Retroperitoneal necrotizing fasciitis masquerading as perforated viscus: a rare case report.

Abstract

Introduction and importance: Necrotizing fasciitis is a rapidly progressive, life-threatening soft-tissue infection associated with high mortality, particularly when diagnosis is delayed. While most cases involve the extremities or perineum, retroperitoneal necrotizing fasciitis is exceedingly rare. Its deep anatomical location often results in vague clinical presentations, allowing extensive infection before overt signs develop, which poses significant diagnostic and therapeutic challenges. Early recognition and timely intervention are critical to improving outcomes.

Presentation of case: We report the case of a 40-year-old male who presented with nonspecific abdominal and flank pain, and low-grade fever of 2 days duration. Imaging revealed extensive retroperitoneal gas and fascial involvement. Urgent exploratory laparotomy confirmed necrosis of the bilateral abdominal wall fascia and retroperitoneal involvement. Initial surgical debridement was performed along with broad-spectrum antimicrobial therapy. Postoperatively, the patient underwent repeat surgical drainage. Despite initial stabilization, he progressed to acute kidney injury, hyperbilirubinemia, and biochemical evidence of pancreatitis, necessitating intensive care. The patient ultimately succumbed to uncontrolled sepsis with multiorgan failure on the sixth postoperative day.

Discussion: Retroperitoneal necrotizing fasciitis is difficult to diagnose due to nonspecific symptoms and deep anatomical location. Imaging, particularly contrast-enhanced computed tomography, is essential for detecting fascial necrosis and retroperitoneal gas. Even with prompt surgical debridement and broad-spectrum antibiotics, the infection can progress rapidly along fascial planes, causing secondary abscesses and multiorgan dysfunction.

Conclusion: Retroperitoneal necrotizing fasciitis can progress silently and rapidly, leading to multiorgan failure. Heightened clinical suspicion, early imaging, and prompt surgical management are crucial for improving patient outcomes.