Necrotising fasciitis secondary to perforated rectal adenocarcinoma presenting as a thigh swelling

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.

Necrotising Myofasciitis of the Lower Limb Secondary to Extra-Peritoneal Rectal Perforation

Necrotising fasciitis (NF) is a severe and life-threatening soft tissue infection that often requires extensive debridement and reconstruction. Isolated extra-peritoneal rectal perforations due to trauma, cancer, inflammatory bowel pathology or iatrogenically induced can rarely cause necrotising fasciitis beyond the perineum. Given its rarity, there is a high threshold of suspicion which often leads to late recognition and poor outcome.

We present a case of necrotising myofasciitis of the right lower limb following occult rectal perforation sustained during elective flexible sigmoidoscopy, and augment this case report with a literature review to guide diagnostics, intervention, and recovery. Therefore, the aim of this work was to review, compile, analyse, and present clinical details to identify masquerading presentations and determine the optimal treatment regimen. A search of PubMed, Scopus, Ovid, MEDLINE, EMBASE, CINAHL Plus, AMED, Web of Science (Science Citation Index), and Google Scholar was supplemented by hand searching. Data extracted included demographics, patient management, and outcome.

Of 104 citations identified by a systematic literature search, eight case reports of eight subjects with necrotising fasciitis of the lower limb secondary to rectal perforation met the criteria for analysis. The most common treatment modality was surgical debridement in all cases and bilateral above knee amputation in one case, disarticulation of the lower limb was the treatment in this case we report. Furthermore, faecal diversion by the formation of de-functioning colostomy was performed in the same setting for four (50%) of the patients and appeared to increase survival. Overall 45 days mean (S.E.) disease-specific survival was found to be 32.8 (7.0) days. There is an insufficient number of cases reported to date to confer a significant survival advantage between having a defunctioning colostomy in the same setting as the debridement as opposed to having it at a later setting or not having it at all (Mantel-Cox p=0.1).

In summary, a review of all the cases in the literature suggests that NF of lower limbs can be an atypical presentation of rectal cancer, pathology, and/or trauma. We report a case of unilateral lower limb NF secondary to rectal perforation in a non-cancer patient, likely due to flexible sigmoidoscopy. Due to the small number of patients, it is inherently difficult to draw firm conclusions however multi-modality management appears to be more effective, with meticulous debridement, defunctioning of the bowel and downstaging radiotherapy if required. We recommend a UK-wide, national database/registry for NF that will help gather data and formulate more standardised management guidelines.

Not your usual hip pain: necrotising fasciitis secondary to sigmoid perforation

Necrotising fasciitis (NF) resulting from sigmoid perforation is rare, but none the less remains life threatening. Early surgical intervention and empiric broad-spectrum antibiotic remains the standard of care. A 65-year-old man with history of stage 4 rectal cancer presented with bilateral hip pain. An X-ray of the hip and pelvis to rule out fracture revealed abnormal gas pattern overlying the right hip. CT imaging revealed distal sigmoid perforation with air extending from the pelvis to posterior aspect of the right hip and thigh. Aggressive surgical intervention and antibiotic initiation was associated with successful outcomes in our patient. Although less common, sigmoid perforation leading to NF in posterior thigh is a reminder of a potentially lethal complication.

Thigh emphysema as the initial presentation of colon ischemia

The incidence of colon ischemia has increased in recent years, and is associated with high morbidity and mortality. The typical presentations of colon ischemia include abdominal pain, bloody diarrhea, and in severe case, ileus, fever and peritonitis. Here, we document a rare case of colon ischemia presenting with subcutaneous and intramuscular emphysema of the thigh. A 76-year-old woman presented to the emergency department for left thigh pain for three days. Physical examination revealed tenderness without obvious crepitus, erythema or swelling over the left groin area and a soft abdomen without tenderness. Plain abdominal film showed abnormal gas formation at the left thigh and chest film demonstrated subphrenic free air. Abdominal computer tomography found sigmoid perforation causing left retroperitoneal abscess, and subcutaneous and intramuscular emphysema over the left pelvic and thigh region. During operation, irreversible ischemia from the terminal ileum through the cecum to the sigmoid colon with gangrene and retroperitoneal abscess were found. Total colectomy with end ileostomy and peritoneal toilet were performed. However, massive bloody ascites from abdominal drainage developed on the 13th day of admission. She later passed away due to hemorrhagic shock. In conclusion, emphysema of the thigh may rarely be caused by an intestinal lesion, such as colon ischemia. Clinicians should be alert of these unusual presentations to find the hidden underlying etiologies.

Necrotising fasciitis caused by metastatic endometrial cancer: a rare cause of a life-threatening condition

We report a case of necrotising fasciitis caused by metastatic endometrial adenocarcinoma. Metastases to the lumbar spine with local invasion to the iliopsoas muscle led to an iliopsoas abscess, which subsequently progressed to necrotising fasciitis of the flank. This patient lacked common risk factors for necrotising fasciitis. There are no previous reports in the literature of necrotising fasciitis with this aetiology. We discuss the available evidence for aetiology of and risk factors for necrotising fasciitis, and the relation of time to surgery with prognosis.