subcutaneous emphysema as presen”>Correspondence 421

References

1. Holger JS, Wandersee SC, Hale DB. cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorb- able sutures. Am J Emerg Med 2004;22:254 - 7.
2. Lo S, Aslam N. A review of tissue glue use in facial lacerations: potential problem with wound selection in accident and emergency. Eur J Emerg Med 2004;11:277 - 9.

Anthony L.H. Moss FRACS, FRS

Consultant Plastic and Reconstructive Surgeon

St Georges Hospital

London, UK

doi:10.1016/j.ajem.2005.02.041

massive subcutaneous emphysema as presenting finding of Colonic perforation and retroperitoneal necrotizing fasciitis

To the Editor,

Retroperitoneal fasciitis is a rare, potentially lethal complication of colonic perforation. We report a case of colonic perforation with retroperitoneal necrotizing fasciitis, initially presenting as massive subcutaneous emphysema, in an Elderly woman undergoing Steroid treatment.

A 70-year-old woman, with known diverticula of the colon and rheumatoid arthritis undergoing chronic steroid treatment was admitted to the emergency department with massive subcutaneous emphysema. Eighteen hours before presentation, the patient started complaining of blunt, progressively increasing abdominal discomfort followed by massive subcutaneous emphysema of the neck, thorax, and abdomen. At presentation, the patient was alert, normotensive, tachycardic, and with a temperature of

37.78C. Her physical examination revealed mild tenderness without guarding at the left upper abdominal quadrant and left flank. Bowel sounds were reduced.

The main laboratory findings on admission were leukocytosis (white blood cells, 22990 mm³), hyperglyce- mia (394 mg/dL), and increased lactate (4.6 mg/dL). arterial blood gases on room air were Pao₂ 72 mm Hg, Paco₂ 27 mm Hg, pH 7.42. A computed tomographic scan of the thorax confirmed X-ray findings of pneumomedias- tinum, pneumoperitoneum, pneumoretroperitoneum, and extensive subcutaneous emphysema (Figs. 1 and 2). The administration of oral contrast media did not reveal perforation of the esophagus, stomach, or duodenum.

Because of probable sepsis without a clearly apparent site of infection or upper gastrointestinal tract perforation, the patient was taken to the operating room because of her deteriorating condition. emergency laparotomy revealed perforation of the colon at the level of the left colic flexure and a small amount of pus at the left subphrenic space, down the left coloparietal gutter, and in the pelvis. No specific pathology at the site of perforation could be found.

Inflammation extended to the retroperitoneum as necrotiz- ing fasciitis, with infiltration of the sheath of the left kidney. The tissue planes in the retroperitoneal space were friable and loose, allowing free separation with finger dissection. Foul odor, gas, crepitation, and a brown, turbid bdishwaterQ fluid were present. The patient underwent hemi- colectomy and debridement of the retroperitoneal tissues with a Hartmann’s diverting colostomy. Fluid cultures developed Escherichia coli and Pseudomonas aeruginosa. The patient had a fulminant postoperative course, with severe septic shock, anuria, and adult respiratory distress syndrome. A violaceous erythema with induration appeared

12 hours postoperatively, progressively spreading in the back, flank, and lateral abdominal wall bilaterally, a finding attributed to spreading of retroperitoneal infection. Because of extreme severity, reoperation was not attempted, and despite intensive support, the patient died on postoperative day 3.

Retroperitoneal necrotizing fasciitis is a rare, fulminant, and often fatal complication of intraabdominal suppuration. The primary event is usually pericolic or perirectal sepsis [1] and may rarely complicate pelvic or perineal infections in gynecological and obstetric patients [2]. Although cases of successful treatment after extensive repeated debridement

1. or even with relatively conservative debridement [4] have been reported, the mortality of necrotizing retroperi- toneal fasciitis is very high [1]. Second-look laparotomy reveals spreading necrosis in most patients [3]. Sometimes, necrotizing fasciitis in a compromised host may have a

Fig. 1 Axial computed tomographic section at the level of upper kidney poles printed on bone-air window settings. Gas is demonstrated in the anterior pararenal space, in close relationship with the proximal descending colon. Gas also dissects the leafs of the left posterior perirenal fascia and the left lateroconal fascia. A small amount of air is seen in the perirenal space. Gas is also present in the peritoneal cavity and in the subcutaneous tissues on the left.

422 Correspondence

Fig. 2 Axial computed tomographic section just above the gastroesophageal junction printed on lung window settings. A significant amount of air is disclosed in the posterior mediastinum between the diaphragmatic crura. Air is present in the anterior mediastinum, the left and the right subphrenic space, and the subcutaneous tissues.

rather indolent initial presentation, without the Intense pain and localizing signs that usually characterize this entity [4]. Chronic treatment with steroids was probably related to the paucity of localized findings in our patient.

The most prominent early finding in our case was massive subcutaneous emphysema accompanied by impres- sive computed tomographic findings of extraluminal air in the peritoneum, retroperitoneal space, and mediastinum. The presence of gas in the left anterior pararenal space surrounding the proximal descending colon and the splenic flexure as well as signs of dissection along the perirenal and lateroconal fascia may indicate the level of perforation, in retrospect. Air from the anterior pararenal space migrates to the posterior mediastinum between the dispersed diaphrag- matic crura and subsequently to the rest of the mediastinum. Air dissecting the left lateroconal fascia may migrate to the left abdominal subcutaneous tissues. The presence of intraperitoneal air may be related to the site of perforation: at the level of the splenic flexure-proximal descending colon, the large bowel wall is partially covered by peritoneum and partially uncovered, surrounded by the fat of the anterior pararenal space. Few case reports connecting colonic perforation and pneumoperitoneum with air in the retroperitoneum, mediastinum, and subcutaneous tissue of the neck and upper torso have been reported [5-7].

This case underlines that localized signs of colonic perforation and retroperitoneal fasciitis may be initially

absent in patients undergoing steroid treatment. Such patients may occasionally present with unusual and remote findings such as massive air leak extending to retroper- itoneum, mediastinum, and subcutaneous tissues of the neck and thorax. Specific sites of gas presence or gas dissection along fascias may indicate the location of bowel perforation. Patients presenting with subcutaneous emphysema of the neck without an obvious thoracic source of air should be scrutinized for signs of retroperitoneal hollow viscus perforation to achieve successful early management. Retro- peritoneal necrotizing fasciitis may be a rare but deadly complication in such cases.

References

1. Woodburn KR, Ramsay G, Gillespie G, et al. Retroperitoneal necrotizing fasciitis. Br J Surg 1992;79:342 - 4.
2. Gallup DN, Freedman MA, Meguiar RV, et al. Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency. Am J Obstet Gynecol 2002;187:305 - 11.
3. Mokoena T. Survival after retroperitoneal necrotizing fasciitis. Br J Surg 1994;81:772.
4. Jayatunga AP, Caplan S, Paes TRF. Survival after retroperitoneal necrotizing fasciitis. Br J Surg 1993;80:981.
5. Hur T, Chen Y, Shu GH, et al. Spontaneous cervical and subcutaneous and Mediastinal emphysema secondary to occult sigmoid diverticulitis. Eur Respir J 1995;8:2188 - 90.
6. Catarino PA, Smith EE. Subcutaneous emphysema of the thorax heralding colonic perforation. Ann Thorac Surg 2001;71:1341 - 3.
7. Hunt I, Van Gelderen F, Irwin R. Subcutaneous emphysema of the neck and colonic perforation. Emerg Med J 2002;19:465.

Nikolaos Markou MD Iraklis Tsangaris MD Dimitris Konstantonis MD George Vretzakis MD Ioannis Pneumatikos MD

ICU, University Hospital of Alexandroupolis 68100 Alexandroupolis, Greece

E-mail address: [email protected]

Nikolaos Katsikoyiannis MD

Department of Surgery University Hospital of Alexandroupolis 68100 Alexandroupolis, Greece

Paraskevi Argiropoulou MD Panagiotis Prassopoulos MD Department of Radiology

University Hospital of Alexandroupolis 68100 Alexandroupolis, Greece

doi:10.1016/j.ajem.2005.01.005