Perforated colonic diverticulum presenting as necrotizing fasciitis of the thigh

Necrotizing fasciitis from perforated sigmoid diverticulitis with subsequent pyoderma gangrenosum: a case report

Postsurgical pyoderma gangrenosum is a very rare form of cutaneous ulceration that is poorly recognized outside of dermatology and in some circumstances has been mistaken for necrotizing fasciitis. Here, we present a rare case of sigmoid diverticulitis with left ureter obstruction that perforated and quickly progressed into necrotizing fasciitis of the left buttock and leg via retroperitoneal spread in an immunocompetent patient. Nearly a year after intense surgical therapy, the patient rapidly developed ulcerating lesions over the left hip which presented a diagnostic dilemma. These were initially thought to represent Marjolin’s ulcers, which would require aggressive local excision. Multiple diagnostic imaging tests and biopsies eventually confirmed pyoderma gangrenosum, which was successfully treated with immunosuppressive therapy. This case highlights the need for a very broad differential diagnosis and wide expertise consultation when managing unusual postsurgical complications, especially when treatment modality critically depends on the correct diagnosis.

Left lower limb fasciitis due to sigmoid colonic perforated diverticulitis: a rare case of colocutaneous fistula

Up to 25% of patients with acute diverticulitis develop complicated disease. Colocutaneous fistula with lower limb fasciitis secondary to complicated diverticulitis is a rare event. A 71-year-old woman with Class 3 obesity and Type 2 diabetes was admitted to the hospital because of left lower limb fasciitis associated with acute sigmoid diverticulitis complicated by covered perforation. The fasciitis was treated with multiple fasciotomies, antibiotics and hyperbaric oxygen therapy. The patient was readmitted 25 days after discharge because of the formation of a left leg colocutaneous fistula associated with an enterocolic fistula. Patient underwent sigmoid resection with primary anastomosis and ileal loop repair. Three-month follow-up showed fistula healing and absence of symptoms. Fasciitis secondary to acute diverticulitis is a rare clinical scenario. Although our therapeutic strategy was successful, the optimal treatment timing and surgical technique for fasciotomy and colon resection remain to be assessed.

Necrotizing fasciitis of the lower extremity caused by perforated sigmoid diverticulitis-a case report

Diverticulosis of the sigmoid colon is a common condition and occurs more often in elderly patients. A well-known complication is infection or even perforation which often requires surgery. Necrotizing fasciitis as a complication of perforated diverticulitis is very rare. Here, we present a case of a covered perforated diverticulitis in an immunosuppressed patient leading to life-threatening necrotizing fasciitis requiring extracorporeal membrane oxygenation. Either hematogenous or local dissemination via the inguinal canal seemed the most probable mechanism of leg infection leading to hip articulation.

[Complicated diverticular disease debuting as necrotising fasciitis of pelvic limb. A case report]

BACKGROUND

Diverticular disease, and the diverticulitis, the main complication of it, are widely studied diseases with multiple chronic cases reported in the literature, but there are no atypical presentations with extra-abdominal symptoms coupled with seemingly unrelated entities, such as necrotising fasciitis.

CLINICAL CASE

Female 52 years old, was admitted to the emergency department with back pain of 22 days duration. History of importance: Chronic use of benzodiazepines intramuscularly. Physical examination revealed the presence of a gluteal abscess in right pelvic limb with discoloration, as well as peri-lesional cellulitis and crepitus that stretches across the back of the limb. Fasciotomy was performed with debridement of necrotic tissue. Progression was torpid with crackling in abdomen. Computed tomography showed free air in the cavity, and on being surgically explored was found to be complicated diverticular disease.

DISCUSSION

It is unusual for complicated diverticular disease to present with symptoms extra-peritoneal (< 2%) and even more so that a diverticulitis is due to necrotising fasciitis (< 1%). The absence of peritoneal manifestations delayed the timely diagnosis, which was evident with the crackling of the abdomen and abdominal computed tomography scan showing the parietal gaseous process.

CONCLUSION

All necrotising fasciitis needs an abdominal computed tomography scan to look for abdominal diseases (in this case diverticulitis), as their overlapping presentation delays the diagnosis and consequently the treatment, making a fatal outcome inevitable.

Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death

Background

Subcutaneous emphysema is an uncommon clinical finding associated both with benign sources and potentially deadly necrotizing infections. Wide ranges of causes exist including trauma, iatrogenic injuries, factitious disorders and necrotizing infections.

Case presentation

A 49-year old male presented to the emergency room with extensive subcutaneous emphysema following blunt trauma. The orthopaedic surgery service was consulted for treatment of suspected necrotizing fasciitis due to his subcutaneous emphysema. A careful patient history and physical examination correlated with laboratory and radiographic findings revealed rib fractures and a long-standing, undiagnosed pneumothorax as the cause for emphysema. Treatment of the underlying condition with chest tubes led to eventual resolution of the emphysema, though multisystem organ failure ultimately resulted in patient death.

Conclusion

This case illustrates the importance of rapidly and appropriately evaluating trauma patients, and in this case specifically diagnosing and treating the underlying cause of subcutaneous emphysema. The late diagnosis of pneumothorax resulted in delayed definitive treatment, which may have contributed to the patient’s ultimate demise. In acute and sub-acute trauma situations a high level of suspicion for life threatening injuries must be maintained. Decision making for initial treatment should be based on the basic tenants of Advanced Trauma Life Support to primarily address these injuries and help prevent further disability or death.

Case report: Bowel perforation presenting as subcutaneous emphysema of the thigh

Necrotizing fasciitis is recognized as a surgical emergency. Early detection and aggressive surgical débridement are crucial to reduce patient mortality and morbidity. There are, however, other causes of subcutaneous emphysema. We present the case of a 64 year-old patient with a history of postsurgical radiation for rectal carcinoma with subcutaneous emphysema of the thigh in the presence of urinary sepsis. Surgical exploration revealed the source of the emphysema to be an enterocutaneous fistula. The patient had an unstable and prolonged hospitalization after débridements of the thigh and abdominal surgery and was readmitted for recurrence of thigh drainage, but eventually was discharged; nine months after the initial diagnosis all wounds had healed and he was walking with a walker. Despite an otherwise benign clinical appearance, the radiographic finding of subcutaneous emphysema in the absence of penetrating trauma must be considered a case of a necrotizing soft tissue infection until proven otherwise.