Necrotizing Fasciitis Masquerading as Stroke: A Diagnostic Dilemma

Abstract

Necrotizing fasciitis (NF) poses a diagnostic challenge due to its rarity and similarity in presentation with other critical conditions. We report a case of a 79-year-old male who initially presented with altered mental status and stroke-like symptoms; he was ultimately diagnosed with abdominal wall NF spreading to the lower extremity. Despite a history of cecal mass perforation noted in prior imaging, the patient had been discharged from an outside emergency room on antibiotics, highlighting a missed opportunity for early intervention. Subsequent deterioration led to sepsis, organ failure, and ultimately, the detection of NF. Prompt recognition of subtle skin changes and laboratory abnormalities, along with a detailed physical examination, is essential for a timely and accurate diagnosis. Surgical debridement, coupled with broad-spectrum antibiotics, remains the cornerstone of treatment. Delays in surgical management significantly increase mortality, emphasizing the importance of prompt diagnosis and intervention. This case underscores the necessity for heightened awareness among healthcare providers to recognize NF promptly, especially when its clinical presentation overlaps with other critical conditions. Multidisciplinary collaboration and continued education are imperative to improve outcomes and prevent delays in the diagnosis and treatment of NF.

Keywords: abdominal wall necrotizing fasciitis; acute care surgery and trauma; cecal perforation; emergent general surgery; necrotizing fasciitis management.

Figure 1. Electrocardiogram showing sinus tachycardia

Figure 2. CT non-contrast of the head showing no evidence of an acute intracranial process

CT: computed tomography

Figure 3. CT angiography of the head and neck revealing no significant large vessel occlusion or stenosis, or perfusion abnormalities

CT: computed tomography

Figure 4. Macroscopic images showing the diffuse erythema with signs of NF extending from the right flank down the lateral aspect of the right lower extremity

Image A shows the extension up to the right flank. Image B shows the infection extending to the lateral aspect of the right lower extremity NF: necrotizing fasciitis

Figure 5. CT of the abdomen and pelvis revealing a cecal mass with micro-perforation

The blue arrow shows the cecal mass and site of micro-perforation. The orange arrow shows the fluid tracking laterally out of the cecum. The yellow arrow shows the necrotizing infection and gas CT: computed tomography

Figure 6. CT image revealing diffuse soft tissue gas present in the right lower extremity

The yellow arrows show the diffuse gas present in the right lower extremity CT: computed tomography