Discussion:
Due to acute and rapidly progressive course, NF has a high mortality
rate estimated at between 25% and 75% [1]. It’s
life-threatening surgical
emergency. Thus, early diagnosis of necrotizing soft-tissue infections
followed by administration of intravenous antibiotics and surgical
debridement is the best way of decreasing its mortality [3]. In our
case, the delay between our physical examination in the operating room
and physical examination in the emergency department highlights the
importance of early care in this type of soft-tissue infection.
NF of the abdominal wall due to colorectal cancer is widely reported in
the literature. However, NF of the thigh caused by colorectal cancer, as
in our case, is extremely rare. In this case, a retroperitoneal abscess
formed through the femoral ring and reaching the thigh caused NF to
occur [1]. Literature review of atypical presentations of perineal
necrotizing fasciitis revealed that perforated gastrointestinal tract
malignancy was the etiology in 16% [4].
Clinical features of NF include high fever with chills, tenderness over
the affected area along with changes in skin color and palpable crepitus
[3]. In this case report, the patient presented with sepsis,
swelling of the thigh and abdominal pain. NF was not suspected as no
suspicious medical history was present. However, imaging showed the
classic findings of fluid and gas tracking along fascial plans. From
swelling of the thigh to septic shock, these clinical presentations
highlight the clinical polymorphism of NF. It is often initially missed
leading to lengthy delays in diagnosis and treatment. Weight loss,
transit disorders and abdominal pain, like in our case, are signs that
can guide to colon cancer as an etiology of NF.
NF can be difficult to recognize in the early stages, so a low index of
suspicion is needed when confronted with rapidly spreading erythema or
subcutaneous crepitus. Skin necrosis and blistering are late signs
[5]. Patients with unexplained soft tissue infections of the thigh
should raise suspicion for abdominal pathology and need urgent CT scan
[5] for timely diagnosis to avoid delays in the management of sepsis
and to offer a better operative planning and counseling for the patient.
The cornerstone of management of NF is recognized as being aggressive
surgical debridement and intensive support [6]. Urgent surgical
debridement down to healthy tissue allows to stop the spread of the
infection and reduces systemic toxicity. In fact, the NF is lethal
without operative debridement. Intravenous antibiotics should be started
promptly and modified when sensitivities return. However, it is
essential to ensure that adequate necrotic material is removed at the
first opportunity to reduce the risk of further progression, regardless
of the defect that will remain [6].