Presentation
Known case of rectal cancer treated by surgery and chemotherapy, now presenting with soft tissue swelling, tenderness and signs of inflammation in the right gluteal region and right thigh.
Patient Data
post-operative changes noted in the rectum. Presacral fluid collection containing oral contrast, with air-fluid level, communicating with the posterior wall of the rectum through a large defect at the site of surgery, suggestive of contained rectal perforation.
fistulous communication between the rectum, the presacral collection and the right gluteal region (through the greater sciatic foramen) with subsequent extensive intermuscular crescentic fluid and air locules in the right gluteal region, as well as in the deep fascial plane of the right thigh, insinuating between the muscles predominantly along the posterior compartment but also in the anterior compartment, with smudged and thickened related fat and fascial planes. Diffusely increased enhancement of the muscles of the right thigh suggestive of inflammatory changes. Extensive bilateral subcutaneous fat stranding and edema.
Imaging findings suggestive of necrotizing fasciitis of right thigh and gluteal region, secondary to rectal perforation and fistulous communication with the right gluteal region.
Case Discussion
Necrotizing fasciitis is an aggressive soft tissue infection that mainly involves the superficial and deep fascia with sparing of the underlying muscles. The most common sites involved are the extremities, abdominal wall and the perineum.
Immunocompromised patients are at an increased risk of developing this disease.
CT is an excellent modality for the diagnosis of necrotizing fasciitis. The presence of soft tissue emphysema is a specific finding, but is not always present. The presence of loculated fluid collections along the fascial planes, and thickening and enhancement of the superficial and deep fascia, are often seen in necrotizing fasciitis. Subcutaneous fat stranding can also be present. Complications include myonecrosis, abscess formation and osteomyelitis.
Necrotizing fasciitis is a surgical emergency that is treated by prompt surgical debridement.
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