A case report of necrotizing fasciitis of the abdominal wall: A rare, life-threatening complication of a common disease process

Unusual Manifestation of a Non-inflamed Appendiceal Fistula as a Necrotizing Soft Tissue Infection in the Setting of a Gigantic Ventral Hernia

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection of the soft tissues that necessitates early identification and emergent aggressive surgical debridement due to its high mortality. NSTI most often results from the introduction of microbes through breaks in the skin. Unique sources, like appendiceal fistulae, can be etiologies of abdominal wall NSTIs. We present the case of a 46-year-old female with a past medical history of poorly controlled type II diabetes mellitus and ventral hernia who presented in septic shock with a necrotic wound in her abdominal wall. The wound was overlying a large ventral hernia and was consistent with NSTI. She was treated urgently with fluid resuscitation, antibiotic therapy, and surgical debridement of the wound. On repeat exploration, an appendiceal fistula was found protruding from the hernial sac. Open appendectomy and primary repair of the ventral hernia were performed. Principles of immediate intervention and repeat surgical debridement allowed control of the septic insult and definitive source control upon identification of an appendiceal fistula.

Retroperitoneal necrotizing fasciitis with the involvement of the anterior abdominal wall following perianal abscess

Necrotizing fasciitis (NF) is a life-threatening infection, which requires immediate debridement and broad-spectrum antibiotic treatment. Delay in prompt diagnosis and operative debridement is associated with significant morbidity and mortality. Retroperitoneal NF is a rare condition whereby the infection within the pelvis or retroperitoneum rapidly expands over the fascial planes to involve the anterior abdominal wall (AW), the thighs and the buttocks. It presents a challenge for surgical access due to the anatomic depth of the structures and may result in extensive soft tissue loss requiring complex AW reconstruction for closure. The case discussed here is a 43-year-old female with a perianal abscess that progressed to retroperitoneal and anterior AW NF with intra-peritoneal abscess collection requiring bilateral tensor fascia-lata graft for the closure of the anterior AW fascia defect.

Necrotizing Fasciitis of the Right Lower Extremity from Ruptured Appendicitis: Case Report

CASE

The patient is a 16-year-old girl with history of dermatomyositis in remission for several years who presented with complaints of right thigh pain and elevated inflammatory markers. She presented to the Emergency Room (ER) on separate occasions and was diagnosed with right lower extremity necrotizing fasciitis secondary to ruptured appendix. She underwent 11 surgical procedures and extended hospital stay.

CONCLUSION

This case is a unique presentation of ruptured appendicitis without abdominal pain that presented as right lower extremity necrotizing fasciitis and posed a diagnostic challenge. This case illustrates the importance of diligent evaluation and aggressive surgical management in musculoskeletal infections.

Acute Perforated Appendicitis Complicated by Necrotizing Fasciitis and Bladder Perforation

Acute uncomplicated appendicitis is a common surgical disease that has been well-studied, and its overall mortality has decreased over time. However, delay in treatment can be associated with rare complications such as necrotizing fasciitis, which carries a high mortality rate, and bladder perforation. We present such a case in an 81-year-old female with no significant surgical history who presented to the emergency department with four days of abdominal pain. A CT scan revealed extensive subcutaneous air in the abdominal wall, an inflamed appendix, and a periappendiceal abscess. During subsequent exploratory laparotomy, she was also found to have bladder perforation. She underwent debridement of necrotic tissue of the abdominal wall, appendectomy, drainage of periappendiceal abscess, and bladder perforation repair. She died of septic shock on post-operative day 19, due to gross spillage of urine into the abdomen and ongoing necrotizing fasciitis. Acute perforated appendicitis can lead to rare and fatal complications. Our case presents such a patient with a poor outcome. In approaching a patient with signs of peritonitis, differential diagnoses must remain broad to include late complications such as abscess formation, soft tissue infection, and perforation of surrounding structures.

Catastrophic appendicitis operation, successful repair in tertiary limited resources hospital: A case report

Introduction

Acute appendicitis is one of the most common surgical diseases. Perforated appendicitis resulting in catastrophic complication because of a burst abdomen with necrotizing fasciitis of the abdominal wall is exceedingly a rare case.

Presentation of case

A 13-year-old girl with perforated appendicitis who had undergone laparotomy had to experience a burst abdomen with necrotizing fasciitis of the abdominal wall. The patient has temporarily closed the abdominal cavity with a urine bag (modified Bogota bag). After 23 times replacement of the Bogota bag and the condition of the sepsis and nutrition had improved, the abdominal wall reconstruction was performed by carrying out two random rotational flaps to close the abdominal defect. One year later, the patient came for ileocolostomy closure; then the patient was sent home with uneventful condition.

Discussion

Perforated appendicitis is a type of acute appendicitis with a low morbidity rate. Compared to other complications, burst abdomen and necrotizing fasciitis (NF) in perforated appendicitis are exceptionally rare events. Surgery with sepsis and recurrent intra-abdominal abscesses as a result of previous surgery are the causes of burst abdomen. The use of abdominal drainage has also been shown to cause NF. Both of these conditions will increase the cost and length of stay, and reduce the quality of life. The rotational flap procedure is the procedure of choice for a large burst abdomen.

Conclusion

Surgeons should and have to perform a meticulous operation to prevent catastrophic complication and to increase the quality of life.

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Acute appendicitis is one of the most common surgical diseases.

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Perforated appendicitis resulting in catastrophic complication as burst abdomen with necrotizing fasciitis is very rare.

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Sepsis, intraabdominal abscesses, use of abdominal drainage had been shown to cause burst abdomen and necrotizing fasciitis.

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Used Bogota bag to temporarily closed abdominal wall and rotational flap is the selected procedure for large burst abdomen.

Recurrent Necrotizing Fasciitis: A Case Report of Fulminant and Sub-Acute Necrotizing Fasciitis in a Diabetic Patient

Necrotizing fasciitis is an uncommon and deadly disease entity characterized by rapidly progressing skin and soft tissue destruction. It presents on a spectrum from an initially indolent appearing sub-acute form to a hyperacute fulminant course. It may often be misdiagnosed due to the paucity of signs early in the disease course and as it can initially mimic other less serious soft tissue infections. Necrotizing soft tissue infections have both high morbidity and mortality. We present a case of a 72-year-old male patient with two anatomically and temporally separate necrotizing infections. The first necrotizing infection was diagnosed after an extended time, due to the subacute disease course in the setting of an abdominal wall infection. The second presentation was a hyperacute fulminant course in the setting of a necrotizing infection of the scrotum. In both instances, once identified, appropriate management was followed: resuscitation, broad-spectrum antibiotics, and most importantly radical surgical debridement. Extensive multidisciplinary inpatient and outpatient input was required to aid the patient's recovery. The presented case demonstrates the necrotizing soft tissue infection's spectrum of disease and the diagnostic dilemma it presents to family physicians and emergency departments alike. The only definitive management step is immediate and radical resection of the affected tissue. Extensive debridement and the resultant tissue defect require comprehensive multidisciplinary care during the extended rehabilitation and wound care treatment plan. Rapid recognition, urgent surgical debridement, and specialist care are required to reduce the mortality and morbidity associated with necrotizing soft tissue infections.

Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report

RATIONALE

Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis.

PATIENT CONCERNS

A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD.

DIAGNOSES

The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess.

INTERVENTIONS

This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis.

OUTCOMES

The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock.

LESSONS

(1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.