CASE REPORT
Retroperitoneal necrotizing fasciitis secondary to a deep anorectal abscess
Ariadna Sol Accialini, Federico Carballo, Pablo Farina, Ignacio Pantanali
Hospital Dr. Ignacio Pirovano; Ciudad de Buenos Aires
The authors declare no conflicts of interest.
Ariadna Sol Accialini: ariadna.accialini@gmail.com
Received: September 2021. Accepted: December 2022
Ariadna Sol Accialini: 0000-0003-2514-779X
Federico Carballo: 0000-0002-8513-4715
Pablo Farina: 0000-0002-1869-1861
Ignacio Pantanali: 0000-0003-1839-6819
ABSTRACT
A 60-year-old female diabetic patient presented with right iliac fossa syndrome, for which laparoscopic appendectomy was performed. At 72 hours he developed retroperitoneal necrotizing fasciitis as a torpid evolution of an initially undiagnosed bilateral pelvi-subperitoneal abscess.
Keywords: Pelvi-subperitoneal abscess; Necrotizing fasciitis; Retroperitonitis.
INTRODUCTION
Anorectal abscesses are a very frequent pathology. However, the pelvi-subperitoneal subtype corresponds to less than 10%.1The latter are usually clinically difficult to diagnose due to their scarce local manifestation.
Spread to the retrorectal and retroperitoneal space as necrotizing fasciitis (NF) has been described as a rare but lethal complication.
The objective of the following presentation is the description of a rare clinical case that can evolve torpidly in the absence of an early diagnosis.
CASE
A 60-year-old female patient, diabetic, consulted for a 7-day history of a right iliac fossa syndrome. With an Alvarado score of 7 points, a laparoscopic appendectomy was performed, which revealed a congested cecal appendix.
At 72 hours he presented hyperdynamic signs and pain in the right lumbar region. Subcutaneous emphysema was found from the lumbar region to the ipsilateral infrascapular region.
The laboratory tests revealed coagulopathy and metabolic acidosis and the computed tomography showed subcutaneous emphysema in the right thoracoabdominal region and free abdominal fluid with air bubbles in the pararectal space (Figs. 1, 2, 3).
During the surgical intervention, peritonitis and retroperitonitis associated with a bilateral pelvic-subperitoneal abscess were found (Figs. 4, 5). Lavage of the abdominal cavity and the retroperitoneal space was performed, closing the wall with polyglactin mesh and draining both ischiorectal fossae.
Due to the great systemic compromise, the patient died on the fifth postoperative day.
Figure 1. Computed tomography showing subcutaneous emphysema.
Figure 2. Computed tomography showing air in the perirectal space.
Figure 3. Computed tomography. Coronal plane showing air in the retroperitoneal and pararectal region.
Figure 4. Retroperitonitis. Surgical drainage.
Figure 5. Drainage of the bilateral pelvi-subperitoneal abscess.
DISCUSSION
NF is an infection of the subcutaneous soft tissues characterized by its rapid progression and high morbidity and mortality.4,5
The diagnosis is exclusively clinical and must be made quickly with a high index of suspicion. Deep anorectal abscesses present a diagnostic challenge due to their unclear local manifestations. They usually present with abdominal pain, fever, and systemic signs and symptoms. The peritoneal irritation in the lower abdomen that they generate can confuse, delaying the diagnosis of certainty.6 Its spread to the retroperitoneum is an extremely rare but potentially fatal complication due to the infection that can evolve into septic shock.
REFERENCES
1. Ramanujam PS, Prasad ML, Abcarian H, Tan AB. Perianal abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum. 1984; 27:593-97.
2. Konstantinos PS, Andreas D, Kleoniki K, Dimitrios F. Extraperitoneal spread of anorectal abscess: A case report and literature review. Ann Coloproctol. 2021; 37(Suppl 1):S11-S14.
3. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000; 87:718-28.
4. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014; 1:36.
5. Pryor JP, Piotrowski E, Seltzer CW, Gracias VH. Early diagnosis of retroperitoneal necrotizing fasciitis. Crit Care Med. 2001; 29:1071-73.
6. Giri S, Kandel BP, Kansakar PBS, Vaidya P. Retroperitoneal necrotizing fasciitis presenting with peritonism in a 33-year-old Nepalese man: a case report. J Med Case Rep. 2012; 6:53.