Delayed antemortem diagnosis of adenocarcinoma of the cecum presenting as lower extremity gas gangrene

Perforation of an Occult Carcinoma of the Prostate as a Rare Differential Diagnosis of Subcutaneous Emphysema of the Leg

We report a case of subcutaneous emphysema caused by perforation of the rectum due to a carcinoma of the prostate. Although rare, an abdominal cause must always be considered as a rare differential diagnosis of subcutaneous emphysema. As a matter of fact adequate diagnostic with rapid treatment is essential for the outcome.

[Gas gangrene of the abdominal wall due to underlying GI pathology: seven cases]

OBJECTIVE

Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall.

PATIENTS AND METHODS

Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated.

RESULTS

The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%).

CONCLUSION

The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

[Abdominal wall abscess as the presenting sign in carcinoma of the colon: report of 4 cases]

PURPOSE

We report four cases of unusual presentation of colonic cancer revealed by an abscess of the abdominal wall.

MATERIALS AND METHODS

Our study included 3 men and 1 women ranging in age from 33 to 66 years presenting with abdominal wall abscess (in the left anterior abdominal wall in 2 patients and in the quadratus lumborum muscle in the other 2 patients). Our cases were listed from the departments of radiology and abdominal surgery of Sahloul hospital from 1995 through 2000. Ultrasonography (US) and computed tomography (CT) were performed in all cases; barium enema in three.

RESULTS

US and CT revealed segmental colonic wall thickening (left colon in three patients and right colon in one patient). The diagnosis of colonic cancer was reached by colonoscopy with biopsy in all 4 cases. All of our patients underwent surgical treatment.

CONCLUSION

In this era of newer diagnostic imaging modalities, US and CT must frequently be used in the evaluation of patients with abdominal wall abscess, to depict intra-abdominal infection and especially malignant lesion causing abdominal wall abscess.

Subcutaneous emphysema mimicking gas gangrene following perforation of the rectum: a case report

We report a case of extensive subcutaneous emphysema of the lower extremity mimicking gas gangrene following perforation of the rectum in a 38-yr-old man. Subcutaneous emphysema of the leg may rarely occur secondary to perforation of the gastrointestinal tract and has often created serious diagnostic problems and high mortality rates. Therefore, prompt diagnosis and aggressive treatment is imperative.

Sacral chordoma, gas gangrene and bilateral renal cell carcinomas

The case history is reported of a 59-year-old man with a locally symptomatic sacral chordoma. During treatment with radical radiotherapy, he developed gas gangrene, which proved rapidly fatal. At post-mortem examination there was evidence of local invasion of the rectum by the tumour and extensive gangrenous myonecrosis (gas gangrene) involving the pelvic tissues and left leg. An unexpected finding was the presence of histologically distinct bilateral renal cell carcinomas. Neither gas gangrene nor renal cell cancer has been reported previously in association with sacral chordoma.

Clostridial bacteremia in cancer patients. A 12-year experience

Over 12 years, 136 episodes of bacteremia caused by clostridial species were documented. Eighty-three were monomicrobial, and 53 were polymicrobial. Gastrointestinal, genitourinary carcinomas, and acute leukemia were the most common underlying malignancies. Septic shock occurred in 29% of monomicrobial bacteremias and 45% of polymicrobial bacteremias and was associated with a high mortality rate. Acute hemolysis, gas gangrene, and diffuse spreading cellulitis occurred infrequently but were associated with a 100% fatality rate. Many infections caused by Clostridium perfringens and C. septicum were associated with abdominal disease. The most commonly isolated organism was C. perfringens, followed by C. septicum and C. sporogenes. Overall survival was 58%, but it was 66% for monomicrobial episodes and 45% for polymicrobial infections. All of the patients with bacteremia due to an aerobic gram-negative bacillus in addition to the clostridial species died of their infection. The most effective antibiotics were clindamycin, penicillin, metronidazole, and moxalactam. Surgical drainage of abscesses was an important component of therapy.

Subcutaneous emphysema of the lower extremity of abdominal origin

Three cases of subcutaneous emphysema of the lower extremity due to abdominal disease are reported. These were due to (a) perforation of the sigmoid, (b) perirectal abscess, and (c) non-traumatic metastatic gas gangrene due to emphysematous cholecystitis. The mechanisms and anatomical pathways are discussed.

Carcinoma of the large intestine and nontraumatic, metastatic, clostridial myonecrosis

Traumatic, clostridial myonecrosis is a rare and serious complication of wounds. Nontraumatic, metastatic, clostridial myonecrosis may be caused by carcinoma of the large intestine. Nontraumatic myonecrosis becomes evident with localized pain, generalized toxicity, local signs of inflammation, and crepitation. Serum creatine kinase determinations may be of help in diagnosing patients suspected of having acute myonecrosis. Immediate heroic surgical intervention, usually with demonstration of Clostridium septicum, is mandatory to control the myonecrosis. Appropriate antibiotic therapy is a valuable adjunct to surgical intervention, and penicillin in massive doses appears to be the agent of choice for the clostridia. Hyperbaric oxygen therapy may help in the optimal control. General supportive measures, including frequent blood transfusions, are most important. To save the life of the patient with nontraumatic, metastatic, clostridial myonecrosis, it is necessary, as soon as the patient's general condition permits, to diagnose and eliminate the cause of the myonecrosis. In addition to the case reported, 16 cases have been reported in the literature, making a total of 17. Five patients have survived (survival rate, 29 percent).