Unusual Manifestation of a Non-inflamed Appendiceal Fistula as a Necrotizing Soft Tissue Infection in the Setting of a Gigantic Ventral Hernia

Abstract

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection of the soft tissues that necessitates early identification and emergent aggressive surgical debridement due to its high mortality. NSTI most often results from the introduction of microbes through breaks in the skin. Unique sources, like appendiceal fistulae, can be etiologies of abdominal wall NSTIs. We present the case of a 46-year-old female with a past medical history of poorly controlled type II diabetes mellitus and ventral hernia who presented in septic shock with a necrotic wound in her abdominal wall. The wound was overlying a large ventral hernia and was consistent with NSTI. She was treated urgently with fluid resuscitation, antibiotic therapy, and surgical debridement of the wound. On repeat exploration, an appendiceal fistula was found protruding from the hernial sac. Open appendectomy and primary repair of the ventral hernia were performed. Principles of immediate intervention and repeat surgical debridement allowed control of the septic insult and definitive source control upon identification of an appendiceal fistula.

Keywords: abdomen ventral hernia; abdominal wall necrotizing fasciitis; appendiceal fistula; appendico-cutaneous fistula; colocutaneous fistula; necrotizing soft tissue infection.

Figure 1. Lower abdominal wall wound at the time of initial presentation

Figure 2. CT image demonstrating a large ventral hernia with an overlying abscess and prominent, associated soft tissue gas (arrow)

Figure 3. CT image demonstrating a large ventral hernia (asterisk) with overlying abscess and prominent associated soft tissue gas (arrow)