Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Necrotizing Myonecrosis of the Abdominal Wall with Candida albicans Following a Missed Bowel Injury Brian Musch, DO 1 , Rachel Daley, OMS-III 2 , Saptarshi Biswas, MD, FACS 1

1. Grand Strand Medical Center, Dept. of Surgery, Myrtle Beach, SC. 2. Edward Via College of Osteopathic Medicine-Carolinas, Spartanburg, SC.

Background

Case Report Cont.

Discussion

• Candida albicans necrotizing myonecrosis is rare and typically associated with immunosuppression, burns, or severe polytrauma trauma • Perforation of the gastrointestinal tract can allow fungal invasion, leading to severe infections • Necrotizing Soft Tissue Infections (NSTI Classification) • Type I: Polymicrobial (common) • Type II: Monomicrobial bacterial (e.g., Streptococcus pyogenes )

• The patient underwent a second look operation the next day and had small bowel anastomosis • Tissue cultures revealed isolated Candida albicans • Antifungal therapy with fluconazole initiated • Serial debridement of skeletal muscle along with nonviable subcutaneous tissue over the next two weeks • Two years later, a ventral hernia developed and was repaired with retro-rectus component separation, transverse abdominis release, and mesh placement

• Necrotizing myonecrosis is a life-threatening skeletal muscle infection, usually bacterial: Streptococcus pyogenes/Staphylococcus aureus or polymicrobial • Rare fungal causes, such as Candida albicans , are significant but uncommon • This case highlights a rare presentation of isolated Candida albicans necrotizing myonecrosis in a healthy elderly female following a small bowel injury

• Type III: Gram-negative ( e.g., Vibrio species ) • Type IV: Fungal ( Candida albicans) , rare but deadly (>47% mortality)

Case Report

• A 77-year-old female underwent an elective hysterectomy

Conclusions

• Postoperatively, she developed severe abdominal pain, vomiting, and green drainage from incision • Diffuse abdominal pain with rigidity and guarding on exam • Small bowel perforation and necrotizing myonecrosis were identified during exploratory laparotomy • Enterotomy was performed, small bowel was resected, and the abdominal wall was debrided • Empiric broad-spectrum antibiotics covering gram positives, gram negatives, and anaerobes were initiated

References This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. Acknowledgements 1. Atallah , Natalie J et al. “Candida albicans necrotizing fasciitis following elective surgery.” Medical mycology case reports vol. 28 39 -41. 20 Apr. 2020, doi:10.1016/j.mmcr.2020.04.004 2. Peetermans , M., et al. “Necrotizing Skin and Soft - Tissue Infections in the Intensive Care Unit.” Clinical Microbiology and Infection, vol. 26, no. 1, 2020, pp. 8-17. 3. Pejman Davoudian, Neil J Flint, Necrotizing fasciitis, Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 5, October 2012, Pages 245 – 250, https://doi.org/10.1093/bjaceaccp/mks033 4. Sartelli, M., Coccolini , F., Kluger, Y., et al. “WSES/GAIS/WSIS/SIS -E/AAST Global Clinical Pathways for Patients with Skin and Soft Tissue Infections.” World Journal of Emergency Surgery, vol. 17, no. 3, 2022, https:// doi.org/10.1186/s13017-022-00406-2. 5. Puvanendran, Rukshini , et al. “Necrotizing Fasciitis.” Canadian Family Physician, vol. 55, no. 10, 2009, pp. 981 -987 . • This case highlights the critical need for early diagnosis and aggressive surgical intervention to prevent mortality • Immediate laparotomy, surgical debridement, and tissue cultures are crucial when abdominal wall infections are suspected • While bacterial pathogens are common, potentially fatal fungal causes like Candida must not be overlooked

Figure 2. Open abdominal wall defect managed with AbThera

Figure 4. CT scan showing abdominal wall ventral hernia

Figure 3. Abdominal wall ventral hernia

Microbiology • No gram positive, gram negative, anaerobic, or aerobic organisms identified • Candida albicans isolated from debrided tissue and abdominal abscess

Figure 1. Abdominal wall abscess and necrosis

2025 Research Recognition Day

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