Necrotizing Fasciitis Secondary to Enterocutaneous Fistula

Author(s):
Julie Valenzuela; Lutfullah Baskoy

Background:

The standard approach to necrotizing fasciitis is to obtain complete surgical source control. We describe a case of necrotizing fasciitis of the right thigh due to a groin enterocutaneous fistula. Surgical control of necrotizing fasciitis was complicated due to severe protein-calorie malnutrition and a hospital course complicated by respiratory failure secondary to COVID-19 infection.

Hypothesis:

A staged approach to obtain source control of necrotizing fasciitis was needed due to the severity and chronicity of the patient’s nutritional status and enterocutaneous fistula.

Methods:

A 60-year-old male was undergoing chemoradiation for metastatic prostate cancer for several months when he sustained a ground-level fall and presented to another hospital complaining of right leg pain. Per the patient’s report, the patient underwent a CT scan at the outside facility, where they diagnosed a right proximal thigh necrotizing soft tissue infection. He underwent debridement and a large volume of bilious staining and output was noted. After 8 days of attempted wound care, NPO, and TPN, the patient was transferred to our quaternary care hospital for continued care.

Results:

On admission, he was septic with confusion, leukocytosis, and an infected right thigh wound with significant bile staining and repeat imaging showing undrained collections of the thigh and iliacus along with communication to a segment of ileum confirming the enterocutaneous fistula and evidence of bony metastatic disease. The patient had lost 30 lb (20% weight loss) in the last 10 months with significant deconditioning. Redebridement and drainage of pelvic collections and leg were performed with an attempt to control the effluent with foley insertion into the fistula with goals to optimize nutritional status prior to further surgical management of the enterocutaneous fistula. Hospital course was further complicated by COVID-19 infection requiring intubation with recurrent sepsis. Ultimate source control was obtained after nutritional optimization, and the patient was weaned from the ventilator, allowing for safer enteric diversion and takedown of his fistula. Cultures were significant for pseudomonas, candida glabrata, and Stenotrophomonas.

Conclusions:

The principles of enterocutaneous fistula in a nutritionally compromised patient required a staged approach to gain ultimate source control of a necrotizing soft tissue infection and COVID PNA. Poor nutritional status and frailty need to be considered in the management of surgical infections.