Multi-limb necrotizing fasciitis in a patient with rectal cancer

Fournier gangrene with concurrent multifocal necrotizing fasciitis: a systematic review and case report

PURPOSE

A patient presented to a regional surgical center with Fournier gangrene (FG) and concurrent multifocal necrotizing fasciitis (NF). Given the rarity, it was decided to undertake a systematic review to investigate the incidence and prevalence of FG with multifocal NF and consequently determine the treatment and approach to management of such presentation.

METHODS

Firstly, the report of the 56-year-old male patient is discussed regarding his surgical management. Secondly, a systematic review was undertaken according to PRISMA guidelines using MEDLINE, Scopus, and Embase databases. Searches used the following MeSH terms: ("fournier's gangrene") AND ((necrotising fasciitis) OR (necrotising soft tissue infection)). Once the search results were obtained, duplicate articles were removed. Titles, abstracts, and articles were reviewed by 2 authors.

RESULTS

The search strategy using the 3 databases revealed a total of 402 studies. Fifty-seven studies were removed due to duplication. A total of 345 records were screened via title and abstract, of which 115 were excluded. Two hundred and thirty studies were reviewed for eligibility. A total of all 230 studies were excluded; 169 were excluded as they included the incorrect patient population (patients suffered from FG or NF, but not both collectively), 60 studies were excluded due to incorrect study designs, and 1 report occurred in the wrong setting.

CONCLUSION

This highlights that while being a relatively known, uncommon infection both FG and NF are well documented separately within the literature. However, FG with concurrent multifocal NF has not been documented within the literature.

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.

An atypical case of necrotizing fasciitis secondary to perforated cecal cancer

Necrotizing fasciitis is an aggressive, life threatening soft tissue infection that requires high index of suspicion for diagnosis. Diagnosis is clinical with management including broad spectrum antibiotics and emergent operative debridement. The majority of cases are secondary to underlying medical processes, local tissue damage, abscess, or inciting procedure, with a paucity of data correlating causation with colon cancer. We describe the case of an 84-year-old man presenting with sepsis of unknown origin who was diagnosed with an atypical presentation of necrotizing fasciitis secondary to a perforated cecal malignancy. His case is unique in that a less virulent polymicrobial infection was likely involved as he initially improved with conservative management alone. He ultimately declined and expired secondary to overwhelming sepsis from his infection. This case highlights the importance of maintaining a high index of suspicion for necrotizing infection and considerations for alternative etiologies of infection including perforated malignancies.

Risk factors of synchronous multifocal necrotizing fasciitis: a case control study in comparison with monofocal necrotizing fasciitis in Taiwan

Background

Monofocal necrotizing fasciitis (MONF) involves a single site in a rapidly progressing infection and necrosis of the fascia and surrounding soft tissue. Synchronous multifocal necrotizing fasciitis (SMNF), the simultaneous development of NF in multiple noncontiguous sites, is rarely reported. This study aimed to compare the clinical characteristics and outcomes between patients with SMNF and MONF, and to determine the risk factors of SMNF.

Methods

Our retrospective case-control study compared the clinical characteristics and outcomes, between January 2006 and January 2013, of patients with SMNF and of patients with MONF of the extremities.

Results

We enrolled 144 patients with NF of the extremities: 19 with SMNF and 125 with MONF. The duration of symptoms before admission was significantly shorter for the former than for the latter (1.7 days vs. 3.3 days, p = 0.001); the prevalence of shock at the initial visit significantly higher (73.7% vs. 36%, p = 0.002); and the total-case postoperative mortality rate significantly higher (68.4% vs. 14.4%, p <  0.001). In further analysis of the total-case mortality, 9 in 13 SMNF deaths (69.2%) within 7 days after fasciotomy were in the majority while 13 with 28-day mortality (72.2%) was the majority of MONF deaths (p <  0.001). SMNF was significantly more likely to involve bacteremia (89.5% vs. 36%, p <  0.001). Independent risk factors for SMNF were liver cirrhosis (LC) (odds ratio [OR] 6.0, p = 0.001) and end-stage renal disease (ESRD) (OR 7.1, p = 0.035). Gram-negative bacteria were most common in SMNF, and Gram-positive bacteria in MONF (83.3% vs. 53.3%, p = 0.005). Vibrio species were the most common single microbial cause (35.4%) of all NF patients and were the overwhelming cause (73.7%) of SMNF. Staphylococcus aureus and group A β-hemolytic streptococcus (45.6%) were the other predominant causes of MONF while both (10.5%) rarely caused multifocal NF.

Conclusions

SMNF was more fulminant than was MONF. SMNF was attributable primarily to marine Gram-negative bacteria. Physicians should be aware of SMNF because of its extremely high mortality rate.

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.

Necrotizing fasciitis of the thigh due to penetrated descending colon cancer: a case report

Background

Necrotizing fasciitis (NF) caused by colorectal cancer is rare, and very few cases associated with colon cancer have been reported. We describe the case of a patient with NF in the left thigh due to penetration of descending colon cancer who was treated with one-stage surgical resection without creating a stoma.

Case presentation

An 80-year-old woman was brought to our hospital complaining of fever and difficulty with body movement. A physical examination showed subcutaneous emphysema from the left lower abdomen to the left femoral region. CT showed abscess formation with emphysema around the descending colon, and the wall of the descending colon was thickened, which led to suspicion of colon cancer. The patient was subsequently diagnosed with NF due to penetration of descending colon cancer. Left hemicolectomy and open drainage of the left femoral region was performed. The histopathological findings were well-differentiated adenocarcinoma, with the tumor grown through the serosa (T4a) and with no metastasis to lymph nodes (N0). After surgery, the patient received intensive care for septic shock and lavage of the open drainage site, and sepsis was controlled progressively. After closure of the drainage site, the patient was transferred to a different hospital at 26 days after surgery, and she has had 6-month relapse-free survival.

Conclusions

In NF caused by colon cancer, early one-stage resection may improve the oncological outcome. Physical status should be assessed carefully, and one-stage resection should be considered if the patient has the capacity to undergo this procedure.

Negative pressure wound therapy: An update

PURPOSE

To get the maximum benefit of vacuum-assisted closure (VAC) in the management of acute and chronic wounds without abuse or misuse.

METHODS

Fourty one patients were included in the study. Among them, 9 patients had chronic wounds and the rest 32 patients had acute wounds. In acute wounds, 19 patients had co-morbid conditions. Seven patients had gaped wounds, 4 patients had necrotizing fasciitis and 2 patients had enterocutaneous fistula.

RESULTS

The hospitalization period varied from 1 to 6 weeks. The follow-up period was up to 6 months. No mortality was recorded during this study. All skin grafts showed complete healing. Necrotizing fasciitis was managed with good outcome. Wounds with enterocutaneous fistula have improved. In chronic wounds, good healing and excellent outcome were obtained.

CONCLUSION

The VAC therapy is an essential element for the management of problematic acute and chronic wounds.

Management and Novel Adjuncts of Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Cross-talk among flesh-eating Aeromonas hydrophila strains in mixed infection leading to necrotizing fasciitis

Necrotizing fasciitis (NF) caused by flesh-eating bacteria is associated with high case fatality. In an earlier study, we reported infection of an immunocompetent individual with multiple strains of Aeromonas hydrophila (NF1-NF4), the latter three constituted a clonal group whereas NF1 was phylogenetically distinct. To understand the complex interactions of these strains in NF pathophysiology, a mouse model was used, whereby either single or mixed A. hydrophila strains were injected intramuscularly. NF2, which harbors exotoxin A (exoA) gene, was highly virulent when injected alone, but its virulence was attenuated in the presence of NF1 (exoA-minus). NF1 alone, although not lethal to animals, became highly virulent when combined with NF2, its virulence augmented by cis-exoA expression when injected alone in mice. Based on metagenomics and microbiological analyses, it was found that, in mixed infection, NF1 selectively disseminated to mouse peripheral organs, whereas the other strains (NF2, NF3, and NF4) were confined to the injection site and eventually cleared. In vitro studies showed NF2 to be more effectively phagocytized and killed by macrophages than NF1. NF1 inhibited growth of NF2 on solid media, but ExoA of NF2 augmented virulence of NF1 and the presence of NF1 facilitated clearance of NF2 from animals either by enhanced priming of host immune system or direct killing via a contact-dependent mechanism.

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.

Necrotizing fasciitis of the thigh secondary to radiation colitis in a rectal cancer patient

Necrotizing fasciitis usually occurs after dermal injury or through hematogenous spread. To date, few cases have been reported as necrotizing fasciitis of the thigh secondary to rectal perforation in rectal cancer patients. A 66-year-old male complained of pelvic and thigh pain and subsequently developed necrotizing fasciitis in his right thigh. Four years earlier, he had undergone a low anterior resection and radiotherapy due to of rectal cancer. An ulcerative lesion had been observed around the anastomosis site during the colonoscopy that had been performed two months earlier. Pelvic computed tomography and sigmoidoscopy showed rectal perforation and presacral abscess extending to buttock and the right posterior thigh fascia. Thus, the necrotizing fasciitis was believed to have occurred because of ulcer perforation, one of the complications of chronic radiation colitis, at the anastomosis site. When a rectal-cancer patient complains of pelvic and thigh pain, the possibility of a rectal perforation should be considered.

Retroperitoneal metastatic adenocarcinoma complicated with necrotizing fasciitis of the thigh in a patient with advanced rectal colon cancer

BACKGROUND

Necrotizing fasciitis of the thigh due to colon cancer has not been previously reported, especially during radiotherapy.

CASE PRESENTATION

A 73-year-old woman admitted to our hospital was diagnosed with sigmoid colon cancer that had spread to the left psoas muscle; radiotherapy was performed. Three months after the initiation of radiotherapy, the patient developed gait disturbance, poor appetite and high fever and was therefore admitted to the emergency department of our hospital. Blood examination revealed generalized inflammation with a high white blood cell count and C-reactive protein level. Computed tomography of the abdomen revealed fluid and gas tracking from the retroperitoneum into the intramuscular plane of the grossly enlarged right thigh. Consequently, emergent debridement was not performed and conservative therapy was done. The patient died.

CONCLUSION

Necrotizing fasciitis of the thigh due to the spread of rectal colon cancer is unusual, but this fatal complication should be considered during radiotherapy in patients with unresectable colorectal cancer.

Retroperitoneal abscess complicated with necrotizing fasciitis of the thigh in a patient with sigmoid colon cancer

BACKGROUND

Necrotizing fasciitis of the thigh due to the colon cancer, especially during chemotherepy, has not been previously reported.

CASE PRESENTATION

A 67-year-old man admitted to the hospital was diagnosed with sigmoid colon cancer that had spread to the left psoas muscle. Multiple hepatic metastases were also found, and combination chemotherapy with irinotecan and S-1 was administered. Four months after the initiation of chemotherapy, the patient developed gait disturbance and high fever and was therefore admitted to the emergency department of our hospital. Blood examination revealed generalized inflammation with a high C-reactive protein level. Computed tomography of the abdomen and pelvis showed gas and fluid collection in the retroperitoneum adjacent to the sigmoid colon cancer. The abscess was locally drained under computed tomographic guidance; however, the infection continued to spread and necrotizing fasciitis developed. Consequently, emergent debridement was performed. The patient recovered well, and the primary tumor was resected after remission of the local inflammation.

CONCLUSION

Necrotizing fasciitis of the thigh due to the spread of sigmoid colon cancer is unusual, but this fatal complication should be considered during chemotherapy for patients with unresectable colorectal cancer.

Successful treatment of perineal necrotising fasciitis and associated pubic bone osteomyelitis with the vacuum assisted closure system

BACKGROUND

Acute necrotising fasciitis is a life-threatening condition, which requires urgent surgical intervention. Surgical debridement is invariably associated with large areas of tissue loss.

CASE PRESENTATION

We present a 58-year old woman with a past history of cervical carcinoma who presented with necrotising fasciitis of the perineum and upper thighs with associated pubic bone osteomyelitis. Following extensive debridement, a Vacuum Assisted Closure (VAC) system was applied to the large residual defect to facilitate skin graft application and optimise wound healing.

CONCLUSION

This case demonstrates the successful management of a complex and potentially lethal wound of the perineum with debridement, skin grafting and the VAC system.