Where does the fascitis come from?

This is a 73-year-old man who goes to the emergency department with cellulitis data close to the stoma of a Bricker reconstruction, doctors suspect a necrotizing fasciitis in the flank and right lower limb. A cystoprostatectomy was performed with Bricker-type reconstruction due to stage IV urothelial carcinoma of the bladder.Upon arrival at the emergency room, the patient presented with leukopenia and neutropenia. A CT study is performed after administration of intravenous contrast, acquisition in portal venous phase. Inflammation of the cecal appendix, located intraperitoneally in the right iliac fossa, was observed. The tip of the appendix rests on the peritoneum, demonstrating the passage of a gas bubble. Extensive right retroperitoneal inflammatory affectation accompanied by numerous gas bubbles. These inflammatory / infectious changes extend to the adjacent abdominal wall and the ipsilateral thigh. No intraperitoneal collections or prominent inflammatory changes in intraperitoneal fat are seen.

Urgent surgery was decided, in which the following findings were detected: cellulitis of the entire right flank, retroperitoneal abscess and cecal appendix with perforation at its base, with an inflammatory plastron towards the blind and retroperitoneum. After surgery, the patient was admitted to the intensive care unit for 12 days, presenting good evolution. In the abdominal wall, perforated appendicitis, complicated diverticulitis, intestinal perforation or complex trauma are the most important causes of necrotizing fasciitis. Retroperitoneal necrotizing fasciitis has been described on very few occasions, and due to the nonspecific symptomatology it is usually diagnosed late, which increases the mortality rate.

Radiologists are very used to the typical presentations of appendicitis but we can not help being alert to other possible less frequent pictures, such as the involvement of adjacent structures such as the retroperitoneum or the abdominal wall.

- Nanavati AJ, Nagral S, Borle N. Retroperitoneal perforation of the appendix presenting as a right thigh abscess. Case Rep Surg. 2015,2015:70 -191 - Carlos A. Cano. Fascitis necrosante por apendicitis evolucionada en saco eventrógeno.Revista Hisp