A 54-year-old woman, obese, with a history of high blood pressure and juvenile rheumatoid arthritis, was treated with methotrexate 10 mg weekly and prednisone 10 mg daily.
She was admitted to the emergency service for 3 days of right inguinal pain associated with erythema.
On admission, tachycardic (110/min) and subfebrile were found.
In the physical examination an extensive sclerosis of the right inguinal region with extension to the right thigh and pituitary area was evidenced, with an area of greater induration and sensitivity in relation to the region
His tests showed a CRP of 39 and leukocytosis of 28,000, with 98% neutrophils, without other alterations.
Magnetic resonance imaging (MRI) revealed a necrotic and perforated appendix within a hernia sac associated with extensive signs of pelvic hypersensitivity and fasciitis of the wall.
She was reanimated with crystalloids and empirical antibiotic therapy with ampicillin-sulphate was initiated.
A surgical debridement was performed showing phascytic tissues with bad odor and draining a purulent collection in relation to the femoral triangle.
The devitalized tissues were resected until healthy margins were obtained.
Tissue and purulent fluid samples were sent for culture.
A necrotic and perforated cecal appendix within a femoral cavity was evidenced, as well as a healthy intra-abdominal hernia base, which was adequate for its ligation and ruled out the intra-tricular extension of the infection.
The hernia sac was resected and a classic cystectomy was performed.
Inguinal and pectile ligaments were identified and femoral hernia repair was performed using the infrainguinal technique.
Debridement was completed and the area was thoroughly washed with saline and chlorhexidine solution.
A continuous vacuum system (VAC®) was used for coverage defect.
Cultures were positive for Streptococcus constellatus.
The patient recovered satisfactorily, with normalization of inflammatory and asymptomatic digestive parameters.
After 48 h of antibiotic treatment and VAC® therapy, the patient underwent a new surgical procedure, which ruled out the progression of the infection and showed a clear improvement in local conditions.
After two new surgical silks to define the edges of the wound and with negative tissue cultures, it was possible the definitive closure of the wound.
Two weeks after admission, the patient was discharged in good condition.
During follow-up, it was found that there was partial dehiscence of the wound, which was managed with cures until its closure.
