Contributed by Scott Kulich, MD PhD and William A. Pasculle, ScD
Published on line in February 1998
The patient is a 22 year old male admitted through the emergency department with a gunshot wound to his right lower back. He was taken to the operating room for an emergent exploratory laparotomy where a subsequent right colectomy and hepatorrhaphy was performed. Postoperatively, the patient was placed on cefotetan and did well until postoperative day five when he had a temperature of 38.8 C. A CT scan of the abdomen revealed a pelvic fluid collection which, on culture, grew Bacteroides thetaiotaomicron. He was treated with piperacillin and metronidazole for 10 days. He subsequently became afebrile and his white blood cell count normalized and he was discharged on postoperative day seventeen on oral metronidazole (500 mg one p.o. t.i.d. times ten days).
In the following months, he reported to the emergency department with multiple times complaints of green and bloody drainage from the bullet entry site. Of note, the patient reported non-compliance with his prescribed antibiotics regimen, taking a total of only 6 of the prescribed 10 day course of metronidazole. Physical examination during these repeated visits showed the patient to be afebrile and with a non-tender abdomen with marked granulation tissue without erythema , warmth, tenderness or drainage near the bullet entry site .
Approximately 4 months after his initial surgery he returned yet again to the emergency department with a complaint of abdominal discomfort. MRI and pelvic x-ray findings revealed an involucrum and sequestrum of the right iliac wing without evidence of involvement of the psoas or iliacus muscles or intrapelvic or abdominal extension. The patient subsequently underwent partial resection of the right ilium. Cultures of both the superficial wound and deep bony tissue were submitted.