Necrotizing Fasciitis as the Clinical Presentation of a Retroperitoneal Abscess

Necrotizing soft tissue infection of the upper leg as first presentation of necrotizing pancreatitis: a case report

Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis.

Necrotizing Fasciitis: A Rare Complication of Acute Necrotizing Pancreatitis

Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.

A rare case of Fournier's Gangrene

We report a rare case that highlights acute pancreatitis as the protagonist of Fournier’s Gangrene. This patient was treated with a radical debridement of his perineum at presentation and subsequently reconstructed with split thickness skin grafting. This is an unusual aetiology of necrotizing fasciitis with only one other case reported in the literature. This serves to emphasize to physicians that acute pancreatitis is a potential source when investigating and treating patients with Fournier’s Gangrene.

Acute pyogenic inguinal abscess from complex soft-tissue infection or intra-abdominal pathology

BACKGROUND

Abscesses involving the inguinal region are uncommon as manifestations of complex soft-tissue infections or intra-abdominal pathology, and the routes by which they cause infection are usually unclear and may be overlooked.

METHODS

A comprehensive review of reports in the English language literature of the clinical presentations, outcomes, and causes of abscess in the inguinal/groin area requiring surgical intervention. The cases of 33 patients, including 30 patients in 27 reports in the literature and 3 patients in the Chang Gung Memorial Hospital at Chia-Yi, were reviewed to determine the ages, positions, gender, hypothesized causes, diagnostic modalities, and clinical outcomes of abscesses in the inguinal/groin area. Clinical data, laboratory examination findings, and culture results were analyzed.

RESULTS

Inguinal abscesses presented as tender inguinal masses that could extend from gastrointestinal, genitourinary, or retroperitoneal sites as well as being of miscellaneous origin. Most patients with such abscesses presented with fever and leukocytosis. Computed tomography provided a sensitive means for establishing the correct diagnosis and surgical plan of treatment for inguinal sbscesses. Gram-positive pathogens were associated with infections involving hip or thigh muscles and gram-negative pathogens were associated with infections involving the gastrointestinal (GI) and genitourinary (GU) tracts as well as with abscesses of the psoas muscle, Discussion: The inguinal region communicates through several routes with the peritoneal and retroperitoneal spaces as well as with the region of the thigh. The lymphatics drain from the external genitalia, inferior anal canal or perianal region, adjoining abdominal wall, and the lower extremities. Evaluation of a patient with inguinal abscess and with signs of infection should include computed tomography (CT) to elucidate the extent of infectious disease. Information obtained from CT is important in guiding the prescription of antibiotics and surgical planning for the treatment of inguinal abscesses.

CONCLUSIONS

Computed tomography is helpful in diagnosing inguinal abscess and determining the extent of infection. In patients presenting with inguinal abscess. Early recognition of its origin can facilitate further surgical planning and possibly improve the outcome.

Retroperitoneal and cutaneous necrotizing fasciitis secondary to necrotizing pancreatitis

BACKGROUND

Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10-25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess.

CASE REPORT

We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course.

The role of cross sectional imaging in the management of acute pyogenic inguinal abscess - extrapelvic versus intrapelvic origin

Background

Abscesses involving the inguinal region as manifestations of complex soft-tissue infections are rare, and the infectious route is usually unclear. The purpose of this study was to ascertain the importance of imaging study and whether the clinical presentations differ between the extrapelvic and intrapelvic origin.

Methods

Patients who presented with inguinal abscess between January 2003 and December 2010 were evaluated retrospectively. All patients received broad-spectrum antibiotic therapy and debridement. Imaging studies, including computed tomography or magnetic resonance imaging, were performed in all patients to elucidate the origin and extent of infectious disease, and the results were reviewed. Clinical data, laboratory examination findings, and culture results were analyzed.

Results

Twenty-eight patients were enrolled in the study: 13 patients whose infections were of extrapelvic origin (Group 1) and 15 patients of intrapelvic origin (Group 2). Imaging studies yielded information that helped guiding the treatment. Gram-positive coccus infection was more frequent in Group 1 (p < 0.001), while mixed pathogen and anaerobic bacterial infection were more frequent in Group 2 (p = 0.002 and p = 0.006, respectively). Group 2 had a higher incidence of history of malignancy and chronic renal failure (p = 0.044 and p = 0.038, respectively).

Conclusions

Computed tomography and magnetic resonance imaging are helpful in diagnosing cases of inguinal abscess and determining the extent of infection. In patients presenting with acute pyogenic inguinal abscess, a higher prevalence of chronic renal failure and history of malignancy were found in those with an intrapelvic, as compared with an extrapelvic, origin of infection.

Lower-extremity soft tissue infections with intra-abdominal sources

This article describes a series of 3 patients who presented with lower-extremity soft tissue infections. Each patient was treated with prompt debridement by an orthopedic surgeon (J.F.G.) and required at least 1 additional procedure by another surgeon.These infections vary from superficial cellulitis to rapidly advancing necrotizing fasciitis. At times, the source of these infections is clear. Other times, no obvious source of infection exists, in which case the abdomen must be considered as a possible source of infection. A high level of suspicion, complete history and physical examination, and appropriate ancillary studies are required to make an accurate and prompt diagnosis. Options for the treatment of the intra-abdominal source of infection depend on the etiology of the infection and anatomic location of the process. Psoas abscesses can often be decompressed by an interventional radiologist using computed tomography guidance. In the case of bowel involvement, such as suspected carcinoma or diverticulitis, a general surgeon is necessary. When the appropriate diagnosis is made, soft tissue infections of the thigh often respond to appropriate surgical debridement and antibiotic therapy. It is important to remember the whole patient when evaluating soft tissue infections, especially in the thigh. A low threshold for imaging of the abdomen and pelvis is important, especially when the physical examination or medical history reveals the abdomen as a possible source of infection.

Streptococcus mutans: a rare cause of retroperitoneal abscess

Retroperitoneal abscesses are uncommonly encountered clinical entities and they represent serious surgical infections associated with significant mortality rates because of their insidious clinical manifestations and diagnostic difficulty. The source of retroperitoneal infections is usually an organ contained within or abutting the retroperitoneum, usually the kidney and the microorganisms most commonly isolated are gram-negative bacilli. Gram-positive cocci, mainly staphylococcal species and rarely streptococcal species, are a less common cause of retroperitoneal abscess and are usually isolated in cases of hematogenous spread. Treatment of retroperitoneal abscesses includes identification and treatment of underlying conditions, intravenous antibiotics and adequate surgical drainage of all well-defined collections. We present a rare case of retroperitoneal abscess caused by monomicrobial Streprococcus mutans infection and discuss the possible pathogenesis, clinical presentation, diagnosis and treatment.

Emphysematous pyelonephritis presenting as necrotizing fasciitis of the leg

We report a 50-year-old man with poorly controlled diabetes mellitus who presented with a painful, swollen right leg. He had also experienced right flank pain for 1 week prior to admission. Physical examination was notable for tenderness over the right flank. The right leg was diffusely swollen and exquisitely tender to touch, with palpable crepitance. Laboratory tests revealed leukocytosis and pyuria. Computed tomography showed a right ureteral stone with hydronephrosis and characteristic findings of emphysematous pyelonephritis. Furthermore, a right perirenal gas-forming abscess with extension to the right leg was noted. The patient was successfully treated with antibiotic therapy, aggressive control of blood sugar, percutaneous drainage of the hydronephrosis and perirenal abscess, and aggressive debridement of the leg.