppers often have dozens of options during this sign-up period. Here are some things to consider.

Don’t put off shopping for Medicare coverage

Start thinking about next year’s coverage before the annual enrollment window begins. Insurers will usually preview their offerings or let customers know about any big changes. That makes anything arriving in the mail from your insurer important to read.

Insurance agents say many people wait until after Thanksgiving to decide coverage plans for the new year. That could be a mistake this year: The holiday falls on Nov. 28, leaving slightly more than a week to decide before the enrollment window closes.

Look beyond the premium

Many Medicare Advantage plans promote a $0 premium. That may sound attractive, but price is only one variable to consider.

Shoppers should look at whether their doctors are in the plan’s coverage network and how prescriptions would be covered. They also should know the maximum amount under the plan that they’d have to pay if a serious health issue emerges.

Plans offer many supplemental benefits, including help paying food or utility bills. Don’t let those distract from understanding the core coverage, said Danielle Roberts, co-founder of the Fort Worth, Texas, insurance agency Boomer Benefits.

“Remember that we buy health insurance for the big things, not the frills,” she said.

How to get help shopping for plans

The federal government operates a plan finder that lets people compare options. The State Health Insurance Assistance Program can be another resource. Insurance brokers or agents also guide customers through searches.

Sometimes a plan’s coverage doesn’t work as expected. If that happens, there’s another enrollment window in the first three-months of each year where some shoppers may be able to make a change.

___

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

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The US is mailing Americans COVID tests again. Here’s how to get them

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WASHINGTON (AP) — Americans can once again order COVID-19 tests, without being charged, sent straight to their homes.

The U.S. government reopened the program on Thursday, allowing any household to order up to four at-home COVID nasal swab kits through the website, covidtests.gov. The tests will begin shipping, via the United States Postal Service, as soon as next week.

The website has been reopened on the heels of a summer COVID-19 virus wave and heading into the fall and winter respiratory virus season, with health officials urging Americans to get an updated COVID-19 booster and their yearly flu shot.

“Before you visit with your family and friends this holiday season, take a quick test and help keep them safe from COVID-19,” U.S. Health and Human Services Assistant Secretary for Preparedness and Response Dawn O’Connell said in a statement.

U.S. regulators approved an updated COVID-19 vaccine that is designed to combat the recent virus strains and, they hope, forthcoming winter ones, too. Vaccine uptake is waning, however. Most Americans have some immunity from prior infections or vaccinations, but under a quarter of U.S. adults took last fall’s COVID-19 shot.

Using the swab, people can detect current virus strains ahead of the fall and winter respiratory virus season and the holidays. Over-the-counter COVID-19 at-home tests typically cost around $11, as of last year. Insurers are no longer required to cover the cost of the tests.

Before using any existing at-home COVID-19 tests, you should check the expiration date. Many of the tests have been given an extended expiration from the date listed on the box. You can check on the Food and Drug Administration’s website to see if that’s the case for any of your remaining tests at home.

Since COVID-19 first began its spread in 2020, U.S. taxpayers have poured billions of dollars into developing and purchasing COVID-19 tests as well as vaccines. The Biden administration has given out 1.8 billion COVID-19 tests, including half distributed to households by mail. It’s unclear how many tests the government still has on hand.

The Canadian Press. All rights reserved.

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Free COVID tests are back. Here’s how to order a test to your home

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WASHINGTON (AP) — Americans can once again order free COVID-19 tests sent straight to their homes.

The U.S. government reopened the program on Thursday, allowing any household to order up to four at-home COVID nasal swab kits through the website, covidtests.gov. The tests will begin shipping, via the United States Postal Service, as soon as next week.

The website has been reopened on the heels of a summer COVID-19 virus wave and heading into the fall and winter respiratory virus season, with health officials urging Americans to get an updated COVID-19 booster and their yearly flu shot.

U.S. regulators approved an updated COVID-19 vaccine that is designed to combat the recent virus strains and, they hope, forthcoming winter ones, too. Vaccine uptake is waning, however. Most Americans have some immunity from prior infections or vaccinations, but under a quarter of U.S. adults took last fall’s COVID-19 shot.

Using the swab, people can detect current virus strains ahead of the fall and winter respiratory virus season and the holidays. Over-the-counter COVID-19 at-home tests typically cost around $11, as of last year. Insurers are no longer required to cover the cost of the tests.

Since COVID-19 first began its spread in 2020, U.S. taxpayers have poured billions of dollars into developing and purchasing COVID-19 tests as well as vaccines. The Biden administration has given out 1.8 billion COVID-19 tests, including half distributed to households by mail. It’s unclear how many tests the government still has on hand.

The Canadian Press. All rights reserved.

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