Lower extremity necrotizing soft tissue infection following foreign body ingestion
Author(s):
Laurence Diggs, St. Louis University School of Medicine; Christin Tu, St. Louis University School of Medicine; Jennifer Lobb, St. Louis University School of Medicine; Charles Andrus, St. Louis University School of Medicine, Veteran's Affairs St. Louis Health Care System; Terrence Wade, Veteran's Affairs St. Louis Health Care System
Background: A 64-year-old male presented with complaints of worsening right lower quadrant pain for three months and debilitating right-sided leg pain over several days. Physical exam revealed tenderness and crepitus of the right lower quadrant and right leg. Computed tomography scan demonstrated gas in the right psoas, iliacus, right medial thigh and calf. Given his overall clinical presentation there was high suspicion for necrotizing soft tissue infection (NSTI). After receiving immediate broad-spectrum antibiotics and fluid resuscitation, the patient was taken for emergent exploration, washout, and debridement of the right lower quadrant and the right lower extremity.
Hypothesis: Lower extremity NSTI can track down the femoral sheath from an intra-abdominal source.
Methods: There are no methods to report for this case report.
Results: A 6cmx3mm wooden foreign body was extracted from the peritoneal cavity. No frank perforation was noted but there was significant inflammation around the cecum. Months prior to presentation, the patient swallowed a toothpick leading to eventual cecal perforation and displacement of the foreign body in the peritoneal cavity. Intra-operative cultures showed a polymicrobial infection including E. coli, Prevotella buccae, Strep, and Staph species, including MRSA. Post-operatively, he developed septic shock with multi-organ failure requiring prolonged intubation and inotropic support. Re-exploration was too high-risk given his hemodynamic instability. His post-operative course was also complicated by cardiopulmonary arrest, development of an enterocutaneous fistula, and multiple diffuse ischemic infarcts noted on CT head. The patient eventually succumbed to his illness and expired.
Conclusions: Necrotizing soft tissue infections pose a high risk of morbidity and mortality to patients and constitute a major challenge to surgeons. When bowel perforation is the source of the infection, a formal exploratory laparotomy during the initial operation may be in order to identify bowel injury, even without the presence of frank perforation. When NSTI are diagnosed in the lower extremities, an intra-abdominal source should be considered. Psoas or iliacus infections can track down to the lower extremity through the femoral sheath given the point of insertion of these muscles. As seen in our case, ensuring proper source control is essential. The difficulty in attaining full source control likely contributed to our patient’s persistent state of septic shock and ultimately to his mortality.