Necrotizing Fasciitis of the Thigh Secondary to Radiation Colitis in a Rectal Cancer Patient
A 66-year-old male patient visited orthopedics due to pains in the right femoral regions and pelvis that had started a month earlier. No abnormal findings were during the diagnosis, including X-ray scanning etc. A week before, the patient had visited the emergency room as he was experiencing more severe pains in the right femoral regions and pelvis, as well as a fever that had started a day before. Four years earlier, the patient had received a lower anterior resection and a resection of the right lobe because of colorectal cancer and liver metastasis (American Joint Committee on Cancer stage T4N2M1, stage IV). After the surgery, adjuvant chemotherapy was performed eight times with capecitabine and radiation therapy at 5,580 cGy; 31 fractions were carried out in the pelvis. Moreover, the patient was under medication due to diabetes and chronic obstructive pulmonary disease. No unusual findings were observed in the family history, and there was no history of drinking or smoking history. Vital signs at the time of his visit indicated 107/77 mmHg, 90/min, 38.1℃, and 18/min for blood pressure, pulse rate, body temperature, and respiration rate, respectively. No unusual findings were found on the chest auscultation, and the abdomen was soft without oppressive and rebound pains. No mass was palpated upon digital rectal examination. Severe pains in the right femoral regions and ion the side of the abdomen, as well as an erythematous rash, oppressive pains, and crepitus in the right femoral regions, were palpated in the patient. General blood tests showed leukocytes of 10,440/mm3, hemoglobin at 12.6 g/dL, a platelet count of 149,000/mm3, and an erythrocyte sedimentation rate of 50 mm/hr; C-reactive protein was elevated (191 mg/dL). General chemical tests resulted in a total protein content of 5.5 g/dL, albumin at 3.1 g/dL, total bilirubin at 1.0 mg/dL, an aspartate aminotransferase/alanine aminotransferase ratio of 55/191 IU/L, alkaline phosphatase at 58 IU/L, r-glutamyl transpeptidase at 14 IU/L, lactate dehydrogenase at 762 U/mL, and a blood urea nitrogen/creatinine ratio of 16.1/0.6 mg/dL; also, increases in creatine kinase (CK, 8,424 IU/L), CK-MB (20.14 ng/mL), and myoglobin (1,325 ng/mL) were noted. The Na/K/Cl ratio upon serum electrolyte examination was 130/3.7/96 mmol/L.\nThe patient showed unique necrotizing fasciitis in the magnetic resonance imaging (MRI); a gluteus maximus muscle, a thick fascia in the exterior section of the right femoral regions, an edema in surrounding soft tissues, and fascial gas were observed (). Resection of extensive necrotic tissues and dissection of epidermis and subcutaneous tissues were immediately carried out, and the abscesses were discharged by inserting drainage tubes. Ceftriaxone, clindamycin, and amikacin were administered as initial antibiotics against all gram-positive, gram-negative, and anaerobic bacteria. Then, the necrotic tissues were repeatedly resected and washed. Enterococcus senstive to Bacteroides thetaiotaomicron and vancomycin were identified in the blood and necrotic lesions culture tests, respectively. Thus, the antibiotics were replaced with meropenem and vancomycin. At the same time, electrolytes were corrected, and fluids were replenished. Five days after the fascial resection, excrement was detected in the lesions of the right femoral regions (), and MRI was carried out in the rectal area because the presence of a rectal fistula was suspected. Pus of 8 cm in diameter had formed in the presacral space, and it was connected to the right gluteus maximus muscle (). Sigmoid endoscopy was implemented in order to confirm the rectal fistula. We were able to observe that the pus was discharging from a gap between the fascia resected region and the rectum (). In the colonoscopy performed two months earlier, a severe ulcer with edema and rubefaction had been observed in the connected region between the rectum and the sigmoid colon (). Since radiation colitis and rectal perforation were considered at that time, we suggested that the patient undergo an ileostomy, but he refused. The rectal perforation was thought to have been caused by a conventional ulcer in the anastomosis region. In order to treat the necrotizing fasciitis radically, we recommended one more time that the patient undergo an ileostomy, but he refused again. In the bacteria cultures performed on the wound, as Klebsiella pneumonia resistant to carbapenem and Enterococcus faecium resistant to multiresistant Acinetobacter baumannii and vancomycin were identified, the antibiotics were replaced with Tigecycline. Although tigecycline was administered for 16 days, 30 days after the fascial resection, the patient died due to septic shock.