Severe Lumbar Necrotizing Soft Tissue Infection Originating from a J-Pouch Fistula

Author(s):
Theodore Delmonico; Andrew Stephen; Charles Adams, Jr.; Stephanie Lueckel; Daithi Heffernan

Background:

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection characterized by tissue necrosis, septic shock, and potentially death.  Key aspects of successful treatment are early recognition and urgent surgical source control by drainage and debridement.  NSTI can occur from traumatic injuries, but also from include ischemic, hematogenous, or rarely gastrointestinal routes.  We report a case of severe back NSTI arising from a pouch fistula in a patient with inflammatory bowel disease.

Methods:

Record Review and Case Report.

Results:

A 62 year old male with a history of ulcerative colitis and ileal J pouch presented with two weeks of lumbar pain and malaise and one day of acute severe cellulitis of the lower back.  He denied changes in bowel habits.

On exam he was afebrile, tachycardic (HR 120) and normotensive.  There was extensive erythema, tenderness and induration from his buttocks to mid-thoracic region. Hemorrhagic blistering and palpable crepitus was noted in his lower back.

Labs were notable for a leukocytosis of 21,500, 14% bands, CRP 364 mg/L and a sodium 129 mEq/l.  A LRINEC Score of 9 was calculated.  CT scan showed extensive inflammatory changes, multiple intramuscular abscesses in the paraspinal and gluteal musculature and an enterocutaneous fistula from a loop of bowel in the pelvis.

Discussion regarding operative approach concluded debridement of infected necrotic tissue was paramount to diminish the inflammatory burden and to offer egress for the paraspinal abscesses.  It was elected to forego a transabdominal approach at this time.

In the OR he underwent extensive debridement of necrotic soft tissue and muscle from his gluteal and paraspinal region to the lower scapula superiorly and deep to the level of the bony spine.  After stabilization and repeat debridement, he underwent pouch endoscopy which confirmed a fistula.  Two days later a diverting ileostomy was performed.

Once source control and full wound debridement was achieved, negative pressure therapy and eventual skin grafting were undertaken.  The patient was discharged on antibiotics for pelvic and spinal osteomyelitis.  He is recovering well with excellent wound healing.

Conclusions:

Fistulization from the GI tract is a rare but potential source of NSTI.  It is not necessary to address the fistula during the initial operation but should be done promptly after the patient stabilizes.  Prompt surgical debridement of infected soft tissue as source control remains the cornerstone of the index operation.