Bowel Perforation Resulting in Necrotizing Soft-Tissue Infection of the Abdomen, Flank, and Lower Extremities

Background: Fournier's gangrene is a necrotizing soft-tissue infection (NSTI) that often originates from a break in bowel integrity and affects the perineum, anus, or genitalia. Although the pathogenesis is similar, NSTI caused by a break in bowel integrity less commonly presents as infection of other sites. Objective: To characterize NSTIs originating from bowel perforation and presenting as infection of the abdominal wall, flank, or thigh but that largely spare the perineum, anus, and genitalia. Methods: We describe a characteristic case and summarize findings from 67 reported cases. Results: The causes of bowel injury included trauma (29%), perforated appendicitis (23%), perforated diverticulitis (16%), and perforation of a gastrointestinal tract cancer (16%). The symptomatic prodrome is indolent and nondescript. Most patients have polymicrobial infections and require antibiotic therapy combined with serial surgical debridements. Because the presentation differs from that of typical Fournier's gangrene, recognition of NSTI was delayed in the reported cases, and the associated bowel perforation often was overlooked, leading to delayed surgical treatment. As a result, the mortality rate was >33%, far exceeding that of typical Fournier's gangrene. Delays in diagnosis or surgical intervention predict a poor outcome. Conclusions: An NSTI resulting from bowel perforation can present in an atypical fashion carrying significant morbidity and mortality rates. Delayed diagnosis and treatment of this condition is associated with a poor outcome.