International Journal of Clinical & Medical Images

Case Presentation: A 38-year-old Taiwanese woman had a 7 month history of abdominal pain over right lower quadrant and microcytic anemia. Upper gastrointestinal (GI) scope revealed gastric ulcer. Lower GI scope was suggested, but she hesitated to it and lost followup. This time, she visited our institution due to dyspnea for 2 days with episodic fever up to 39.4° C. Pale conjunctiva, hypoactive bowel sound, a protruding lesion with tenderness and subcutaneous crepitus over right flank and buttock were noticed on physical examination. Significant laboratory findings were white blood cell counts of 19.5 ×109 /l with segmented neutrophils of 88% and band forms of 3%, hemoglobin 3.5 g/dl, C-reactive protein 21.2 mg/l, albumin 2.3 g/l, and calcium 1.85 mmol/l. Contrast-enhanced computed tomographic scan of the abdomen demonstrated ascending colon cancer with abscess formation and subcutaneous gaseous infiltration (Figures 1A-1C). Right hemicolectomy (Figure 1D), ileostomy and debridement with rotation flap were conducted. This patient was admitted to surgical intensive care unit for postoperative critical care. Cultureof abscess grew Escherichia coli and Streptococci viridans. Surgical pathological findings showed advanced adenocarcinoma of cecum, moderately differentiated, with invasion to mesocolic soft tissue, ileocecal valve and metastasized to mesocolic lymph nodes. She was discharged on the 25th postoperative day under uneventful condition.

Discussion: Necrotizing fasciitis (NF) is a fulminant and life-threatening gangrenous soft-tissue infection with mortality rate of 20-40% [1-4]. NF is usually caused by trauma to the skin or surgical wounds and less common due to underlying intestinal diseases such as perforated colonic diverticulitis or cancer [2-4]. 3.3% of patients with colon cancer had localized perforation and 0.3-0.4% of these patients had abscess formation [3,4]. Fewer cases of retroperitoneal abscess and NF caused by perforated colonic cancer have been reported and potentially fatal in immunocompromised patients with mortality rate of 50% [3].

It most commonly occurs in the abdominal wall, extremities and perineum. Clinical features of NF include fever, chills, tenderness and crepitus on the involved region with skin discoloration [1-4]. Early diagnosis by US or CT and treatment with broad-spectrum antibiotics and surgical debridement can reduce the mortality rate associated with abscess and NF [1-5]. We highlighted that colon cancer could be a cause of unexpected retroperitoneal abscess followed by NF.