This work was supported by the Soonchunhyang University Research Fund.
Necrotizing fasciitis (NF) is a rare and rapidly progressive disease involving the skin, subcutaneous tissue, and deep soft tissue. A 76-year-old man presented to the emergency room with melena. Abdominopelvic angiographic computed tomography (CT) revealed a foreign body with calcific density in the ascending colon. Explorative operation was performed, and the foreign body observed on CT was identified to be a chicken bone. Mucosal tearing was found in the ascending colon, and right hemicolectomy was performed. Two days postoperatively, leakage from the anastomosis site was noted and eventually progressed to panperitonitis. One week later, the patient’s skin and soft tissue changed to a purplish color, and swelling was observed. As the area gradually increased, a foul odor and purulent discharge were noted. We diagnosed this patient as having NF, and debridement and antibiotic treatment were started. Extended-spectrum β-lactamases positive
Necrotizing fasciitis (NF) is a rapidly progressive disease involving the skin and deep soft tissue. Although the incidence is relatively low, reported to be approximately 0.24 to 0.4 out of 100,000 adults, the rate has recently increased, and its mortality rate is high [
Soft tissue foreign bodies, which often cause superficial or deep tissue infection, are a common reason for emergency room visits [
In this study, we report a case of secondary NF after panperitonitis caused by bowel mucosal wall injury due to ingestion of a chicken bone.
A 76-year-old man with melena visited the emergency room. Abdominopelvic angiographic computed tomography (CT) was performed in the emergency room, and high-density fluid was observed inside the small and large bowel. While this fluid was considered hemorrhage, definite active bleeding was not observed. CT of the ascending colon revealed material with a calcific density (
To treat panperitonitis, abdominal exploration was again performed. After sufficient irrigation, segmental resection of unviable ileum was performed. End ileostomy was performed to restore function of the large intestine. After this second surgery, the patient stayed in the intensive care unit for 1 week. After moving to a general room, the patient’s abdomen skin and soft tissue turned purplish in color. As the area gradually increased, a foul odor and purulent discharge were present. These skin surface changes had not been detected in the intensive care unit. Epidermolysis progressed in the skin where color change occurred, and it was observed that the soft tissue was involved with partial exposure of muscle fascia. The skin and soft tissue defect area increased not only in the abdomen but also in the perineal area and right thigh.
The patient was referred to the plastic surgery department for wound management. We suspected NF with polymicrobial origin and performed emergent debridement in the operating room. A large amount of necrotic tissue was observed, and the dermis, subcutaneous tissue, and muscle fascia were damaged and displayed purulent discharge. Wound culture was performed on the first debridement. Laboratory test results showed elevations in white blood cell count (26,200/mm3) and C-reactive protein levels (21.05 mg/dL; normal range <0.5 mg/dL). Other laboratory parameters (hemoglobin, 13.7 g/dL; sodium, 133 mmol/L; creatinine, 0.7 mg/dL; and glucose, 135 mg/dL) were near the normal range.
The culture of excised tissue yielded extended-spectrum beta-lactamases positive
We performed daily wound irrigation in the operating room, and observed a decrease in the amount of wound discharge after 1 week. The patient’s general condition and the intermittent fever also improved. After sign of infection were attenuated, negative pressure wound therapy was performed twice per week for 3 weeks. Granulation tissue formed by 3 weeks of negative pressure wound therapy (
NF is a rare but serious soft tissue infection. NF can lead to extensive local tissue destruction and, in severe cases, systemic toxicity can lead to multiorgan injury. Patients older than 50 years or who have chronic medical conditions such as diabetes, immunosuppression, obesity and peripheral vascular disease are more likely to progress to NF.
The earliest clinical finding of NF is persistent pain and change of involved skin color, which is due to occlusion of the perforating nutrient vessels and nerve infarction. Pain is induced in the infarctional nerve-dominated skin area. With NF, the overlying skin is accompanied by redness, vesicles, bullae, necrosis, or crepitus [
Simple radiographic imaging, CT, and magnetic resonance imaging can help to diagnose NF which in itself is a surgical emergency. Simple radiographic images are insensitive in the early stages of NF, because findings such as an increase in soft tissue thickness and opacity are similar in both NF and cellulitis. CT images can show abnormal gas distribution along the fascial plane and thickening of the fascial layer along with fluid collection, which findings make it easier to diagnose NF than plain radiographic images. In our case, CT was useful for assessing the extent of soft tissue infection and diagnosing NF.
NF most commonly occurs as infection due to damage of the external skin surface barrier. It can also rarely occur as an infection due to internal organ problems. In our case, abdominal exploration and right hemicolectomy were performed because of mucosal tearing caused by a chicken bone. After abdominal operation, panperitonitis occurred due to anastomosis site leakage. Soft tissue infection then occurred during the treatment of panperitonitis causing NF in the abdomen, perineal area, and thigh. In summary, NF was caused by panperitonitis.
NF is a surgical emergency that should be treated immediately using surgical procedures. In previous studies, if treatment was solely based on antibiotic treatment and support, mortality approached 100%. Surgery is an important treatment for infection source control, the goal of which is to debride all necrotic tissue, leaving and exposing only viable tissue. In a previous study, to treat Fournier’s gangrene with fecal contamination, colostomy was performed to resolve contamination, and defect sites were reconstructed by skin graft with vacuum assisted wound therapy [
Antibiotics can prevent the progression of septic shock when used early. Kumar et al. [
Although the incidence is rare, NF should be diagnosed and treated promptly because it progresses rapidly and causes invasive soft tissue infection. While NF most commonly occurs as infection due to damage of the external skin, we should not overlook the fact NF can be caused by internal organ infection such as panperitonitis. In particular, patients with a high risk of infection or changes in skin color should be diagnosed with and treated for NF.
No potential conflicts of interest relevant to this article are reported.
Initial abdominopelvic angiographic computed tomography finding. A foreign body with calcific density (arrow) was found in the ascending colon.
Computed tomography findings after panperitonitis. (A, B) Collections of fluid containing air bubbles were found in the right flank and thigh (arrow).
Photographic finding before skin graft. We performed surgical debridement and ne-gative pressure wound therapy three times per week. Although vastus lateralis muscle fascia was partially exposed, healthy granulation tissue is observed on the raw surfaces as a whole.
Postoperative findings. We reconstructed the defect with mesh split thickness skin graft. The patient recovered without any postoperative infection or the other complications. (A, B) Thigh, (C) inguinal crease area.