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Rare presentation of necrotizing fasciitis in complicated diverticulitis

Left-sided colonic diverticulosis is common in the Western population, with risk of diverticulitis occurring in 4% of the population. Complicated diverticulitis occurs when perforation occurs, and approximately 15–20% of patients admitted with acute diverticulitis have an abscess on computed tomography of the abdomen. This case report describes a rare phenomenon of a case of perforated diverticulitis presenting as gluteal necrotizing fasciitis. A 67-year-old female presented to hospital with a 2-week history of lethargy, fevers and vague abdominal pain. She was initially treated for a presumed recurrent urinary tract infection as she grew Escherichia coli in her urine. Her background included hypertension and polio (mobilizes with leg braces and reduced sensation in legs). After 3 days of admission, she still had ongoing fevers with vague abdominal pain and a surgical consult was requested. Examination revealed left lower quadrant abdominal pain, as well as an area of left gluteal skin discolouration, suggestive of an underlying infection. Computed tomography of the abdomen and pelvis demonstrated a complex collection in the left pelvis adjacent to the sigmoid colon, and extensive inflammatory changes and gas in the subcutaneous tissues in the left gluteal region (Figs 1–3). There was absence of gluteus muscles likely related to her polio. Investigations revealed a white cell count of 35 × 10/L and C-reactive protein of 300 at the time of surgical review. These findings were consistent with necrotizing fasciitis in the left gluteal region. However, this was likely secondary to perforated sigmoid diverticulitis with extension via the sciatic foramen into the left gluteal region. At this stage, she was becoming septic and required vasopressors. Empiric intravenous antibiotics for necrotizing fasciitis (meropenem, vancomycin and clindamycin) were commenced, and she was taken to the operating theatre for an emergency laparotomy and exploration of the left gluteal region. Intraoperative findings revealed perforated sigmoid diverticulitis with pelvic side wall abscess containing frank pus, tracking laterally into the left gluteal region. Hartmann’s procedure was performed. Stab incision over discoloured left gluteus demonstrated necrotic tissue with dishwater fluid, consistent with necrotizing fasciitis. Extensive debridement (20 × 40 cm) was performed until healthy bleeding tissue was reached. The absence of gluteus muscle was confirmed. The large wound was packed with povidone-iodine (betadine) soaked gauze. Subsequently, she underwent further debridements of her gluteal wound to ensure complete eradication of necrotic tissues. A vacuum dressing was applied at the last debridement where there was no more necrotic tissue. Complicated diverticulitis occurs when inflammation of the diverticulum leads to abscess, perforation or peritonitis. It can present as a phlegmon, local abscess or a fistula, often to the bladder or vagina. In rarer cases, extra-abdominal spread of the inflammatory process can result in formation of abscess in the retroperitoneum, thigh, hip or buttock, especially in older patients. The presence of superficial gas in the abdominal wall or thighs can be an indication of unsuspected intra-abdominal or retroperitoneal abscess. Diagnosis is often delayed due to insidious changes on the skin. Despite adequate treatment, mortality may be as high as 22–48%.