Clinical communication: Adult
Necrotizing Fasciitis as the Clinical Presentation of a Retroperitoneal Abscess

https://doi.org/10.1016/j.jemermed.2007.03.048Get rights and content

Abstract

Infections of the retroperitoneal space may present with insidiously vague symptoms and non-specific clinical signs. We report a case of a retroperitoneal abscess presenting as necrotizing fasciitis of the thigh from direct spread over the iliac crest. In cases of necrotizing fasciitis of the thigh with no obvious source, an intra-abdominal nidus of infection may be considered.

Introduction

Infections of the retroperitoneum and psoas sheath may present with insidious symptoms and non-specific clinical signs. These infections commonly present with indolent fevers and chills; weight loss; abdominal, flank, groin, or back pain; malaise; and anorexia. Diagnosis is usually delayed, often for months, or confused with other clinical entities (1, 2). Presentations may be dramatic, with the rapid onset of septic shock or other complications after perforation and release of bacterial contents into the peritoneum, thorax, meninges, and thigh (3, 4, 5, 6, 7). Before the age of antibiotics, spread of infection from tuberculous vertebral osteomyelitis to the lower extremities via the psoas fascia was also common. These complications are now rarely seen due to improved diagnostic and therapeutic modalities. We report a case of retroperitoneal abscess whose diagnosis was delayed for weeks before it developed into a lower extremity necrotizing fasciitis.

Section snippets

Case Report

A 45-year-old man presented to the Emergency Department (ED) with the chief complaint of a painful and swollen left thigh. The pain and swelling began 3 days before presentation, worsening until he was unable to walk. He reported having hit his left thigh several days before presentation, and to having ”fallen in the kitchen” a month earlier, with subsequent left flank and hip pain. In the weeks before presentation, he made two visits to community EDs and was evaluated with plain films of the

Discussion

A rare but life-threatening complication of intra-abdominal infection is extension to the thigh. In the absence of a clear lower extremity origin for soft tissue infection of the thigh, the peritoneum, psoas sheath, and retroperitoneum must be evaluated for occult infection. Historically, retroperitoneal and psoas abscesses were most frequently encountered with tuberculous vertebral osteomyelitis, but cases have been described resulting from appendicitis, ischiorectal abscess, vaginal delivery,

Conclusion

Retroperitoneal and psoas abscesses can occur secondary to a range of abdominal pathologies and are an important differential diagnostic consideration in the evaluation of patients with chronic non-specific complaints. The clinician must aggressively obtain imaging studies in patients with suggestive histories, as physical examination and laboratory evaluation are insensitive for these frequently fatal infections. In cases that progress to necrotizing fasciitis or clostridial gangrene,

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      2012, American Journal of the Medical Sciences
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      Necrotizing fasciitis is a life-threaten soft-tissue infection that commonly begins at the site of a small insignificant wound or surgical incision. Herein, we demonstrated that retroperitoneal abscess could be an unusual etiology of necrotizing fasciitis of the thigh.1,2 A computed tomography scan establishes the evaluation of the extension of involvement.

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