Post-Surgical Necrotizing Fasciitis: A Case Report of Abdominal Wall and Limb Involvement

A 42-year-old woman with stage IIIC2 cervical adenocarcinoma developed a rectovaginal fistula two months post-surgery, leading to surgical intervention for abscess evacuation and a colostomy. Subsequently, she experienced necrosis of left thigh muscles and pelvic organs, along with left external iliac artery and vein thrombosis. Due to severe sepsis, revascularization was not viable, necessitating bilateral ureterostomy and ligation of the left external iliac vessels. Despite palliative care, she succumbed to multivisceral failure from sepsis one month after surgery.

Necrotizing lesions in soft tissues are very rare in routine surgery. Diagnosing necrotizing fasciitis is challenging and relies on clinical symptoms, the specifics of the mixed infection, and patient risk factors. Treatment involves urgent, intensive surgical debridement and targeted broad-spectrum antibiotics.  

A 42-year-old woman suffering from stage IIIC2 cervical adenocarcinoma developed a recto-vaginal fistula and fever two months post-surgery. After surgical intervention and a bypass colostomy, she experienced vast necrosis of pelvic organs and thigh muscles, along with thrombosis in the left external iliac artery and vein.

Postoperative complications, particularly infectious ones, have witnessed a recent decline in incidence owing to the widespread use of perioperative antibiotics. However, infection affections remain a concern, often manifesting as fistulas, pelvic collections, urinary tract strictures, albeit rarely, pelvic organ necrosis and necrotizing fasciitis (NF). NF, firstly described by Jones in 1871, encompasses a spectrum of severe and rapidly progressing infections involving the skin, subcutaneous tissue, and fascia, potentially leading to thrombosis, muscle destruction, and fat liquefaction.

Various predisposing factors, including diabetes, obesity, immunocompromised states, prior radiotherapy or chemotherapy, and pelvic surgeries, contribute to infection susceptibility, exacerbated by the absence of prophylactic antibiotic therapy during primary surgery.  Anaerobic and aerobic bacteria like Aerococcus viridans, Enterococcus faecalis, Peptostreptococcus spp, and Escherichia coli are commonly implicated pathogens. Treatment approaches lack standardized consensus and necessitate individualization based on patient morbidities and case specifics.

Urgent intervention, typically involving surgical debridement and broad-spectrum antibiotics, is paramount for pelvic necrosis management, with delayed surgical intervention substantially impacting prognosis. This case report elucidates an unusual case of NF affecting the abdominal wall and extremities that occurred following surgery for cervical cancer.

MEDICAL HISTORY

The case of stage IIIC2 adenocarcinoma-affected 42-year-old female was presented without any personal or family medical history and without any underlying health conditions.

The patient received four courses of cisplatin-based chemotherapy and 45 Gy of pelvic radiotherapy, which led to post-radiation rectitis and cystitis. Brachytherapy was not administered due to being past the deadline.

Pelvic magnetic resonance imaging (MRI) investigation (Post treatment 1- Chemotherapy):

• 32 mm vs. 40 mm tumor size regression
• Resolution of lymph node invasion and parametrial involvement

The patient had a colpohysterectomy with an uneventful recovery and was discharged four days later.

Histological examination (Post treatment 2 - Colpohysterectomy):

The final histological investigation revealed a 10 mm remnant of human papillomavirus (HPV)-positive cervical adenocarcinoma, with clear surgical margins. The multidisciplinary committee recommended no adjuvant therapy.

Emergency department presentation (2 month follow-up):

• Fever: 39°C
• Pain in pelvis
• Painful mobilization of lower left limb
• Primary or acquired immunodeficiency not detected
• Abdominal CT scan investigations: Rectovaginal fistula supplied from the uterus cavity via a 5 cm pelvic collection

The patient was admitted, given antibiotics, and subsequently had the collection surgically evacuated along with a bypass colostomy. The initial progression was positive. However, within two weeks, she developed few symptoms.

Presentation after 2 weeks (Post treatment 3: Antibiotics, Bypass colostomy):

• Body temperature rise
• Edematous, swollen, hot skin
• Crackling snow crepitus (left lower limb)   

Urgent computed tomography scan findings (chest, abdomen, and pelvis):

• 10 cm pelvic collection, left-sided, fistulated into the rectum and bladder
• Thrombosis of the left femoral vein and external iliac artery
• Intramuscular collections, pan-diaphyseal air bubbles in the left femur
• Myositis-like appearance in the gluteal muscles, anterior and medial thigh compartments, and left leg muscles, all indicative of an infectious case

Postoperative findings:

• Severe necrosis to the pelvic organs, spreading to the left leg's medial and anterior thigh compartment muscles
• Left artery and external iliac vein thrombosis, with necrosis of their vascular surfaces

Treatment 1

• Four courses of cisplatin-based chemotherapy and 45 Gy of pelvic radiotherapy
• Complications: Post-radiation rectitis and cystitis
• No brachytherapy received due to missing the deadline

Treatment 2

• Colpohysterectomy
• Immediate postoperative course: Uneventful
• Discharged four days after surgery

Treatment 3

• Antibiotic therapy
• Bypass colostomy

Treatment 4

• Left external iliac vessels ligature
• Bilateral ureterostomy
• Excision and revival of necrotic tissue in the left lower limb
• Evolution marked by loss of functionality in the left lower limb despite collateral circulation development

Treatment 5

• Post-surgical palliative treatment

NF is a rare, rapidly progressing gangrenous infection of the skin and subcutaneous tissue, often linked to thrombosis from necrosis and muscle destruction. It was initially termed as "hospital gangrene. Wilson in 1952 noted that surgical treatments, chemotherapy, and radiotherapy can rarely trigger NF due to tissue hypoxia and necrosis. Nakano et al. found an 18% incidence of late pelvic radiation complications, with the risk influenced by radiation dose and tumor extent. The condition can result in fistulas, abscesses, and ultimately NF. NF typically presents with fever, pain, and limited limb movement in only 35% of cases and is often masked by abscesses or cellulitis.

NF is characterized by swollen, discolored skin, tense edema, necrosis, and crepitus. Computed tomography imaging is useful for its diagnosis, showing skin thickening and necrosis, while MRI helps examine infection extent. The condition can spread from rectal fistulas to the limbs, potentially requiring limb amputation or aggressive debridement. Mortality rates without treatment can be as high as 100%, and even with treatment, can range from 50-80%. Thrombosis and necrosis of the bladder can occur, particularly following radiotherapy. Prompt diagnosis, surgical debridement, and broad-spectrum antibiotics are crucial for survival, with delays considerably impacting prognosis.

In this study, an uncommon occurrence of NF was reported. Regrettably, the diagnosis was delayed, significantly affecting the patient's chances of survival. Despite undergoing surgical excision and receiving antibiotic therapy, the patient showed no response to treatment and lost her life after 1 month of treatment. Lessons drawn from this case emphasize the critical aspect of timely diagnosis and treatment, particularly as the early stages of the disease often go unrecognized due to the absence of specific clinical indicators explaining disease progression and eventual mortality.

Learning
NF is a rare and serious ailment, with diagnosis relying on clinical and radiological assessments; Computed tomography scans are particularly beneficial. Predisposing factors encompass diabetes, neoadjuvant radiotherapy, and chemotherapy. Prognosis improves with prompt management, including surgical removal of necrotic tissue and antibiotic therapy tailored to suspected anaerobic pathogens.

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