Abdominal Wall Necrotizing Fasciitis - A Hidden Presentation

Abstract

A 55-Year-Old female, known case of type 1 diabetes, presented to the emergency department complaining of weakness and Abdominal Pain. The pain was constant, initiated since 10 days ago and was localized at the Right side of the Abdomen. She had no fever, vomiting or abnormal Bowel habits. Initial vital signs were as followings: Blood pressure: 110/60 mmHg, Pulse Rate: 120/min, Respiratory Rate: 18/min, Oxygen Saturation: 93% (Room Air), Oral Temperature: 37.8°C. On inspection, the patient had mild erythema on the area (from inguinal ligament up to lower costal margin) without any bulla or discharge. Crepitation was found by palpation of the skin. Other parts of the abdomen were soft without any tenderness or guarding. Supine Abdominal X-ray (Figure 1) revealed gas formation at the Right Side of the abdomen; the finding was confirmed by an emergent non-contrast abdominal Computed tomography (Figure 2). Primary Laboratory tests showed: Hemoglobin: 11.5 g/dl, white blood cell count 16.2 × 103 /ml (neutrophil 85%), mild hyponatremia (Na 127 mmol/l), hyperkalemia (K 5.5 mmol/l), serum creatinine 1.8 mg/dl and urea 50.2 mmol/l. The ultimate diagnosis was Abdominal necrotizing Fasciitis. Along with immediate resuscitation with intravenous fluid and antibiotics, patient was prepared and transferred to operating room. Unfortunately Despite prompt extensive surgical debridement, wide spectrum antibiotic therapy and 2 days of intensive care, unfortunately, the patient did not survive. Discussion Necrotizing fasciitis is a critical diagnosis that needs aggressive debridement, and broad spectrum antibiotic therapy. In 85% of cases, at first examination, necrotizing fasciitis has misleading clinical manifestations [1]. There are cases of necrotizing fasciitis that just presented as mild cellulitis [2]. Necrotizing fasciitis has dire outcomes in 50% to 80% of patients [3]. Mortality depends on comorbid diseases and complications that would rise during the course of the disease (acute renal insufficiency, acute respiratory distress syndrome, multi-organ failure) [4]. Conclusion Necrotizing fasciitis should always be considered as a critical diagnosis, especially in immunocompromised and diabetic patients.