Necrotizing fasciitis of the thigh should raise suspicion of a rectal cancer

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.

Necrotizing fasciitis of the lower extremity secondary to a perforated rectosigmoid tumor

Necrotizing fasciitis (NF), which is a rare but life-threatening soft tissue infection, can present as a complication of colorectal diseases. The development of NF of the lower extremity secondary to a perforated colorectal tumor has been reported in only a few patients. We present a case of a 68-year-old woman, in which necrotizing soft tissue infection of the left lower extremity was the presenting feature of a perforated rectosigmoid tumor. On examination, there was a tender swelling and edema with palpable crepitus in the left inguinal region and thigh. Computed tomography showed gas within the retroperitoneal tissues, with subcutaneous edema and emphysema extending from the thigh to the ankle. NF was diagnosed, and the patient underwent Hartmann's procedure and fasciotomy with an aggressive debridement of the left thigh and inguinal region. In the case of NF of the lower extremity or abdominal wall without an obvious cutaneous source, an intraabdominal cause should be considered and sought.

Stage IV colorectal cancer presenting after necrotizing soft tissue infection

Necrotizing soft tissue infections (NSTIs) are highly aggressive and may be lethal if untreated. Polymicrobial infections of the groin and lower limb have been documented secondary to invasive colorectal cancer (CRC). We present a case of CRC diagnosed more than 4 years after the development of NSTI. There are documented cases of NSTIs concomitant with a preexisting CRC. In this case, however, the patient's initial presentation was an NSTI followed by later diagnosis of CRC. A previously treated NSTI that is not healing appropriately may be an early indicator for CRC.

Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: A case report

Necrotising fasciitis, widespread necrosis of the skin, subcutaneous tissue, and superficial fascia, may be caused by many factors, among which underlying malignancy is observed rarely. We report a case with necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion. A 62-year-old male with newly diagnosed renal cell carcinoma was diagnosed with necrotising fasciitis at the end of 2 days in hospital. One day after debridement surgery, biliary contamination of dressings and tomography demonstrated fistulation from the duodenum to retroperitoneum and then to the right thigh because of renal tumour invasion. The second operation was performed to repair the duodenum. Intravenous antibiotics and hydration were maintained postoperatively. Although there was no surgical complication, the patient died because of respiratory collapse at the 12th day postoperatively. Renal cell carcinoma may invade the duodenum and, with retroperitoneal fistulation, may be the cause of necrotising fasciitis of the thigh. Laparotomy may be needed to control the origin of infection. However, necrotising fasciitis may be fatal in spite of aggressive treatment. The fasciitis should be diagnosed early to initiate timely aggressive treatment, and a possible endogenous source should be kept in mind.

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.

Locally advanced adenocarcinoma of the rectum presenting with necrotising fasciitis of the perineum: successful management with early aggressive surgery and multimodal therapy

Colorectal cancer is a common malignant neoplasm and its treatment usually involves surgery associated, in some cases, depending on the staging, with chemoradiotherapy. Necrotising fasciitis of the perineum is a highly lethal infection of the perineum, perirectal tissues and genitals, requiring emergency surgical debridement, broad-spectrum antibiotics and control of sepsis. We present the case of a 59-year-old man with necrotising fasciitis of the perineum as the first clinical manifestation of locally advanced adenocarcinoma of the rectum, in which successful management consisted of early and aggressive surgical debridement, followed by multimodal therapy with curative intent. 2 years and 6 months after surgery the patient is well, with no evidence of local or systemic relapse.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

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

A 62-year-old man was admitted to the medical admissions ward with right thigh pain presumed to be a deep vein thrombosis (DVT). Subsequent duplex ultrasonography excluded a DVT but noted the presence of a significant amount of subcutaneous gas. A plain film radiograph was performed with the same finding raising the possibility of necrotising fasciitis (NF). Only at this point was digital rectal examination performed revealing a large rectal mass oozing pus and blood. CT imaging showed thickening of the rectum consistent with a tumour with gas and fluid in the perirectal space extending to the anterolateral right femur. Despite aggressive debridement and treatment, the patient deteriorated and died 6 weeks later. This case should serve as a reminder to consider digital rectal examination and the occurrence of a rectal perforation in all patients who present with suspicious thigh swellings.

Necrotising fasciitis of the thigh

Necrotising fasciitis (NF) is an extremely virulent form of infectious fasciitis. It affects skin, subcutaneous fat and superficial and deep muscular fascia by rapidly progressive necrosis. Expeditious diagnosis and radical debridement is necessary to prevent the onset of sepsis, multisystem organ failure and possible death. Perforated rectal cancer resulting in NF can spread to the perineum and genitals known as Fournier gangrene. This case describes an unusual case of NF of the right thigh as first presentation highly suggestive for rectal cancer.

Necrotising fasciitis of the thigh secondary to colonic perforation: the femoral canal as a route for infective spread

A 57 year-old man with a history of corticosteroid use presented with abdominal pain and diarrhoea. He was initially treated for presumed Clostridium difficile colitis, but later developed a left inguinal mass with spreading erythema. A CT scan showed gas within the retroperitoneal tissues, with surgical emphysema of the left groin. Necrotising fasciitis was diagnosed, and the patient underwent extensive debridement of the left thigh and inguinal region. The femoral vein was covered in infected fascia in the femoral canal, and a laparotomy revealed a posterior perforation of the sigmoid colon. Necrotising fasciitis of the thigh is a rare complication of colonic perforation. Our case highlights the femoral canal as a potential channel for the spread of intra-abdominal infection into the thigh.

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.