Bowel Perforation Resulting in Necrotizing Soft-Tissue Infection of the Abdomen, Flank, and Lower Extremities

Lower extremity necrotizing fasciitis with iliopsoas abscess secondary to perforated colon cancer: a diagnosis not to miss

Necrotizing fasciitis (NF) is a life-threatening soft tissue infection, typically caused by preexisting conditions such as trauma, complicated intraabdominal infections, or even small wounds. However, it is very rare for NF to occur as a result of perforated colon cancer (CC). Diagnosis primarily relies on clinical findings, imaging, and laboratory tests. Early diagnosis and treatment are crucial for patient survival. In this study, we present a case of an 82-year-old female a known case of CC diagnosed 1 month ago. She presented with hip pain persisting for 10 days duration, along with skin changes over the proximal anterolateral aspect of the thigh. The patient was diagnosed with NF associated with an iliopsoas abscess caused by perforated CC that was managed with surgical debridement, left hemicolectomy, and end colostomy along with broad-spectrum antibiotics.

Necrotising fasciitis secondary to a perforated hepatic flexure tumour - A case report

INTRODUCTION AND IMPORTANCE

Necrotising fasciitis caused by a perforated colon cancer is a very rare occurrence and can be very life threatening needing urgent intervention involving tissue salvage and oncological treatment. There is not enough evidence in the literature regarding management of the same. This case report highlights one such case along with management principles.

PRESENTING CASE

We present a 66 year old male with 3 weeks of a progressive right lower quadrant lump and constitutional symptoms. He had a computed tomography scan demonstrating a complex collection in the right anterior abdominal wall, containing multiple locules of gas and air fluid levels near an abnormally thickened hepatic flexure. He was taken for an urgent debridement followed by laparotomy which demonstrated extensive abdominal wall necrotising fasciitis secondary to a perforated hepatic flexure tumour invading into the duodenum. He was given a diverting ileostomy. He had a relook laparotomy the next day for a right hemicolectomy and part of the duodenum resected with a refashioned end ileostomy. He was subsequently managed on the ward for two weeks and then discharged home. He remains well and has been referred to medical oncology for adjuvant chemotherapy.

CLINICAL DISCUSSION

A two step surgical approach was key in this case, first step for source control and the second step focused on an oncological resection.

CONCLUSION

This case explains the importance of excluding malignant causes of necrotising fasciitis. Perforated cancers can manifest as necrotising fasciitis and management should include timely debridement as well as oncological principles.

Prognostic value of free air under diaphragm on chest radiographs in correlation with peritoneal soiling intraoperatively

PURPOSE

Gastrointestinal perforation is a significant injury that originates mainly from gastrointestinal ulcers. It is associated with a high rate of morbidity and mortality. The height of the column of the air under the diaphragm can be used to estimate the amount of peritoneal soiling due to viscus perforation. This study aimed to determine the correlation between this estimate and the incidence of morbidity and mortality.

METHODS

To achieve this aim, a prospective cohort study was conducted on 83 patients at Kasr al ainy hospital who, between March 2021 and March 2022, presented to the emergency department with free air under the diaphragm at chest X-ray and required surgical intervention for a perforated viscus. For each case, the amount of peritoneal soiling and the amount of air under the diaphragm as determined by a chest X-ray were recorded.

RESULTS

The mean air under the diaphragm in a plain erect chest X-ray was 1.78 ± 1.92 cm, and the mean amount of peritoneal soiling was 1201.83 ± 948.99 CC. There are positive correlations between the amount of air under the diaphragm as shown on an X-ray and the size of the perforation (p = 0.034), the amount of peritoneal soiling (p = 0.003), and the mortality (p = 0.013).

CONCLUSION

There was a statistically significant correlation between air under the diaphragm according to X-ray and the amount of peritoneal soiling in patients with a perforated viscus. This measure can be used as a sensitive tool to predict morbidity and mortality as more free air in the chest X-ray is associated with significant mortality. These results may enhance the decision making using sensitive and available tool of diagnosis.

An Unusual Case of Gas Gangrene in Intravenous Heroin Addict

BACKGROUND: Gas gangrene is a clostridium infection primarily of muscle tissue, most commonly caused by C. perfringens. Clinical diagnosis is usually made by local inspection of the wound: the infected tissue shows characteristic signs of tissue inflammation with blistered changes. The disease can starts suddenly, 4-6 hours after the injury, but most commonly the incubation period lasts 2-4 days. Without proper medical intervention, death occurs in 4-24 hours after the development of the first symptoms, but even with timely and adequate therapy, the lethality is very high (around 12%). Due to its fulminant course, in all cases with fatal outcomes, a forensic autopsy is an obligatory procedure. However, discovering the entrance gate and source of infection is not an easy task, especially in the absence of a traumatic injury. CASE PRESENTATION: Male, 27 years old, an intravenous heroin addict for about 10 years, injured his left leg in a traffic accident. He only visited the doctor after 5 days. Upon examination, it was determined that there were no externally visible injuries and no fracture, and he was given a splint immobilization for an ankle luxation. Twelve days after the accident (or 7 days after the immobilization) his mother found him unconscious. CONCLUSION: From medicolegal aspects, it’s important to have in mind even the less frequent paths of infection, in order to give an expert professional opinion on origin and cause of death.

Unusual presentation of appendicitis as soft tissue infection of the thigh

Appendicitis remains one of the most common causes of abdominal pain across the world typically presenting with right iliac fossa pain, fever and nausea or vomiting. We describe an unusual case of appendicitis presenting as a soft tissue infection of the thigh, thereby causing a delayed diagnosis from presentation. We discuss the pathophysiological process behind soft tissue infections caused by appendicitis and highlight investigation and management strategies to ensure prompt treatment to reduce patient mortality.

An atypical case of necrotizing fasciitis secondary to perforated cecal cancer

Necrotizing fasciitis is an aggressive, life threatening soft tissue infection that requires high index of suspicion for diagnosis. Diagnosis is clinical with management including broad spectrum antibiotics and emergent operative debridement. The majority of cases are secondary to underlying medical processes, local tissue damage, abscess, or inciting procedure, with a paucity of data correlating causation with colon cancer. We describe the case of an 84-year-old man presenting with sepsis of unknown origin who was diagnosed with an atypical presentation of necrotizing fasciitis secondary to a perforated cecal malignancy. His case is unique in that a less virulent polymicrobial infection was likely involved as he initially improved with conservative management alone. He ultimately declined and expired secondary to overwhelming sepsis from his infection. This case highlights the importance of maintaining a high index of suspicion for necrotizing infection and considerations for alternative etiologies of infection including perforated malignancies.