Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: A case report

Abstract

Necrotising fasciitis, widespread necrosis of the skin, subcutaneous tissue, and superficial fascia, may be caused by many factors, among which underlying malignancy is observed rarely. We report a case with necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion. A 62‐year‐old male with newly diagnosed renal cell carcinoma was diagnosed with necrotising fasciitis at the end of 2 days in hospital. One day after debridement surgery, biliary contamination of dressings and tomography demonstrated fistulation from the duodenum to retroperitoneum and then to the right thigh because of renal tumour invasion. The second operation was performed to repair the duodenum. Intravenous antibiotics and hydration were maintained postoperatively. Although there was no surgical complication, the patient died because of respiratory collapse at the 12th day postoperatively. Renal cell carcinoma may invade the duodenum and, with retroperitoneal fistulation, may be the cause of necrotising fasciitis of the thigh. Laparotomy may be needed to control the origin of infection. However, necrotising fasciitis may be fatal in spite of aggressive treatment. The fasciitis should be diagnosed early to initiate timely aggressive treatment, and a possible endogenous source should be kept in mind.

1. INTRODUCTION

Necrotising fasciitis, a potentially lethal bacterial infection characterised by widespread necrosis of the skin, subcutaneous tissue, and superficial fascia, may be caused by many factors, among which underlying malignancy is observed in only 3% of cases.1 Renal cell carcinoma, which rarely invades adjacent organs owing to the central retroperitoneal location of the kidney and protective effect of Gerota's fascia, may cause gastrointestinal bleeding, sepsis, or renal failure in the case of duodenal invasion.2, 3, 4 We report the first case of necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion.

2. CASE REPORT

A 62‐year‐old male with newly diagnosed renal cell carcinoma in the right kidney was brought to the emergency department with deterioration of general condition, weakness, loss of appetite, and pain at right inguinal region. His white blood cell count was 4000/μL, C‐reactive protein: 213 mg/L, blood albumin: 2.1 g/dL, haemoglobin:8 g/dL, and haematocrit:26%. Then, he was admitted to the palliative care unit at the internal medicine ward. On the second day of clinical follow up, orthopaedics consultation was performed because of hyperaemia and tenderness of the right thigh, and the patient was taken to the operation room emergently with a diagnosis of necrotising fasciitis. The day after debridement surgery, biliary contamination of dressings alerted the orthopaedic team to a general surgery consultation (Figure 1).

Figure 1.

Biliary contamination of the thigh the day after the debridement surgery

Abdominal computerised tomography with an oral and intravenous contrast medium demonstrated the passage of intestinal content from the duodenum to retroperitoneum and then to the right thigh (Figure 2). The patient was taken to the operation room for an emergent laparotomy. There was a big, fixed, renal carcinoma invading the junction of the second and third parts of the duodenum. Detachment of the duodenum from the tumour demonstrated the retroperitoneal fistulation extending to the right thigh. After debridement, the fistula tract was irrigated rigorously. Following the Kocher manoeuvre, the duodenal defect was repaired in a double‐layer fashion. (Figure 3) A bulky omental flap was spread over the retroperitoneum.

Figure 2.

Computed tomography findings. A, Renal tumour invasion side to duodenum (red arrow); B, air fluid at retroperitoneal space over the psoas muscle (red arrow); C, air fluid passage from the femoral canal (red arrow)

Figure 3.

Duodenum to retroperitoneum fistula at laparotomy. A, Duodenal defect separated from invasion side of the renal tumour (asterisk), retroperitoneal fistula orifice (black arrow). B, Final view of the operation. Repaired duodenum and widened fistula orifice

Postoperatively, the patient was followed up on the surgical ward. His first bowel movement was on the first postoperative day, and he tolerated oral intake on the second day. Intravenous antibiotics (tigecycline 50 mg b.i.d, meropenem 1 g t.i.d, fluconazole 200 mg q.d), blood transfusion, and intravenous hydration was maintained to correct metabolic and haemodynamic status of the patient. Although there was no fistula anymore, and the thigh wound healed progressively, the general condition of the patient slowly deteriorated, and he was taken to intensive care unit because of respiratory collapse on the 12th day postoperatively. Unfortunately, the patient died in the ICU 2 days later.

3. DISCUSSION

Necrotising fasciitis is a rapidly progressive infection of skin, subcutaneous fat, and superficial fascia of the extremities, abdomen, and perineum.5 İnjury to the skin (needle puncture, insect bikes, burns, lacerations, surgical wound, blunt trauma, etc.) or haematogenous spread may initiate the infection.1 However, spread of an endogenous infection source was described in a few reports. The cases were mainly of colorectal origin: cancer,6, 7, 8 diverticulitis9, 10, 11 and steroid‐related colonic perforation.12 The only fasciitis case caused by duodenum perforation was related to iatrogenic perforation of duodenum by a percutaneous transhepatic drainage catheter in a patient with pancreatic head cancer, but fasciitis was found in the scrotum (ie, Fournier's gangrene).13 To the best of our knowledge, this is the first report of necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion.

Diagnosis of necrotising fasciitis is usually delayed because of insidious changes on the skin and can be mistaken as cellulitis. In this case, although there was deterioration in inflammatory parameters, diagnosis could only be made after 3 days of admission to the palliative care unit. As in most of the cases reported in the literature (6, 8‐10, 12), endogenous origin could be established after the debridement operation, usually via computerized tomography (CT). Although biliary contamination the day after the surgery obviously pointed to an intestinal fistula, a CT with oral contrast medium was ordered to aid the management of the case. CT showed that the spread of infection was through the femoral canal, which was confirmed with the irrigation of the fistula tract during the operation. This finding was parallel to that described by Wiberg et al.12

The management of necrotising fasciitis is best achieved with early diagnosis, aggressive surgical intervention, and appropriate antimicrobial therapy.5 In such cases with a predisposing pathology, control of the source is also important. Emergent laparotomy was the preferred approach in most cases6, 7, 8, 10, 12, 13 except the one in which delayed colectomy after percutaneous drainage was performed.9 We performed emergent laparotomy to repair the duodenal fistula. After the operation, the infectious disease team ordered antibiotic treatment according to wound culture results.

Necrotising fasciitis may end in mortality in 22% to 48% of cases despite aggressive surgical and medical treatment (1, 5). Associated diseases can be a predisposing factor, as well as a risk factor, for mortality. In this case, locally invasive renal carcinoma was the aetiological factor for the development of necrotising fasciitis, besides precluding the recovery of the patient with its cachectic effect. Although the duodenal fistula was healed, allowing oral intake, and the granulation of the wound started, the patient developed respiratory collapse during clinic follow up and died.

In conclusion, renal cell carcinoma may invade the duodenum and, with retroperitoneal fistulation, may be the cause of necrotising fasciitis of the thigh. Laparotomy may be needed to control the origin of infection. However, necrotising fasciitis may be fatal in spite of aggressive treatment. The fasciitis should be recognised early to initiate timely aggressive treatment, and a possible endogenous source should be kept in mind.

Okkabaz N, Turgut MA. Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: A case report. Int Wound J. 2019;16:1195–1198. 10.1111/iwj.13186