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Introduction:
While many randomized trials demonstrated the possibility of non-operative management of uncomplicated appendicitis, appendectomy remains the standard of care. In distinct contrast, perforated acute appendicitis is widely treated non-operatively; supported by many prior studies. Although few reports demonstrated that Fournier's gangren and necrotizing fasciitis are potential complications of perforated appendicitis, we are reporting the first case of abdominal wall necrotizing fasciitis and Fournier's gangrene during the non-operative management of perforated appendicitis in a young healthy gentleman. This case demonstrates the need for close observation and the potential for significant disease progression in complicated appendicitis.
Case report
Our patient is a 23 year-old Afro-Caribbean gentleman with no significant medical history. He presented with a gradual onset of diffuse abdominal pain of 7 days duration, progressively localized to the right lower abdominal region. On physical exam, the patient was normotensive, pulse 108/minute, temperature 100.1 F, mild distended abdomen and right lower abdominal tenderness with an elevated WBC of 20k/cc. On admission, CT of abdomen and pelvis demonstrated an appendicolith, thickening of the cecum, a 5.9 x 2.6 x 14.8 cm gas and fluid containing locules in the right lower abdominal quadrant compatible with perforated appendicitis. These locules were not drainable, with the appearance of an appendicluar mass rather than a contained abscess. The patient was admitted to the hospital for non-operative management which included intravenous broad spectrum antibiotics and serial abdominal exams. On hospital-day 4, the patient developed vomiting, more abdominal distension, a scrotal abscess, pulse 120, fever 102 F, WBC decreased to 16k/cc. A repeat CT demonstrated stable locules of air and fluid (mostly retroperitoneal) and diffuse
abdominal wall edema. The patient underwent a diagnostic laparoscopy that was converted to open due to difficulty developing an appropriate working domain. A perforated appendix adherent to the right pelvic side wall and an extraperitoneal purulent collection was noted. After appropriate abdominal washout and appendectomy, incision and drainage of the right hemiscrotal abscess was performed. Postoperatively, the patient had a protracted hospitalization course (60 days) consistent with septic shock and multi-system organ failure. The patient's condition necessitated multiple returns to the operative room for debridement of necrotizing fasciitis involving the scrotum and most of the lower half of his abdominal wall. The patient was also managed by the burn critical care unit for extensive skin loss, received appropriate wound care (including negative pressure wound dressing), and later was covered successfully with skin grafts and was discharged in stable condition.