Necrotizing Fasciitis of Abdominal Wall in a Super Obese Patient-A Case Report and Literature Review

超級肥胖症病患發生腹壁壞死性筋膜炎－案例報告與文獻回顧

阮智楷(Chih-Kai Juan) ； 趙崧筌(Song-Chuan Chao) ； 楊為舜(Wei-Shun Yang) ； 鄭乃禎(Nai-Chen Cheng) ； 戴浩志(Hao-Chih Tai) ； 楊永健(Eng-Kean Yeong)

《臺灣整形外科醫學會雜誌》 30卷3期 (2021/09) Pp. 193-201

摘要

Background: Necrotizing fasciitis (NF) can be fatal and rapidly progressive, spreading along subcutaneous fat, fascia, or muscle. It is a surgical emergency with high mortality rate. Early identification and surgical intervention, appropriate antibiotic treatment, and intensive care are the most important keys for survival. Aim and Objectives: NF, which is diagnosed clinically, is fatal and rapidly progressive during the disease course. About 90% of all NF cases involves the extremities. The cases of abdominal wall necrotizing fasciitis are uncommon and the overall incidence rate is approximately 4%. The infective etiologies for NF in the torso region are mostly open abdominal surgeries or ostomy creation. Herein, we present a super obese patient with NF of the abdominal wall to reinforce awareness of NF in the torso region and review current literature regarding NF in super obese conditions. Material and Methods: A 34-year-old man with underlying hypertension and super obesity (body mass index of 53.75) presented with lower abdominal wall tenderness and erythema for 3 days. There were many old carbuncle scars on his abdominal skin. Abdomen and pelvic CT disclosed prominent fat stranding in the anterior abdominal wall with left side predominance. Leukocytosis was noted and the patient was admitted to the hospital for antibiotic treatment under the impression of cellulitis. Nevertheless, hemorrhagic bullae emerged from the abdominal skin 3 days after admission. The progressive skin lesions highly indicated of NF, the patient was immediately receiving regional fasciectomy. Results: Septic shock developed during the first emergent operation, and vasopressor was administered. Surgical wound culture yielded Citrobacter koseri, Haemophilus parainfluenzae, and Peptostreptococcus asaccharolyticus. Blood culture sets were negative. After receiving 4 times of surgical debridement and 32 days of antibiotics treatment, the patient was discharged with a healed wound. However, a residual 4 cm dead space with seroma formation in his left lower abdomen was found 2 weeks postoperatively. No local signs of infection were noticed. After debridement under local anesthesia, the wound healed well without recurrence. Conclusion: NF is difficult to diagnose and the optimal timing to receive fasciectomy and debridement is indeterminate. In this case, severe deteriorating laboratory data yet fair clinical symptoms were the hints for us to suspect NF and make a surgical decision. Besides, we should be much more alert to obese patient as the immune response may be weakened and serum antibiotic level may not be enough. Early and prompt surgical intervention is the gold standard for treating NF as well as the most decisive factor for patient survival.

關鍵字

abdominal wall ； necrotizing fasciitis ； super obese

並列摘要

背景：壞死性筋膜炎是快速進展且致命的疾病，感染會沿著肌肉筋膜或皮下脂肪快速蔓延，是一個高致死率的外科急症。及早清創、適當抗生素治療及密切照護是拯救此類病人最重要的關鍵。目的及目標：壞死性筋膜炎是一個高度依靠臨床經驗診斷的疾病，快速進展的病程和高致死率為其特徵。大約90%壞死性筋膜炎發生在四肢，而腹壁壞死性筋膜炎的案例較不常見，於壞死性筋膜炎病人中約4%，絕大部分感染源自開腹手術傷口或腹壁造口。在此，我們提出一個超級肥胖症病患發生腹壁壞死性筋膜炎的案例報告，不要輕忽軀幹部位的壞死性筋膜炎且保持警覺，並針對超級肥胖狀況與壞死性筋膜炎作相關文獻回顧。材料及方法：一位34歲男性有高血壓及超級肥胖症（身體質量指數BMI = 53.75）病史，下腹部壓痛及紅腫三天。送來急診時，理學檢查發現腹部有許多之前癰化膿癒合後的疤痕。腹部骨盆腔電腦斷層發現腹部左側脂肪層顯著顯影，但病人因病態性肥胖，身體無法通過電腦斷層儀器而沒完成完整檢查。實驗室數據顯示嚴重白血球增多（White blood cell count ＞ 30,000/uL）及急性腎損傷（Cre: 3.4mg/dL）。在初步診斷為蜂窩性組織炎之下，病人先住院接受抗生素治療。然而在住院三天後，腹部皮膚開始出現出血性水泡。在高度懷疑壞死性筋膜炎下，立即安排病人接受緊急區域筋膜切除手術。結果：病人在接受手術中產生敗血性休克而用上血管升壓劑，手術傷口培養出三種細菌：Citrobacter koseri, Haemophilus parainfluenzae, and Peptostreptococcus asaccharolyticus，血液培養則全為陰性。病人接受4次積極清創及32天抗生素治療後，病人傷口完全癒合。在手術後兩週追蹤時，發現在左下腹約有4公分死腔積血清腫，局部沒有感染症狀。接受局部麻醉清創手術後，傷口完全癒合，沒有復發。結論：壞死性筋膜炎是一種很難診斷的疾病，接受清創及筋膜切除手術的最佳時機很難決定。這位案例上，尚可的臨床症狀與嚴重惡化的實驗室數據無法相互解釋，暗示我們應高度懷疑為壞死性筋膜炎並決定做清創手術。此外，肥胖病人的免疫反應相對較弱，且血中抗生素濃度也較易不足，對此類病人應有更高警覺性。對於壞死性筋膜炎病人，即時且及早手術清創是最重要的治療。