Necrotising fasciitis secondary to perforated rectal adenocarcinoma presenting as a thigh swelling

Abstract

A 62-year-old man was admitted to the medical admissions ward with right thigh pain presumed to be a deep vein thrombosis (DVT). Subsequent duplex ultrasonography excluded a DVT but noted the presence of a significant amount of subcutaneous gas. A plain film radiograph was performed with the same finding raising the possibility of necrotising fasciitis (NF). Only at this point was digital rectal examination performed revealing a large rectal mass oozing pus and blood. CT imaging showed thickening of the rectum consistent with a tumour with gas and fluid in the perirectal space extending to the anterolateral right femur. Despite aggressive debridement and treatment, the patient deteriorated and died 6 weeks later. This case should serve as a reminder to consider digital rectal examination and the occurrence of a rectal perforation in all patients who present with suspicious thigh swellings.

Fascitis necrotizante del muslo secundaria a cáncer de recto perforado: el agujero ciático como vía de diseminación infecciosa

“…Debridement should be repeated when necessary. In cases of rectal perforation, fecal diversion is recommended 3 .…”

“…However, rectal perforation should always be ruled out, especially in patients with a prior history of rectal disease [3][4][5] . In this patient, the femoral canal provided a channel for the intra-abdominal infection to invade the thigh.…”

Not your usual hip pain: necrotising fasciitis secondary to sigmoid perforation

“…[2][3][4][5][6][7] Rectal perforation leading to NF of the thigh has been explained by entry of faecal matter through femoral sheath, femoral canal, psoas sheath, sciatic notch and obturator foramen. 8 Clinical presentation usually consists of pain, swelling and fever on history and tenderness, erythema of the involved site on physical examination. Presence of crepitus, skin necrosis, bullae and sensory deficits over the involved area are supportive to diagnosis, however their presence are typically seen later in the course or may be indicative of a rapidly developing fulminant infection.…”

Necrotising fasciitis caused by metastatic endometrial cancer: a rare cause of a life-threatening condition

“…A systematic review 2 incorporating US, Asian and Australasian cohorts reported the most common aetiology to be trauma (including major and minor trauma and surgical wounds), followed by infection with marine bacteria from ingestion of undercooked seafood or injury by fish fins; the latter was largely reported in Asian cohorts. Case reports abound describing necrotising fasciitis secondary to perforation of a viscus due to gastrointestinal malignancy 6 or immediately following administration of a specific chemotherapeutic agent for rectal cancer. 7 Necrotising fasciitis secondary to pelvic malignancy without perforation of a viscus or recent chemotherapy has not been previously reported.…”