SUN-647 - Fournier'S Gangrene in A Female Patient Treated with A Sodium-Glucose Cotransporter-2 Inhibitor (SGLT-2I)

Background:
Treatment with SGLT-2i has been associated with an increased risk of Fournier’s gangrene (FG),
life-threatening polymicrobial necrotizing fasciitis of the perineum. There is a significant male
sex disparity for FG among patients with or without diabetes mellitus (DM). We present an
unusual case of FG in a female patient prescribed an SGLT-2i for management of DM2.

Case Presentation:
A 55-year-old woman with DM2, hypertension, stage 3 chronic kidney disease, and obesity
presented with 5 d of fever and a painful, spontaneously draining left gluteus lesion. DM2 was
managed with insulin glargine, insulin lispro, dulaglutide, and empagliflozin, which had been
started 2 y prior to presentation. Long term glycemic control was poor as indicated by HbA1c of
10.5%. The patient was septic, and admission laboratories were notable for severe
hyperglycemia (glucose 615 mg/dL) and leukocytosis (22.2 × 10³/µL, ref range 3-4-9.4).
Examination revealed a large erythematous wound on the left gluteus with malodorous, purulent
drainage and tenderness beyond wound margins and ulceration of the left gluteal fold. Computed
tomography demonstrated an 18-cm subcutaneous gas collection indicating FG. Urgent surgical
debridement was performed followed by treatment with multiple parenteral antibiotics
(vancomycin, metronidazole, and ceftriaxone). The hospital diabetes team managed
hyperglycemia. Fortunately, the patient experienced a full clinical recovery.

Discussion:
FG predominantly affects males; in a large series from the National Inpatient Sample the male
to-female (M:F) ratio was 2.2:1, and in a series of DM patients the M:F ratio was 2.4:1. The
U.S. Food and Drug Administration first published a warning about increased risk of FG for
patients treated with SGLT-2i in 2018, with glucosuria-enhanced growth of urogenital bacterial
flora the posited major risk factor for FG. This patient’s risk factors for FG included treatment
with an SGLT-2i, DM2, and obesity. Although FG is less common in women -- potentially due
to anatomical differences in drainage of pelvic secretions between males and females -- women
experience higher rates of morbidity and mortality from FG. DM and longer time to
debridement have also been identified as a mortality risk factors in cases of FG, and the patient
unfortunately waited 5 d before seeking medical intervention. This case demonstrates the need
to educate patients of the increased risk of genitourinary (GU) infections if an SGLT-2i is
prescribed, potential symptoms and signs of serious GU infections including FG, and the
importance of prompt treatment for GU infections. Though risk of FG is higher in men than
women, evaluation for FG should be performed when female patients treated with an SGLT-2i
present with advanced GU infections.

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