體外震波碎石後壞死性筋膜炎：罕見案例報告

徐偉巽¹、翁竹浩⁴、陳建志^1、2、3、李致樵¹

馬偕紀念醫院泌尿科¹；馬偕醫學院²；馬偕醫護管理專科學校³；新北市立聯合醫院⁴

Necrotizing Fasciitis after Extracorporeal Shock Wave Lithotripsy: A Case Report

Wei-Hsun Hsu¹ , Chu-Hao Weng⁴, Marcelo Chen^1,2,3, Chih-Chiao Lee¹

¹Department of Urology, MacKay Memorial Hospital, Taipei City, Taiwan

²MacKay Medical College, New Taipei City, Taiwan,

³MacKay Junior College of Medicine, Nursing, and Management, New Taipei City, Taiwan

⁴New Taipei City Hospital, New Taipei City Government, New Taipei City, Taiwan

Introduction

     Since the 1980s, extracorporeal shock wave lithotripsy (ESWL) has become the most common treatment for urinary lithiasis. Although ESWL is a safe method to treat stones, localized iatrogenic injury can allow bacteria in urine to enter the bloodstream and potentially cause complications. Predisposing factors for infectious complications following ESWL include pre-existing urinary tract infection, infected calculi, multiple stones, staghorn stones, history of recurrent urinary tract infection, urinary obstruction and instrumentation used during ESWL.

Case presentation

     A 67-year-old woman presented with a persistent cough for one month after ESWL. She underwent ESWL with 3000 shock waves (13-16 kV for each wave) using the machine of Ziel ZEUS Extracorporeal Shock Wave Lithotripter without anesthesia due to a right upper ureter stone measuring 1.2x0.3 cm with right hydronephrosis found on abdominal X-ray and renal sonogram. No fever, chills or dysuria were mentioned. She had a history of Parkinson's disease, hypertension and undiscovered type 2 diabetes mellitus (HbA1c 9.4%). The initial abdominal CT showed perirenal and pararenal hematoma of the right kidney and serum hemoglobin decreased from 14.9 to 10.5 g/dL. After conservative treatment and antibiotics for two weeks at a district hospital, hemoglobin decreased persistently to 8.3 g/dL and she was transferred to our emergency department. On physical examination, we found right flank knocking tenderness. A biochemical examination revealed normal WBC count (9000/uL) with bandemia (band 12%). The contrast abdominal CT at emergency department showed perirenal and pararenal hematoma of the right kidney with extension to the right posterior pararenal space, right psoas muscle and right paraspinal region. We then prescribed empiric antibiotic treatment, antihemorrhagic agents and controlled her blood sugar.

     After one week of conservative treatment at our hospital, a follow-up CT scan showed necrotizing fasciitis involving the groups of muscles in the right lateral and posterior abdominal and thoracic walls, right axillary region, supra- and infra-clavicular regions, right breast, right arm, bilateral upper anterior chest walls and right neck. The abscess was immediately drained surgically through a retroperitoneal incision and three fasciotomies from the axillary fossa and right abdominal wall. Hemorrhagic purulent material was drained, and a microbiologic examination showed that Escherichia coli was the pathogenic agent. Four weeks after the surgical intervention for three times, the inflammatory process had almost resolved. At three months, nearly complete resolution of the abscess was observed.

Conclusions

     The development of necrotizing fasciitis after ESWL is rare. Abscess extension may occur quickly and invade adjacent structures. Urologists should be aware of this fatal complication and perform a surgical intervention immediately.