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A swollen right leg
CASE REPORT
Case report
A swollen right leg S D Pande, A Hossenbocus An 80-year-old man presented in June, 1997 with a 2-week history of malaise and 2 days of fever, generalised rigors, and a painful inflamed right thigh and leg. He did not have any abdominal symptoms, was not diabetic, and had not injured the leg. His medication was ibuprofen, ciprofloxacin, and paracetomol. On examination he was pyrexial (38⋅8⬚C), dehydrated, and tachycardic (110/min) and his BP was 120/60 mm Hg. His abdomen was soft and non-tender, with normal bowel sounds. Rectal and systemic examination were normal. The right thigh and leg were red, hot, and swollen with inguinal lymphadenopathy. Thigh and calf circumferences were 52⋅5 and 42 cm (right), 44 and 39⋅5 cm (left). Investigations showed a haemoglobin of 141 g/L, white-cell count 13⫻109/L (11⋅9 neutrophils), ESR 72 mm/h, urea 17⋅2 mmol/L, glucose 6⋅8 mmol/L, and C-reactive protein 420 mg/L. After taking blood for culture, intravenous benzylpenicillin 1⋅2 g and flucloxacillin 1 g four times daily were started. The cellulitis worsened, blisters formed, and after 48 h crepitus was noticed on his thigh and lower leg. Radiographs of the thigh showed the presence of gas. Antibiotics were changed to intravenous metronidazole 500 mg and ceftazidime 2 g three times daily and benzylpenicillin was increased to 1⋅8 g four times daily. A computed tomography (CT) scan of his abdomen and pelvis showed abnormal tissue in the right iliopsoas muscle, with gas in the muscle sheath extending to right the thigh and calf (figure). A laparotomy was done and a moderate sized appendicular abscess was found in a retroperitoneal position with pus tracking to the thigh. Appendicectomy was done and the right thigh and leg were incised, and pus drained. His antibiotics were changed to clindamycin 900 mg three times daily and fluconazole 200 mg intravenously once daily; benzylpenicillin was continued. Two sets of blood cultures were negative. Bacteroides spp, Candida spp and nonhaemolytic streptococci were grown on culture from swabs of the leg, pus from the thigh, and from the appendicular abscess. Histology of the appendix showed chronic inflammation. He recovered and when last seen in January, 2001 was well. Appendicitis in the elderly is often atypical and there is an increased risk of perforation, abscess formation, and death. The high complication rate is thought to be due to delayed presentation rather than any other factors.1 The case we have described with surgical emphysema, cellulitis of the leg, and no abdominal symptoms, is most unusual. Causes of retroperitoneal abscesses and subcutaneous emphysema include colonic
Computed tomography scan of the abdomen showing appendicular mass and gas shadow (arrow)
cancer, perinephric abscesses, Crohn’s disease, diverticular disease, and ulcerative colitis.3 Various organisms can form gas such as Clostridium spp, as can many other organisms including aerobic and anaerobic streptococci, staphylococci, bacteroides, E coli, and Klebsiella spp. Infection devitalises tissue and lowers the oxidation reduction potential. Anaerobic organisms can then proliferate freely.4 Pus and gas from a bowel perforation can track down the leg by various routes such as the femoral canal, the sciatic and obturator foramina, and most commonly by following the course of the iliopsoas muscle.2,3,5 In our patient pus and gas spread retroperitoneally along the iliopsoas muscle down the thigh and lower leg. We believe the subcutaneous emphysema resulted mainly from direct tracking of gas from the intestine via the perforated appendix. Non-clostridial crepitant cellulitis may be more prevalent than its clostridial counterpart. Subcutaneous gas does not necessarily mean clostridial infection especially in diabetic patients who are susceptible to many infections.4 Clostridial infections cause destruction of muscle, late gas formation, and more severe pain than other infections. Anaerobic cellulitis is more localised to subcutaneous and fascial planes, muscles are not usually affected, and gas formation occurs early. Onset of toxaemia and septicaemia is slower than in clostridial infection.4 References 1 2 3
Lancet 2001; 357: 1762 Purley Hospital, Purley, Surrey CR8 2YL, UK (S D Pande MRCP. A Hossenbocus FRCP) Correspondence to: Dr Pande
1762
4 5
Franz MG, Norman J. Increased morbidity of appendicitis with advancing age. Am Surg 1995; 61: 40–44. Nicell P, Tabrisky J. Thigh emphysema and hip pain secondary to gastrointestinal perforation. Surg 1975; 78: 555–59 Jager GJ, Rijssen HV. Subcutaneous emphysema of the lower extremity of abdominal origin. Gastro Radiol 1990; 15: 253–58. Markantone SS, Vinikoor J. Nonclostridial gas gangrene. J Foot Surg 1989; 28: 213–16. Gutknecht DR. Retriperitoneal abscess presenting as emphysema of the thigh. J Clin Gastroenterol 1997; 25: 685–87.
THE LANCET • Vol 357 • June 2, 2001
Case report
A swollen right leg S D Pande, A Hossenbocus An 80-year-old man presented in June, 1997 with a 2-week history of malaise and 2 days of fever, generalised rigors, and a painful inflamed right thigh and leg. He did not have any abdominal symptoms, was not diabetic, and had not injured the leg. His medication was ibuprofen, ciprofloxacin, and paracetomol. On examination he was pyrexial (38⋅8⬚C), dehydrated, and tachycardic (110/min) and his BP was 120/60 mm Hg. His abdomen was soft and non-tender, with normal bowel sounds. Rectal and systemic examination were normal. The right thigh and leg were red, hot, and swollen with inguinal lymphadenopathy. Thigh and calf circumferences were 52⋅5 and 42 cm (right), 44 and 39⋅5 cm (left). Investigations showed a haemoglobin of 141 g/L, white-cell count 13⫻109/L (11⋅9 neutrophils), ESR 72 mm/h, urea 17⋅2 mmol/L, glucose 6⋅8 mmol/L, and C-reactive protein 420 mg/L. After taking blood for culture, intravenous benzylpenicillin 1⋅2 g and flucloxacillin 1 g four times daily were started. The cellulitis worsened, blisters formed, and after 48 h crepitus was noticed on his thigh and lower leg. Radiographs of the thigh showed the presence of gas. Antibiotics were changed to intravenous metronidazole 500 mg and ceftazidime 2 g three times daily and benzylpenicillin was increased to 1⋅8 g four times daily. A computed tomography (CT) scan of his abdomen and pelvis showed abnormal tissue in the right iliopsoas muscle, with gas in the muscle sheath extending to right the thigh and calf (figure). A laparotomy was done and a moderate sized appendicular abscess was found in a retroperitoneal position with pus tracking to the thigh. Appendicectomy was done and the right thigh and leg were incised, and pus drained. His antibiotics were changed to clindamycin 900 mg three times daily and fluconazole 200 mg intravenously once daily; benzylpenicillin was continued. Two sets of blood cultures were negative. Bacteroides spp, Candida spp and nonhaemolytic streptococci were grown on culture from swabs of the leg, pus from the thigh, and from the appendicular abscess. Histology of the appendix showed chronic inflammation. He recovered and when last seen in January, 2001 was well. Appendicitis in the elderly is often atypical and there is an increased risk of perforation, abscess formation, and death. The high complication rate is thought to be due to delayed presentation rather than any other factors.1 The case we have described with surgical emphysema, cellulitis of the leg, and no abdominal symptoms, is most unusual. Causes of retroperitoneal abscesses and subcutaneous emphysema include colonic
Computed tomography scan of the abdomen showing appendicular mass and gas shadow (arrow)
cancer, perinephric abscesses, Crohn’s disease, diverticular disease, and ulcerative colitis.3 Various organisms can form gas such as Clostridium spp, as can many other organisms including aerobic and anaerobic streptococci, staphylococci, bacteroides, E coli, and Klebsiella spp. Infection devitalises tissue and lowers the oxidation reduction potential. Anaerobic organisms can then proliferate freely.4 Pus and gas from a bowel perforation can track down the leg by various routes such as the femoral canal, the sciatic and obturator foramina, and most commonly by following the course of the iliopsoas muscle.2,3,5 In our patient pus and gas spread retroperitoneally along the iliopsoas muscle down the thigh and lower leg. We believe the subcutaneous emphysema resulted mainly from direct tracking of gas from the intestine via the perforated appendix. Non-clostridial crepitant cellulitis may be more prevalent than its clostridial counterpart. Subcutaneous gas does not necessarily mean clostridial infection especially in diabetic patients who are susceptible to many infections.4 Clostridial infections cause destruction of muscle, late gas formation, and more severe pain than other infections. Anaerobic cellulitis is more localised to subcutaneous and fascial planes, muscles are not usually affected, and gas formation occurs early. Onset of toxaemia and septicaemia is slower than in clostridial infection.4 References 1 2 3
Lancet 2001; 357: 1762 Purley Hospital, Purley, Surrey CR8 2YL, UK (S D Pande MRCP. A Hossenbocus FRCP) Correspondence to: Dr Pande
1762
4 5
Franz MG, Norman J. Increased morbidity of appendicitis with advancing age. Am Surg 1995; 61: 40–44. Nicell P, Tabrisky J. Thigh emphysema and hip pain secondary to gastrointestinal perforation. Surg 1975; 78: 555–59 Jager GJ, Rijssen HV. Subcutaneous emphysema of the lower extremity of abdominal origin. Gastro Radiol 1990; 15: 253–58. Markantone SS, Vinikoor J. Nonclostridial gas gangrene. J Foot Surg 1989; 28: 213–16. Gutknecht DR. Retriperitoneal abscess presenting as emphysema of the thigh. J Clin Gastroenterol 1997; 25: 685–87.
THE LANCET • Vol 357 • June 2, 2001