Thigh Abscess Secondary to Intra-Abdominal Pathologic Conditions

Three Cases Progressing to Necrotizing Fasciitis

Arife Simsek, MD

Disclosures

Wounds. 2021;33(9):226-230. 

In This Article

Results

Case 1

A 77-year-old male was admitted to the emergency department with left knee and hip pain of 5 days' duration. He was a nonsmoker with a history of hypertension, coronary heart disease, and colon cancer, for which he had undergone left hemicolectomy 1 month previously. Following symptomatic treatment with nonsteroidal anti-inflammatory drugs, the patient was discharged. He returned to the emergency department 2 days later with abdominal pain and swelling in the left thigh. Physical examination revealed fever (38.3°C) and tachycardia. The abdomen was comfortable, hip flexion range of motion was limited, and a thigh abscess was detected on the left side. Laboratory tests revealed a white blood cell (WBC) count of 38.6×109/L, hematocrit (HCT) of 38.3%, C-reactive protein (CRP) level of 25.9 mg/dL, and biochemical values in the normal range. Abdominal computed tomography (CT) showed a multilocular abscess begining at the level of the left renal vein and extending from the paracolic gutter down to the left knee (Figure 1). The patient was transferred to the general surgery unit. Percutaneous drainage catheters were inserted for both abdominal and thigh abscesses on day 4 of admission. The abscess, urine, and blood cultures were negative. The thigh abscess was surgically drained, and negative pressure wound therapy (NPWT) was applied on day 12 and day 19 of admission. The patient was discharged on day 24 because he declined further therapy. Four days after the patient was discharged, he was readmitted to the hospital with a recurrent thigh abscess. Laboratory tests revealed a WBC count of 11.2×109/L, HCT of 34%, CRP level of 15.5 mg/dL, and biochemical values in the normal range. Abdominal CT findings were the same as those previously recorded, but the size of the abscess had decreased. A percutaneous drainage catheter was reinserted for the abdominal abscess. Surgical debridement and NPWT were used to treat NF of the thigh 5 times in 18 days. Tissue culture was positive for Klebsiella pneumoniae and enterobacteria. The patient died of overwhelming sepsis on day 18 of the third admission at the treating institution. A broad-spectrum antibiotic regimen had been started on second admission and subsequently de-escalated based on culture results and clinical response.

Figure 1.

Abdominal computed tomography scan showing a multilocular abscess located on the proximal left thigh.

Case 2

A 53-year-old male was admitted to the neurosurgery outpatient clinic with back pain spreading to the right leg of 3 months' duration. He was a nonsmoker and had a history of diabetes mellitus and rectal cancer, for which he had undergone low anterior resection and colorectal anastomosis 10 years earlier. Endoscopic follow-up had been performed for anastomotic stricture over the previous 5 years. Laboratory tests revealed a WBC count of 8×109/L, HCT of 29.7%, and CRP level of 15.1 mg/dL. The patient underwent posterior foraminotomy and diskectomy for vertebral disk hernia based on physical examination and magnetic resonance imaging. On postoperative day 3, the patient had a fever of 38.4°C, and an abscess of the right thigh was detected. The abscess was drained percutaneously on postoperative day 8 when the patient was transferred to the orthopaedic surgery and traumatology unit. The abscess culture was positive for Escherichia coli. The patient was transferred to the infectious diseases unit on postoperative day 13. Although there was no sign of abdominal pain, the patient was transferred to the general surgery unit on postoperative day 19; a multilocular abscess beginning at the level of the colorectal anastomosis and extending into the gluteus bilaterally and down to the right thigh was identified by an abdominal CT scan (Figure 2), but the patient refused surgery. He was medically treated for the pericardial effusion, which developed on postoperative day 20. The colonoscopy, which was performed on day 26, revealed that the rectum was lateralized into a 10-cm pouch at 7 cm proximal to the anal verge. The patient was discharged on postoperative day 29. Ten days later, he was readmitted to the hospital with recurrent thigh abscess on the left side. Hyponatremia resulting from a syndrome of inappropriate antidiuretic hormone secretion was diagnosed. Resection of the stenosis and construction of a new coloanal anastomosis with ileostomy and debridement of the left thigh to manage NF were performed on day 13 of second admission. On postoperative day 14, cardiac arrest occurred due to cardiac tamponade. Sputum and blood cultures were positive for K pneumoniae and Pseudomonas aeruginosa. The patient died of overwhelming sepsis on postoperative day 36. A broad-spectrum antibiotic regimen had been started on initial admission and subsequently de-escalated based on culture results and clinical response.

Figure 2.

Abdominal computed tomography scan showing a multilocular abscess located bilaterally on the gluteus and proximal aspect of the right thigh.

Case 3

A 68-year-old male without diabetes was admitted to the medical oncology unit with hip pain spreading to the right leg of 7 days' duration. He had a 10 pack-year history of smoking and of rectal cancer, for which he had undergone low anterior resection 4 years previously. The patient did not have any recent hospitalization, except that he had been hospitalized at a different center owing to urosepsis over the previous 4 days. Physical examination revealed a fever of 38.8°C and tachycardia. The abdomen was comfortable, hip range of motion was limited, and a right-sided thigh abscess was detected. Laboratory tests revealed a WBC count of 14.1×109/L, HCT of 41.9%, CRP level of 16.3 mg/dL, and lactate of 1.8 mmol/L. The thigh abscess was drained surgically by orthopaedic surgeons on day 2 of admission. The abscess culture was positive for E coli, and the urine culture was positive for Candida albicans. The patient was transferred to the general surgery unit on postoperative day 4 based on physical examination (colocutaneous fistula; Figure 3) and abdominal CT findings (a multilocular collection begining at the level of the colorectal anastomosis and extending into the gluteus bilaterally and down to the right thigh). Abdominoperineal resection, ilial resection with side-to-side anastomosis, and surgical debridement of the right thigh to manage NF were performed (Figure 4A). Surgical debridement followed by NPWT were performed and applied, respectively, 4 times in 30 days. Surgical debridement of the scrotum was performed to manage Fournier's gangrene, and the urethra was repaired to manage urethral fistula on day 80 (Figure 4B). The tissue culture was positive for extended-spectrum β-lactamase–producing E coli, Klebsiella, and C albicans. Both urine and blood culture were positive for C albicans. The patient died of overwhelming sepsis on day 89. A broad-spectrum antibiotic regimen had been started on admission and subsequently de-escalated based on culture results and clinical response.

Figure 3.

Colocutaneous fi stula.

Figure 4.

(A) Necrotizing fasciitis of the right thigh. (B) The scrotum was debrided, and the urethral fi stula was repaired.

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