Early diagnosis of retroperitoneal necrotizing fasciitis

Objective: To report survival of retroperitoneal necrotizing fasciitis in an immunocompromised patient and to demonstrate early clinical signs that may help in the prompt diagnosis and treatment of this severe infection. Design: Case report and literature review. Setting: An adult, 18-bed intensive care unit within a university hospital. Patient: A 38-yr-old man who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 5 for erythema around the hemorrhoidectomy and a dirty brown discharge from the wound. Interventions: Early diagnosis of retroperitoneal necrotizing fasciitis, wide and repeated debridement, broad-spectrum antibiotics, and eventual abdominal wall reconstruction. Measurements and Main Results: This patient manifested periumbilical and bilateral flank erythema, reminiscent of the pattern of ecchymosis seen in cases of retroperitoneal hemorrhage, The findings demonstrate a variation of Cullen's and Grey Turner's sign, most often found in patients with hemorrhagic pancreatitis. An abdominal radiograph revealed a ground glass appearance with radiolucency outlining the bladder, consistent with retroperitoneal air. The chest radiograph showed mediastinal air extending into the neck. Sharp debridement of the retroperitoneal fat, the right anterior rectus sheath, and the right anterior thigh fascia was required to gain control of the infection. Operative cultures grew a mixed flora with Escherichia coli, beta -hemolytic streptococcus, and Bacteroides fragilis predominating. The hospital course was complicated by hemodynamic instability, renal failure, pneumonia, and a pelvic abscess. The patient ultimately survived and underwent abdominal wall reconstruction with mesh. Conclusion: Retroperitoneal necrotizing fasciitis is an uncommon soft tissue infection that is often fatal. Early diagnosis in this case was facilitated by the unique clinical findings of a modified Cullen's and Grey Turner's sign. A review of the limited available literature suggests that survival of retroperitoneal fasciitis is possible with prompt debridement and antibiotic therapy.