Necrotizing Fasciitis of the Abdominal Wall with Lethal Outcome: A Case Report

摘要

Necrotizing fasciitis is an acute surgical condition that demands a prompt and combined treatment. Early recognition, aggressive surgical debridement, and targeted antibiotic therapy significantly affect the overall course of treatment and, ultimately, survival. The authors present a case of a woman with necrotizing fasciitis of the abdominal wall and the course and methods of treatment. Because of comorbidy factors (extreme obesity, diabetes), and late proper diagnosis of necrotizing fasciitis (the clinical signs were "hidden" by celullitis, and phlegmona of abdominal wall), and then as the consequence, overdue adequate surgical treatment, unfortunately contributed to medical treatment failure, respectively lethal outcome. Introduction Progressive necrotizing inflammatory lesions of soft tissues are relatively rare entities in our everyday surgical practice. In USA there are approximately around 500 - 1500 cases per year.(1)The term necrotizing fasciitis is used as the generic name for necrotizing infections of soft tissue. This term includes different syndromes of progressive necrotic infections of skin and subcutaneous tissue.(2) It concerns rapid progressive infection, which affects the fascia and subcutaneous tissue, with simultaneous development of thromboses of skin microcirculation, resulting in necrosis of soft tissue and skin, destruction of muscles and liquefaction of fat(2,3)Medical treatment is a very complex one. On the front burner is surgical debridement beside the aimed application of broad-spectrum antibiotics. Additionally, auxiliary measures can be applied, such as negative pressure wound therapy (NPWT) or hyperbaric oxygenation.(4,5) Infection outcome is always uncertain, and the mortality in these patients is up to 80 %, depending upon associated comorbid factors, the way of treatment and the development of complications (the acute renal insufficiency, acute respiratory distress syndrome - ARDS and multiorganic failure - MOF).(6,7,8,9,10,11,12) In this article has been presented the case of female patient with the necrotic fasciitis of bottom of abdominal wall, perineum and inquinofemoral region, who in spite of all the executed measures, resulted with the lethal outcome. Case Report Clinical status and course of treatmentA female patient 60 years old, obese (high 161 cm, weight 114 kg, BMI = 44), mother of five children, diabetic, had raised temperature, inflammatory changes in the area of groins and light pains in this area, which lasted in the past 3 days. During the examination, a surgeon made the diagnosis of excessive body weight, hanging stomach, erythema and cellulites beside minimal sore spots of the bent and hanging bottom of abdomen. Furthermore, he recommended antibiotic therapy and directed the patient to the dermatologist. Two days after she was examined by the dermatologist who described the skin erythema of abdominal wall and groins, which were warm and milder painful sensitive. Because of the general plight, the patient was hospitalized at the Internal Clinic, and the same day was moved to the Department of Nephrology, under the diagnosis of abdominal walls phlegmona. At the admittance the patient was conscious, febrile 38,4°C with the expressed erythema of wall of lower half abdomen and groins, with skin bullae filled with yellowish liquid contents. At the admittance sedimentation was 132, and leukocytes 8,23 x 109 / l. From urinoculture were isolated Escherichia coli and hemocultures were sterile. Daily doses of combined Tazocin 4 x 2,25 g and Diflucan a 100 mg were administered. Anemia was corrected with transfusions. During the hospitalization at the Internal Clinic, on a few occasions, the patient was examined by the surgeon when necrectomy and incisions were done. Microbiologically, Staphylococcus epidermidis was isolated from wound svab.In spite of intensive antibiotic therapy, inflammatory and necrotic progression occurred and patient was moved to the Surgical Clinic until she die