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Gluteal necrotizing myofascitis: An unusual delayed complication of abdominal sacrocolpopexy
Gluteal necrotizing myofascitis: An unusual delayed complication of abdominal sacrocolpopexy Jay Goldberg, MD,a Michael Weinstein, MD,b Matthew Fagan, MD,a Michael Nagy, MD,b and Paul Nyirjesy, MDa Philadelphia, Pa Persistent low back pain developed in a 51-year-old woman after she had undergone abdominal sacrocolpopexy. Four months postoperatively, necrotizing myofascitis developed in her gluteal muscles. The infected mesh, which had eroded into the vagina, was removed. Cultures of the infected mesh and abscesses grew common vaginal flora, including Gardnerella vaginalis and Actinomyces. (Am J Obstet Gynecol 2001;185:1273–4.)
Key words: Abdominal sacrocolpopexy, mesh erosion, necrotizing myofascitis, Actinomyces
Abdominal sacrocolpopexy is a commonly performed procedure for the correction of uterovaginal and posthysterectomy vaginal vault prolapse. Complications from use of synthetic mesh with this procedure include erosion into the vaginal vault and infection. In previously reported series of patients with mesh erosion, all patients presented with vaginal discharge or bleeding.1 We describe a patient who instead presented with persistent back pain and gluteal necrotizing myofascitis originating from infected mesh that eroded into the vagina after the patient underwent abdominal sacrocolpopexy. Case report A 51-year-old woman, gravida 2 para 2, underwent a vaginal hysterectomy with anterior and posterior repairs, bilateral salpingo-oophorectomy, and abdominal sacrocolpopexy with GORE-TEX mesh (WL Gore, Flagstaff, Ariz) for pelvic organ prolapse. Approximately 2 months later, she had low back pain, which was thought to be musculoskeletal in origin. Her symptoms persisted despite multiple treatments with nonsteroidal anti-inflammatory drugs, narcotics, and muscle relaxants. A renal ultrasonography and intravenous pyelogram showed moderate hydronephrosis on the right side, leading to placement of a ureteral stent. Subsequently, magnetic resonance imaging of the
From the Department of Obstetrics and Gynecologya and the Department of Surgery,b Jefferson Medical College, Thomas Jefferson University. Received for publication May 30, 2001; accepted June 19, 2001. Reprint requests: Jay Goldberg, MD, Department of Obstetrics and Gynecology, Thomas Jefferson University, 834 Chestnut St, Suite 400, Philadelphia, PA 19107. E-mail: [email protected]. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/118154 doi:10.1067/mob.2001.118154
Figure. Computed tomography scan of the pelvis showing necrotizing myofascitis of the gluteal and right piriformis muscles.
lumbar spine revealed an L5-S1 disk extrusion. The patient was referred for physical therapy and fitted for a back brace. Approximately 4 months after the initial operation, the patient had acute onset urinary retention and perirectal numbness. She was transferred to our institution for evaluation of possible cauda equina syndrome caused by the herniated disk. She was afebrile, but hypotensive. Her abdomen was soft and nontender, but erythema overlying both buttocks was noted, with exquisite tenderness. Computed tomography scans of the abdomen and pelvis demonstrated extensive necrotizing myofascitis of the gluteus maximi (Figure). In the operating room, extensive myonecrosis and pus were encountered in the gluteal muscles, with the areas of purulence tracking to the sacrum; these areas were widely debrided and packed. The patient was taken to the inten1273
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sive care unit for ongoing resuscitation. She required mechanical ventilation and dopamine for hemodynamic support. Antibiotic therapy with piperacillin-tazobactam, initiated preoperatively, was continued. Cultures taken of the gluteal abscesses grew Gardnerella vaginalis, Peptostreptococcus sp., Prevotella melanogenica, and Prevotella loescheii. Two days later, the patient was taken again to the operating room after purulent vaginal discharge was noticed. Mesh was identified eroding through the vaginal cuff, but was unable to be removed vaginally. Via exploratory laparotomy, the GORE-TEX (WL Gore) mesh, surrounded by purulence, was identified and removed. The underlying sacrum had tunneling areas of erosion. A sigmoid loop colostomy was performed to prevent future contamination and aid in wound healing. Cultures of the infected mesh grew G vaginalis, S sp, and A sp. Thereafter, the patient slowly progressed. By the fourth postoperative day, she no longer required dopamine and was extubated. She required multiple debridements of the gluteal wounds and was given antibiotics for the duration of her hospitalization. The patient was discharged on hospital day 43. Comment This case represents an unusual complication of abdominal sacrocolpopexy occurring months after the initial procedure. The polymicrobial nature of the wound cultures, with the presence of G vaginalis, strongly supports the theory that the vagina was the original source of
November 2001 Am J Obstet Gynecol
infection. We hypothesize that infecting organisms seeded the mesh after vaginal erosion. Alternatively, the inoculation of pathogens may have occurred at the time of the original operation. The presence of Actinomyces in the mesh culture suggests that this case may represent an unusual presentation of pelvic actinomycosis. The indolent nature of her infection, which caused her relatively mild symptoms relative to the impressive findings, is consistent with actinomycosis. In addition, the manner in which it spread, failing to respect usual connective tissue planes, is also fairly typical of Actinomyces, especially with the presence of a foreign body.2 With the aging of the population of American women, abdominal sacrocolpopexy is being performed more frequently. Mesh erosion occurs after 3% to 12% of these operations, from 1 month to 6 years postoperatively.1 This unusual presentation underscores the need to consider possible infections of the mesh in women who have had a sacrocolpopexy and later present with any unusual type of symptom, even at a date far removed from the time of the operation. REFERENCES
1. Kohli N, Walsh PM, Roat TW, Karram MM. Mesh erosion after abdominal sacrocolpopexy. Obstet Gynecol 1998;92:999-1004. 2. Smego RA Jr, Foglia G. Actinomycosis. Clin Infect Dis 1998;26:1255-63.
Key words: Abdominal sacrocolpopexy, mesh erosion, necrotizing myofascitis, Actinomyces
Abdominal sacrocolpopexy is a commonly performed procedure for the correction of uterovaginal and posthysterectomy vaginal vault prolapse. Complications from use of synthetic mesh with this procedure include erosion into the vaginal vault and infection. In previously reported series of patients with mesh erosion, all patients presented with vaginal discharge or bleeding.1 We describe a patient who instead presented with persistent back pain and gluteal necrotizing myofascitis originating from infected mesh that eroded into the vagina after the patient underwent abdominal sacrocolpopexy. Case report A 51-year-old woman, gravida 2 para 2, underwent a vaginal hysterectomy with anterior and posterior repairs, bilateral salpingo-oophorectomy, and abdominal sacrocolpopexy with GORE-TEX mesh (WL Gore, Flagstaff, Ariz) for pelvic organ prolapse. Approximately 2 months later, she had low back pain, which was thought to be musculoskeletal in origin. Her symptoms persisted despite multiple treatments with nonsteroidal anti-inflammatory drugs, narcotics, and muscle relaxants. A renal ultrasonography and intravenous pyelogram showed moderate hydronephrosis on the right side, leading to placement of a ureteral stent. Subsequently, magnetic resonance imaging of the
From the Department of Obstetrics and Gynecologya and the Department of Surgery,b Jefferson Medical College, Thomas Jefferson University. Received for publication May 30, 2001; accepted June 19, 2001. Reprint requests: Jay Goldberg, MD, Department of Obstetrics and Gynecology, Thomas Jefferson University, 834 Chestnut St, Suite 400, Philadelphia, PA 19107. E-mail: [email protected]. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/118154 doi:10.1067/mob.2001.118154
Figure. Computed tomography scan of the pelvis showing necrotizing myofascitis of the gluteal and right piriformis muscles.
lumbar spine revealed an L5-S1 disk extrusion. The patient was referred for physical therapy and fitted for a back brace. Approximately 4 months after the initial operation, the patient had acute onset urinary retention and perirectal numbness. She was transferred to our institution for evaluation of possible cauda equina syndrome caused by the herniated disk. She was afebrile, but hypotensive. Her abdomen was soft and nontender, but erythema overlying both buttocks was noted, with exquisite tenderness. Computed tomography scans of the abdomen and pelvis demonstrated extensive necrotizing myofascitis of the gluteus maximi (Figure). In the operating room, extensive myonecrosis and pus were encountered in the gluteal muscles, with the areas of purulence tracking to the sacrum; these areas were widely debrided and packed. The patient was taken to the inten1273
1274 Goldberg et al
sive care unit for ongoing resuscitation. She required mechanical ventilation and dopamine for hemodynamic support. Antibiotic therapy with piperacillin-tazobactam, initiated preoperatively, was continued. Cultures taken of the gluteal abscesses grew Gardnerella vaginalis, Peptostreptococcus sp., Prevotella melanogenica, and Prevotella loescheii. Two days later, the patient was taken again to the operating room after purulent vaginal discharge was noticed. Mesh was identified eroding through the vaginal cuff, but was unable to be removed vaginally. Via exploratory laparotomy, the GORE-TEX (WL Gore) mesh, surrounded by purulence, was identified and removed. The underlying sacrum had tunneling areas of erosion. A sigmoid loop colostomy was performed to prevent future contamination and aid in wound healing. Cultures of the infected mesh grew G vaginalis, S sp, and A sp. Thereafter, the patient slowly progressed. By the fourth postoperative day, she no longer required dopamine and was extubated. She required multiple debridements of the gluteal wounds and was given antibiotics for the duration of her hospitalization. The patient was discharged on hospital day 43. Comment This case represents an unusual complication of abdominal sacrocolpopexy occurring months after the initial procedure. The polymicrobial nature of the wound cultures, with the presence of G vaginalis, strongly supports the theory that the vagina was the original source of
November 2001 Am J Obstet Gynecol
infection. We hypothesize that infecting organisms seeded the mesh after vaginal erosion. Alternatively, the inoculation of pathogens may have occurred at the time of the original operation. The presence of Actinomyces in the mesh culture suggests that this case may represent an unusual presentation of pelvic actinomycosis. The indolent nature of her infection, which caused her relatively mild symptoms relative to the impressive findings, is consistent with actinomycosis. In addition, the manner in which it spread, failing to respect usual connective tissue planes, is also fairly typical of Actinomyces, especially with the presence of a foreign body.2 With the aging of the population of American women, abdominal sacrocolpopexy is being performed more frequently. Mesh erosion occurs after 3% to 12% of these operations, from 1 month to 6 years postoperatively.1 This unusual presentation underscores the need to consider possible infections of the mesh in women who have had a sacrocolpopexy and later present with any unusual type of symptom, even at a date far removed from the time of the operation. REFERENCES
1. Kohli N, Walsh PM, Roat TW, Karram MM. Mesh erosion after abdominal sacrocolpopexy. Obstet Gynecol 1998;92:999-1004. 2. Smego RA Jr, Foglia G. Actinomycosis. Clin Infect Dis 1998;26:1255-63.