A 74-year-old male was brought into the emergency department for worsening subjective fevers, weakness, and altered mental status over several weeks. The patient has a medical history of recent upper respiratory infection approximately 2 weeks prior and had been taking a 2 week course of antibiotics. Medical history included moderate ischemic heart disease. Surgical history includes a small bowel resection for ileal carcinoid tumor with metastasis to the liver and hepatic arterial embolization 16 years prior. Vitals: temperature of 36.9oC, blood pressure 102/56 mm Hg, respiration rate 20, heart rate 89. Physical exam demonstrated patient to be alert and orient to person, place, and time. Heart regular rate and rhythm, diminished breath sounds, and abdomen was soft and nontender. Extremity exam showed mild tenderness with left hip movement. Significant labs included elevated white count of 13,100/uL with left shift and troponins five times upper limit of normal. Electrocardiogram(ECG) showed ST depression in lateral leads. Urinalysis was negative for infection. The patient was admitted to the medical service with concern for sepsis, fever of unknown origin, and non-ST elevation myocardial infarction(NSTEMI). Chest x-ray was unremarkable.
The patient continued to have waxing and waning fevers with a T-max of 38.6oC, rising leukocytosis of 23,100/uL, gram negative bacteremia, which eventually grew E. coli and Proteus, and positive C. difficile infection. He also began complaining of left hip pain.
Cardiology consultation obtained echocardiogram showing ejection fraction on 40–45% and no further evidence of ischemia was noted on cardiac catheterization and no further treatment indicated. Infectious Disease consultation recommended intravenous Gentamycin, Cefepime, and Metronidazole, and oral Vancomycin.
CT abdomen and pelvis obtained on hospital day one and showed enlarged bilateral adrenal masses consistent with metastatic carcinoid disease. More significantly, there was air in the left aspect of the pelvis and presacral retroperitoneal area. Air was also infiltrating the soft tissue musculature of the left hip and surrounding the joint(Fig. 1).
Evaluation by Orthopedic surgery for left hip pain and concern for septic joint, found the patient to have no physical deficits, deformities, or crepitus on exam, but tenderness with movement of the left hip. General surgery was consulted and had no clinical suspicion for a necrotizing soft tissue infection, no intraperitoneal air, and a benign abdominal exam excluded concern for bowel perforation and no clear indication for surgery. Recommendation was made for a left hip and pelvis magnetic resonance imaging(MRI) after multi-departmental discussion.
MRI was significant for left posterior perianal fluid collection with gas, suspicious for abscess and possible fistulous communication with anal canal and skin and gas dissecting from the collection along the left hemipelvis(Fig. 2).
Colorectal Surgery was consulted on hospital day four, and was taken to the operating room for rectal exam under anesthesia. Operative findings of a complex transsphincteric fistula with connection to a large supralevator abscess. The fistula tract was partially opened outside of the sphincter complex and a seton placed. Given the large size of the abscess a Malecot drain was placed to assist and assure drainage of the abscess cavity.
The patient had routine postoperative course with resolution of leukocytosis and fevers and was discharged home on postoperative day two. The patient had the Malecot drain removed on his two week follow up appointment, but retains a posterior silastic Seton drain in the trans-sphincteric fistula.