Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management

We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed.Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. The precise aetiology of necrotising fasciitis is unclear in many cases. We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.A 52 year old male presented with a one week history of discomfort and swelling in the right iliac fossa, and 12 hours of skin erythema which was rapidly progressing. Within 2 hours of assessment, the cellulitis was noted to have spread outside the boundaries marked on admission. He was hypotensive, tachycardic, febrile and noted to have an elevated white cell count.On examination of the area there was diffuse oedema of the skin with marked erythema and heat in the area of skin from the right loin to groin across to midline. Subcutaneous crepitus was present. A lateral abdominal X-Ray revealed free gas within the subcutaneous tissues (Fig. 1).A presumed diagnosis of necrotising fasciitis was made and the patient commenced on intravenous antibiotics, resuscitated with intravenous fluids, and taken immediately to the operating theatre.Extensive debridement of the affected cutaneous, subcutaneous tissue, and muscle was performed and pus noted to extend to the right loin area. Histology and bacteriology confirmed a diagnosis of necrotising fasciitis, with a β-haemolytic group streptococcus cultured. Exploration revealed a retroperitoneal abscess arising as a result of a perforation of a caecal carcinoma. The caecum was resec