Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report

A rare case of necrotizing fasciitis secondary to a perforated appendix

Introduction and importance

Acute appendicitis is a common emergency, but its variable presentation can delay diagnosis and treatment, leading to severe complications. Necrotizing fasciitis, although rare, can arise as a life-threatening consequence of perforated appendicitis. Prompt recognition and intervention are crucial to prevent fatal outcomes.

Case summary

A 23-year-old male presented with right iliac fossa pain and vomiting. Physical examination revealed tenderness and rebound tenderness in the right iliac fossa, with an Alvarado score of 7/10 and leukocytosis, suggestive of acute appendicitis. Emergency laparotomy revealed a perforated appendix with purulent fluid, which was drained, and abdomen was irrigated. Postoperatively, the patient initially stabilized but deteriorated on the second postoperative day. A CT scan revealed multiple abscesses and necrotizing fasciitis of the abdominal wall. Re-exploration with abscess drainage and debridement was performed, but the patient developed septic shock and multiple organ failure, leading to his death.

Discussion

This case underscores the potential for severe complications like necrotizing fasciitis following perforated appendicitis, even in previously healthy individuals. Delays in diagnosis and imaging, as well as reliance solely on clinical judgment, can contribute to adverse outcomes. Early recognition of necrotizing fasciitis and aggressive management, including broad-spectrum antibiotics and surgical debridement, are essential to improve survival in such cases.

Conclusion

Delayed diagnosis and management of acute appendicitis can result in rare but fatal complications such as necrotizing fasciitis. This case emphasizes the importance of timely intervention, imaging, and a high index of suspicion to mitigate mortality in these uncommon but severe presentations.

Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report

Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.

A Rare Complication of Perforated Appendicitis: A Case of Necrotizing Fasciitis

Acute appendicitis is considered one of the most common surgical emergencies with low morbidity and mortality. However, delay in the diagnosis may lead to perforation of the appendix. Hence, complications may arise, including necrotizing fasciitis, a rare complication of a perforated appendix. We present a case of perforated appendicitis complicated by necrotizing fasciitis leading to rapid deterioration.

A 75-year-old male patient presented to our emergency room with a three-day history of right lower quadrant abdominal pain and abdominal distention. On admission, computed tomography (CT) scan showed a perforated appendix and peri-appendicular abscess. An exploratory laparotomy was performed. The appendix was resected and the wound closed. The patient was recovering well and tolerating food after the procedure. However, the patient developed progressive erythema/swelling over the right flank with new-onset leukocytosis. The diagnosis of necrotizing fasciitis was suspected and confirmed by careful evaluation and laboratory/radiological tests. Antibiotics were changed to clindamycin and piperacillin/tazobactam, and the patient was taken back to the operation room (OR) for surgical debridement. Postoperatively, the patient was shifted to the intensive care unit (ICU). He developed hearing impairment, which improved after the cessation of clindamycin. He was discharged in good condition after three weeks of hospital stay.

This case report highlights the importance of maintaining a high index of suspicion for necrotizing soft tissue infection in immunocompromised patients with perforated appendicitis and being cautious when prescribing clindamycin to patients at risk of hearing loss.

Nonoperative management of appendicitis in children

Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.