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Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult.

Saigusa S, Ohi M, Imaoka H, Uratani R, Kobayashi M, Inoue Y - Case Rep Emerg Med (2015)

Bottom Line: He presented to us with general fatigue, low grade fevers, and perineal pain.The sutured wound had foul-smelling discharge and white exudate.Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie 514-0832, Japan ; Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.

ABSTRACT
A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.

No MeSH data available.


Related in: MedlinePlus

Abdominal CT after 10 days in the hospital. Subcutaneous gas remains in the left flank despite prompt disappearance of emphysema in the scrotum. Subcutaneous gas (arrow head).
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fig3: Abdominal CT after 10 days in the hospital. Subcutaneous gas remains in the left flank despite prompt disappearance of emphysema in the scrotum. Subcutaneous gas (arrow head).

Mentions: Abdominal computed tomography (CT) showed that there was subcutaneous emphysema from the scrotum to the left chest (Figure 1), multiple fractures of bilateral ribs, a right pleural effusion, multiple transverse process fractures, fracture of the fourth lumber vertebral body, and a retroperitoneal hematoma; he had no recurrence of a right inguinal hernia. Neither pelvic fracture nor urethral injury was observed. Upon examination of the anoperineal area, the sutured and contused/lacerated wound had foul-smelling discharge and white exudate. Digital examination demonstrated reduced anal sphincter tone. Magnetic resonance imaging (MRI) showed high intensity around the perineum on short T1 inversion recovery (STIR) sequences, strongly suspicious for necrotizing fasciitis (Figure 2). Additionally, MRI suggested a left anal sphincter injury. We immediately opened the wound and performed an initial debridement and lavage with copious irrigation. On laboratory examination, abnormal values were as follows: white blood cell 11200/μL (normal range, 3500–9000/μL), platelet 11.8 × 104/μL (normal range, 14.0–37.9 × 104/μL), aspirate aminotransferase 43 IU/L (normal range, 10–35 IU/L), lactate dehydrogenase 265 IU/L (normal range, 110–225 IU/L), creatinine kinase 1054 IU/L (50–200 IU/L), and C-reactive protein 7.27 mg/dL (0–0.45 mg/dL). Wound cultures showed Enterobacter cloacae, Pseudomonas aeruginosa, and yeast. After admission to our hospital, we administered meropenem (2 g/day) and clindamycin (1800 mg/day), kept the patient NPO, and initiated parenteral nutrition. We continued antibiotics and wound lavage until the infection was controlled. Although low grade fever continued for ten days and subcutaneous gas remained in the left flank despite prompt disappearance of emphysema in the scrotum (Figure 3), the inflammation-related laboratory data improved gradually. He resumed oral intake after a week in the hospital. He required no further surgery and was discharged on hospital day 15. The subcutaneous air completely disappeared on abdominal CT two months after the first visit to our hospital. He had no fecal incontinence despite the injury to his sphincter. He is still followed carefully in the ambulatory setting.


Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult.

Saigusa S, Ohi M, Imaoka H, Uratani R, Kobayashi M, Inoue Y - Case Rep Emerg Med (2015)

Abdominal CT after 10 days in the hospital. Subcutaneous gas remains in the left flank despite prompt disappearance of emphysema in the scrotum. Subcutaneous gas (arrow head).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4546953&req=5

fig3: Abdominal CT after 10 days in the hospital. Subcutaneous gas remains in the left flank despite prompt disappearance of emphysema in the scrotum. Subcutaneous gas (arrow head).
Mentions: Abdominal computed tomography (CT) showed that there was subcutaneous emphysema from the scrotum to the left chest (Figure 1), multiple fractures of bilateral ribs, a right pleural effusion, multiple transverse process fractures, fracture of the fourth lumber vertebral body, and a retroperitoneal hematoma; he had no recurrence of a right inguinal hernia. Neither pelvic fracture nor urethral injury was observed. Upon examination of the anoperineal area, the sutured and contused/lacerated wound had foul-smelling discharge and white exudate. Digital examination demonstrated reduced anal sphincter tone. Magnetic resonance imaging (MRI) showed high intensity around the perineum on short T1 inversion recovery (STIR) sequences, strongly suspicious for necrotizing fasciitis (Figure 2). Additionally, MRI suggested a left anal sphincter injury. We immediately opened the wound and performed an initial debridement and lavage with copious irrigation. On laboratory examination, abnormal values were as follows: white blood cell 11200/μL (normal range, 3500–9000/μL), platelet 11.8 × 104/μL (normal range, 14.0–37.9 × 104/μL), aspirate aminotransferase 43 IU/L (normal range, 10–35 IU/L), lactate dehydrogenase 265 IU/L (normal range, 110–225 IU/L), creatinine kinase 1054 IU/L (50–200 IU/L), and C-reactive protein 7.27 mg/dL (0–0.45 mg/dL). Wound cultures showed Enterobacter cloacae, Pseudomonas aeruginosa, and yeast. After admission to our hospital, we administered meropenem (2 g/day) and clindamycin (1800 mg/day), kept the patient NPO, and initiated parenteral nutrition. We continued antibiotics and wound lavage until the infection was controlled. Although low grade fever continued for ten days and subcutaneous gas remained in the left flank despite prompt disappearance of emphysema in the scrotum (Figure 3), the inflammation-related laboratory data improved gradually. He resumed oral intake after a week in the hospital. He required no further surgery and was discharged on hospital day 15. The subcutaneous air completely disappeared on abdominal CT two months after the first visit to our hospital. He had no fecal incontinence despite the injury to his sphincter. He is still followed carefully in the ambulatory setting.

Bottom Line: He presented to us with general fatigue, low grade fevers, and perineal pain.The sutured wound had foul-smelling discharge and white exudate.Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie 514-0832, Japan ; Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.

ABSTRACT
A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.

No MeSH data available.


Related in: MedlinePlus