Necrotizing fasciitis secondary to bevacizumab treatment for metastatic rectal adenocarcinoma
A 49-year-old man was admitted to clinic with rectal bleeding. Low anterior resection with ileostomy was performed for rectal mass 5 cm from anus. According to the tumor, node, metastases classification, the pathological stage of the carcinoma was T3N1M0 (stage IIIA). The patient was treated with adjuvant 45 Gy chemoradiotherapy with 5-fluorouracil 225 mg/m2 daily and then fluorouracil-leucovorin-oxaliplatin (FOLFOX4) regimen. After two cycles of FOLFOX4 regimen, serum carcinoembryonic antigen levels had increased. In the radiologic evaluation with chest and abdominal computed tomography, new liver metastases in both lobes were detected. The hepatic metastases were unresectable, hence the patient shifted to regimen of 5-fluorouracil-leucovorin-irinotecan (FOLFIRI). After 12 courses of the FOLFIRI regimen every 2 weeks, the chemotherapy was stopped due to the stable liver metastases. Because of the new metastatic lesions in the liver and pelvic recurrence, bevacizumab added to FOLFIRI regimen. After 10 days of the third cycle of the FOLFIRI-bevacizumab regimen, the patient was admitted with fever, weakness, abdominal pain and erythema of the proximal side of right thigh. The laboratory evaluation revealed a white blood cell count of 22.000/μl (normal value 4,400-11,000/μl) with increased C-reactive protein to 160 mg/l (normal value: 0-10 mg/l). The magnetic resonance imaging (MRI) of the pelvis showed widespread significant air-fluid level abscess in the tissues of right gluteus maximus, gluteus minimus and vastus muscles. A clinical diagnosis of necrotizing fasciitis was made. Ultrasonography-guided drainage of the abscess was performed and 10F pigtail catheter was inserted to the abscess location. The microbiological culture of the material was revealed vancomycin-resistant enterococcus (VRE), Escherichia coli, and Bacteroides fragilis. The patient was treated with linezolid, imipenem, and metronidazole. Patient responded to treatment for initial few days, but on the 7th day of the antibiotic treatment, acute renal failure and septic shock was developed. The patient died due to the refractory septic shock.