RECTAL PERFORATION COMPLICATED BY FOURNIER’S GANGRENE SECONDARY TO ACCIDENTAL TOOTHPICK INGESTION

Abstract

SESSION TITLE: Case Report Semifinalists 9 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Necrotizing fasciitis (NF) is a life threatening soft-tissue infection. Fournier’s Gangrene (FG) is NF involving the genital, perianal and perineal regions. Accidental Foreign body (FB) ingestion resulting in life threatening NF and FG is extremely rare. We report one such interesting case. CASE PRESENTATION: A 57-year-old male with past medical history of diabetes mellitus presented with chief complaints of vomiting, non-bloody diarrhea and rectal pain. Physical exam was remarkable for high grade fever and normal digital rectal exam. Laboratory investigations were remarkable for leukocytosis with negative infectious workup and autoimmune panel. CT abdomen/pelvis was suggestive of proctitis. The patient was started on broad spectrum antibiotics. He continued to spike high grade fevers with up trending leukocytosis, followed by hypotension and new onset painful bilateral testicular swelling . CT pelvis of soft tissues showed a peri-rectal opacity, massive subcutaneous edema, air in the perineum and scrotum with extension to the right lateral aspect of the anus concerning for FG. The patient underwent sigmoidoscopy followed by local exploration via a peri-rectal incision. A toothpick 3.1 x 0.2 x 0.1 cm was found to have perforated the rectum 6cm from the anal sphincter forming a fistulous connection, with perirectal abscess and extending cephalad to the base of the scrotum. The patient had multiple debridements and eventually underwent sigmoid colostomy. A follow up colonoscopy at eight months showed recovery from the perforation and the colostomy was closed electively. DISCUSSION: Accidental ingestion of a foreign body (FB) is not uncommon. FB has been reported to cause bleeding, obstruction, perforation, fistula formation and in rare cases necrotizing fasciitis (NF). Symptoms, complications and site of lodgment depends on size and sharpness of the FB and frequently involve the duodenum (23%) and large intestine (37%). Less than 1 % FB cause perforation. Investigation modalities include plain film, ultrasound, CT scan and MRI. Broad-spectrum antibiotics, surgical debridement and control of the perforation are imperative in the management of cases like our patient. The option for stoma creation versus primary colonic repair depends on severity of the perforation and the patient’s general condition. It should be noted that while cases of intestinal perforations secondary to diverticulitis or gastrointestinal tract malignancies resulting in NF are not uncommon. To the best of our knowledge, this is the third case in literature of NF and FG caused by accidental tooth pick ingestion. CONCLUSIONS: This case brings to light an interesting and rare presentation of accidental tooth pick ingestion leading to life-threatening FG. Reference #1: Intestinal Perforation by a Toothpick as Reason for Necrotizing Fasciitis. Markus Rupp, Gero Knapp, David Weisweiler, Christian Heiss, Volker Alt. J Bone Jt Infect. 2018; 3(4): 226–229. Reference #2: Right Hip Necrotizing Fasciitis. Lee I-H, How C-K, Chen J-D, Yen DH-T, Chiu Y-H. N Am J Med Sci. 2011;341:499 Reference #3: Necrotizing fasciitis. Green RJ, Dafoe DC, Rajfin TA. Chest. 1996;110:219–29. DISCLOSURES: No relevant relationships by Andrey ILiev, source=Web Response No relevant relationships by Muneer Khan, source=Web Response No relevant relationships by Mariam Saeed, source=Web Response