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Necrotising Fasciitis of the Leg as a Complication of Ischiorectal Abscess

1993; BMJ; Volume: 139; Issue: 2 Linguagem: Inglês

10.1136/jramc-139-02-09

2052-0468

D J Vassallo, John Lovegrove, M S Owen-Smith,

Amoebic Infections and Treatments

This case report describes the rare complication of necrotising fasciitis of the right thigh and calf after drainage of an ischiorectal abscess.The important early symptoms and signs of this life threatening infection, and the need for urgent treatment with aggressive surgical debridement and broad spectrum antibiotics, are emphasised in order to facilitate early recognition and prompt initiation of the appropriate therapy in future cases. Case Historyinflammation and crepitus proximally up to the buttock A 35-year-old otherwise healthy married male soldier and distally as far as the ankle.Under GA, the incision was admitted as an emergency to the Surgical Depart-was therefore extended in the midline from the buttock ment of the British Military Hospital Munster, with down to the heel, being curved transversely across the severe anal pain.back of the knee.Widespread necrotising fasciitis was Examination under anaesthetic revealed normal bowel found throughout the posterior compartment of the mucosa to 25cm, and a large boggy mass extending thigh and calf.Pus had tracked down alongside the around the lower rectum and anal canal.Incisions were sciatic nerve from within the pelvis through the greater made into this, draining copious amounts of pus, sciatic foramen, down to the popliteal fossa, and thence establishing the diagnosis of a horseshoe-type high in-along the fascial planes around gastrocnemius and tersphincteric ischiorectal abscess.A pure growth of soleus as far as the tendo Achilles.All necrotic fascia was Bacteroides was cultured.The patient initially made a therefore excised, and the wound was irrigated with good recovery, though his temperature remained ele-hydrogen peroxide and saline.Yeates drains were placed vated.alongside the sciatic nerve, and the wound dressed as On the third post-operative evening, he complained of before.pain over the lateral aspect of the right popliteal fossa, A post-operative ultrasound showed no evidence of a preventing him from walking or straightening his knee.pelvic abscess, and rectal examination was normal.The On examination he was tender over a localised region patient's health improved markedly thereafter and a around the insertion of biceps femoris onto the head of further change of dressing and wound toilet under GA the fibula, where there was slight swelling and redness.revealed little residual pus.He then developed inflam-This was at first thought to be a sprain.By the morning mation in the anterior aspect of his right thigh.Under there was tenderness and swelling over the whole GA, the right femoral triangle was incised.This revealed popliteal fossa.An abscess was suspected and he was pus alongside the femoral nerve and vessels, extending taken to theatre.from the inguinal ligament down to the adductor hiatus, Under general anaesthetic (GA), the patient was where it communicated with the popliteal fossa.This pus found to have subcutaneous emphysema in the popliteal was washed out.Porto-Vac drains were laid alongside fossa.A long postero-lateral calf incision was made, the sciatic and femoral nerves, and connected to infusion releasing large amounts of green pus, containing bubbles tubing.The wounds were then dressed, and a slow conof foul smelling gas.The pus was dissecting along the tinuous irrigation with Betadine (povidone-iodine) and fascial planes around gastrocnemius, with extensive Normal Saline, mixed in a 1: 1 ratio within a Polyfusor necrosis of fascia.but with healthy muscle and sub-Normal Saline 1 litre container, was commenced at the cutaneous fat.This established the diagnosis of rate of 1 litre every 24-36 hours into each drain.necrotising fasciitis.The pus was washed out with warmThe patient subsequently underwent daily or alternate saline and hydrogen peroxide, and all necrotic fascia was daily wound toilet under GA.Betadine irrigation was excised.The wound was left open and dressed with continued for 10 days; intravenous antibiotic therapy gauze, cotton wool and crepe bandages.The patient was was maintained for 14 days, followed by oral antibiotics commenced on high dose intravenous metronidazole, for 12 days.All wounds were closed secondarily in stages cefuroxime and benzylpenicillin.Pus culture grew without skin grafting (Figs 1, 2).The patient underwent Bacteroides fragilis and anaerobic Streptococci, his last, 16th GA exactly one month after his first.Dursensitive to the above antibiotics, which were therefore ing this time he required transfusion of six units of blood continued.as well as receiving intravenous human albumin solu-By the next day the patient had developed further tion, a high protein diet and ferrous sulphate.He re-