Abstract
Background SGLT2 inhibitors have gained popularity in treatment of Type 2 Diabetes, and recently in lowering the risk of major adverse cardiovascular events (MACE). Genitourinary infections are well known side effects of SGLT2 inhibitors. Fournier's gangrene is a necrotizing fasciitis of the perineum which can be rarely associated with SGLT2 inhibitors. Between 2013 to 2018, the FDA received 12 case reports of Fournier's gangrene in patients taking SGLT2 inhibitors. Glucosuria from the medication creates a milieu which increases the chances of developing Fournier's gangrene. The annual incidence of Fournier's gangrene in the general population is 1.6/100,000 males in the US. Here, we present a case of Fournier's gangrene within few months of starting Dapagliflozin. Clinical case A 62-year-old male with history of poorly controlled Type 2 DM was brought to the ED after being found down at his residence covered in feces. He reportedly had nausea, vomiting and diarrhea for 3 days prior to his presentation. His diabetes home regimen consisted of metformin 1000 mg BID, oral semaglutide 14 mg daily, glimepiride 8 mg daily, pioglitazone 45 mg daily and dapagliflozin 10 mg daily. Of note, dapagliflozin was started 3.5 months prior to presentation. Workup revealed WBC count 14.2 k/ul with left shift, sodium 132 mmol/L, HCO3 15 mmol/L, anion gap 26 mmol/L, glucose 432 mg/dL, Cr 3.27 mg/dL (Baseline 1.18 mg/dL), Lactic acid 2.7 mmol/L, AST 131 u/l, CK 905 u/l and A1c 9.2%. CT abdomen and pelvis with contrast showed necrotizing infection of the scrotum and perineum, consistent with Fournier's gangrene. Gas was seen tracking into the mesorectal fascia layer in the extraperitoneal spaces of the pelvis. He was given IV antibiotics and IV fluids per sepsis protocol. Urology and General Surgery consultations were obtained with the patient taken emergently to the operating room and underwent exploration of groin with debridement of genitals, right gluteal and perianal debridement, and bilateral orchiectomy. The patient had an extensive hospital stay with gradual improvement in clinical status. He later underwent extensive reconstructive plastic surgery. All oral diabetes medications were discontinued, and he was ultimately discharged on an insulin regimen consisting of insulin glargine 20 units BID, insulin lispro 5 units before meals and insulin lispro correction scale. Conclusion SGLT2 inhibitors remain valuable drugs in treating Type 2 Diabetes. Fournier's gangrene is a rare but serious possible adverse effect of SGLT2 inhibitors that requires a high index of suspicion to recognize. Time to onset of Fournier's gangrene after initiation of SGLT2 inhibitor therapy can be variable. Patients on SGLT2 inhibitors should be alerted to seek medical attention if they develop fever associated with pain, redness, or swelling in the genital or perineal area. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.