Fasciitis and septic shock complicating retrocecal appendicitis

Spontaneous Necrotizing Fasciitis

Necrotizing soft tissue infections typically begin with direct inoculation of bacteria into the subcutaneous tissues. Here, we present a case with no such exposure, but with severe necrotizing fasciitis. We present a middle-aged man presented to the emergency department for a presumed allergic reaction after having initially sought care twice at an urgent care facility. The patient had swelling, but no tenderness of his right lateral chest and flank. Subsequent imaging showed extensive fluid in the fascial planes of the right chest wall requiring surgical debridement. Necrotizing fasciitis that is not treated with surgical debridement carries a mortality rate approaching 100%. This case highlights a potential atypical presentation as well as highlights the fact that the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score lacks sensitivity to rule out a necrotizing soft tissue infection, requiring surgical debridement for diagnosis.

Necrotizing soft tissue infection following a peripheral bypass

BACKGROUND

Necrotizing soft tissue infection (NSTI), formerly referred to as necrotizing fasciitis, is a rare but serious postoperative complication. NSTI following arterial bypass is seen only once in the literature (for a coronary artery bypass) and is not mentioned following peripheral bypass. Although surgical site infections have been studied extensively, there are limited published data on postoperative NSTI and no data for NSTI following peripheral arterial bypass.

CASE PRESENTATION

Here we present the first, to our knowledge, reported instance of an NSTI following a lower extremity peripheral bypass. Despite the continued function of the bypass, the patient became rapidly systemically ill with a focus at the surgical site. Because of prompt surgical debridement, the patient survived this severe infection, though did require an above the knee amputation to control the rapid spread of the disease. The patient, a native of American Samoa, was infected with organisms infrequently associated with NSTI, Morganella morganii and Aeromonas hydrophila. This article discusses the diagnosis and treatment of this rare postoperative complication, along with a brief review of the microbiology of the disease.

CONCLUSIONS

NSTI is a rare but lethal postoperative complication. To our knowledge, this is the first reported case of an NSTI following an arterial peripheral bypass. This patient survived because of prompt and aggressive intervention.