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Acute Sigmoid Diverticulitis Presenting as Necrotizing Fasciitis of the Thigh and Retroperitoneum

Necrotizing fasciitis and its subdiagnosis Fournier’s gangrene result from a variety of etiologies. Skin, anorectal, and intraabdominal sources have all been implicated, though often the etiology remains unknown due to subsequent obliteration of the inciting event. We present a patient who succumbed to an unusual pattern of necrotizing fasciitis of the retroperitoneum and left thigh that developed as a complication of perforated diverticulitis. The patient was an 88-year-old female who was presented to our emergency department with several days of progressively worsening abdominal and left leg pain, and was found to be newly diagnosed with atrial fibrillation. Her past medical history included arthritis, hypertension, colon cancer treated with a right hemicolectomy 30 years ago, and lupus treated with daily steroids for approximately 10 years. She had a remote history of smoking tobacco. Shewas a febrile, her initial vitals were stable, and her physical examination was remarkable only for mild tenderness to palpation of the left lower quadrant, and for pain in her left hip and thigh that was not reproducible to palpation but relieved with flexion. Her initial labs revealed a leukocytosis of 20.5, hemoglobin of 9.2, and platelets of 134. Her sodium level was 145, potassium 3.1, chloride 114, bicarbonate 12, blood urea nitrogen 66, creatinine 2.2, and lactic acid 2.4. A CT scan of her abdomen and pelvis revealed leftsided retroperitoneal air that extended from the diaphragm down to the obturator foramen and femoral canal into the adductor muscular fascia well into the leg (Figs. 1 and 2). Air was also noted in the anterior mediastinum. The patient was resuscitated, but due to surgical judgement, she remained in the intensive care unit for 12 hours after initial evaluation. A second surgeon evaluated the patient, and immediately took her for an emergent exploratory laparotomy. She was found to have a perforated sigmoid diverticulitis with no intraabdominal purulence but a large amount of pus and necrotic fat, fascia, and muscle in the left retroperitoneum. The sigmoid colon and surrounding necrotic tissue were resected, leaving a low distal rectal pouch. Because of the patient’s acutely worsening hemodynamics during the procedure, a wound vac was applied to the abdomen, leaving the patient in enteric discontinuity. The patient was transferred to the intensive care unit for resuscitation, and antibiotics and stress dose steroids resolved the patient’s hypotension writhing in 24 hours. Multiple organisms grew from surgical cultures, including Klebsiella, enterococcus, Escherichia coli, and bacteroides species. On hospital day 3, the patient was taken back to the operating room, and was found to have more necrotic tissue in the same regions, further debridement was performed, and the abdomen was again left open. On hospital day 4 at approximately 1900, the patient’s abdomen was again explored, and the infection and necrotic tissue appeared to be largely under control. An end colostomy was placed in the left upper quadrant. An abdominal wound vac was again placed out of concern for some continued necrosis still remaining. Unfortunately, the patient subsequently developed profound hypotension, and suffered a pulseless electrical activity arrest at 2300, and Advanced Cardiac Life Support protocols were initiated. The patient underwent resuscitative efforts for about 20 minutes, at which time the family requested to cease such efforts, and the patient expired. Necrotizing soft tissue infection was first described by Hippocrates around the year 500 BC. It was described as “hospital gangrene” by British Naval surgeons in the 18th and 19th centuries. In 1871, Dr. Joseph Jones, a Confederate Army Surgeon, described the condition in 2642 patients with an associated mortality of 46 per cent.1 In 1883, Jean Alfred Fournier described necrotizing infection in the perineum of male patients, yielding us the namesake diagnosis that Address correspondence and reprint requests to Nathan Smith, M.D., General Surgery Residency, Kendall Regional Medical Center, 12989 SW 135th Terrace, Miami, FL 33186. E-mail: nsmithwfusm@ gmail.com.