Thigh Cellulitis

Thigh cellulitis: atypical presentation of intra-abdominal infection

Ann Fr Anesth Reanim. 2001 Nov

Tramoni G,
Mohammedi I,
Peguet O,
Petit P.

Service de reanimation polyvalente, pavillon G, hopital Edouard-Herriot, place d'Arsonval, 69003 Lyon, France.

The initial clinical presentation of intraabdominal disease can be an extraabdominal location. We report three cases of patients admitted to our intensive care unit because of a severe soft tissue infection of the lower extremity. Systematic research of the primitive source by using computed tomography (CT) scan allows us to find perforation of the gastrointestinal tract. Despite an unusual presentation, a high index of suspicion for lower intestine perforation must always be considered in face of a patient presenting with a spontaneous thigh cellulitis. Immediate radical debridement, appropriate antibiotics, and intensive care support are critical to control these life-threatening infections.

PMID: 11759323 [PubMed - indexed for MEDLINE]

Related Article:

Necrotizing soft tissue infection of the thigh: consider an abdominal cause.

Nijhof HW,
Steenvoorde P,
Bonsing BA,
Hartgrink HH.

Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. h.w.nijhof@lumc.nl

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved.

METHODS: Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance.

RESULTS: Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus.

CONCLUSIONS: High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.

Springer Link

Related Article:

Cellulitis of the right thigh, with gas.

J R Soc Med. 2003 Nov

Departments of General Surgery, Medicine, and Radiology, Glan Clwyd Hospital, Rhyl, North Wales LL18 5UJ, UK.

Cellulitis involving the lower limb is a common cause of admission to hospital. In instances where cellulitis affects the thigh and groin region, anorectal causes should be sought.

CASE HISTORY

A woman of 69 was admitted after four weeks of rigors, low backache and anorexia. In addition her right hip had been painful for three weeks. There had been no change of bowel habit or abdominal pain. Three days before admission she had been started on trimethoprim by her general practitioner for a possible urinary tract infection. The medical history included hypertension, a pleomorphic salivary gland adenoma (excised one year previously) and rheumatoid arthritis. She was taking co-codamol, lansoprazole, lisinopril and prednisolone (15 mg once daily); she had recently stopped taking methotrexate.

On examination she was pyrexial (temperature 38.4°C) and mildly jaundiced. Her abdomen was soft and non-tender, but the right thigh was erythematous, warm and swollen on the anteromedial aspect from just below the inguinal ligament to the mid thigh. Haemoglobin was 11.5g/dL, white cell count 18.0 x 109/L, bilirubin 41 µmol/L. Cellulitis was diagnosed and she was started on intravenous benzylpenicillin 1.2 g four times daily and flucloxacillin 1 g four times daily. After 48 hours the thigh was slightly less erythematous but the fever persisted. Blood cultures were negative as were antistreptolysin titres. The treatment was changed to intravenous metronidazole 500 mg three times daily and clindamycin 600 mg four times daily and hyperbaric oxygen. After a further three days the cellulitis had spread over the whole thigh, her temperature was 39°C and there was evidence of an underlying soft tissue collection with crepitus. An ultrasound scan revealed gas in the soft tissues from the thigh to the ankle, confirmed by a plain X-ray. On clinical examination of the abdomen and perineum there was still no evident septic focus. Drainage of the thigh abscess yielded a large volume of foul smelling gas and pus, and the incision was extended from the groin to the knee. Most of the pus was subcutaneous; a small amount extended between the muscle groups but there was no evidence of myonecrosis. A tract was seen to be extending extraperitoneally up the femoral canal, with pus coming from above. A drain was placed up the femoral canal and the thigh wound was left open. On culture the pus gave a mixed growth of coliforms, anaerobic flora, streptococcus species and Pseudomonas aeruginosa. A CT scan showed extensive diverticular disease and a gas collection in the region of the right femoral canal closely related to a loop of bowel (Figure 1). At this stage faeces began to emerge from the thigh wound. At laparotomy there was a perforated diverticular mass in the right iliac fossa which had tracked down the femoral canal without contamination of the peritoneal cavity. A Hartmann's procedure was performed, with resection of about 15 cm of diseased sigmoid colon. After sixteen days she underwent debridement of the right thigh wound which was then closed with deep tension sutures. A lymphocutaneous fistula developed but this settled spontaneously. Five months later the colostomy was reversed without complications.

COMMENT

A possible cause of the gas tracking in the soft tissue was necrotizing fasciitis. However, no debridement of necrotic tissue was necessary during the initial procedure; moreover, necrotizing fasciitis is usually associated with a thin brown exudate rather than a large amount of frank pus.1 A largebowel origin is more likely, and the perforation might have occurred several weeks earlier, with partial walling off in the right iliac fossa. The patient was insistent about her lack of gastrointestinal symptoms, but the manifestations could have been limited by the steroid she was taking.

Although femoral hernias usually contain omentum or small bowel, occasionally they contain appendix, caecum, testicle, ovary, a Meckel's diverticulum or a caecal diverticulum.2
Previous workers have described necrotizing fasciitis of the abdominal wall secondary to a strangulated femoral hernia containing a perforated sigmoid diverticulum in the presence of a rectosigmoid cancer, though this involved the left femoral canal.3 Necrotizing fasciitis has also been described in the abdominal wall over the right iliac fossa secondary to perforation of a sigmoid diverticulum.4 We have not found any previous report of a perforated sigmoid diverticulum presenting with cellulitis and abscess formation in the right thigh.

REFERENCES

Nichols RL, Florman S. Clinical presentations of soft-tissue infections and surgical site infections. Clin Infect Dis 2001;33(suppl 2):84 -93[CrossRef]

Naunton-Morgan RM, Maw A. Solitary caecal diverticulum strangulated in a femoral hernia. Br J Surg1996; 83:1547[Medline]

Conn IG, Martin DL, La Ferla G. Necrotising fasciitis secondary to a strangulated femoral hernia containing a perforated sigmoid diverticulum. J R Col Surg Edinb1996; 31:91 -2

Harrison BJ. Perforated sigmoid diverticulum with necrotizing fascilitis of the abdominal wall. J R Soc Med1981; 74:625 -6[Medline]

Royal Society of Medicine