Giri et al. Journal of Medical Case Reports 2012, 6:53 http://www.jmedicalcasereports.com/content/6/1/53 With a provisional diagnosis of enteric perforation peri- tonitis, our patient was immediately taken to the operation theatre for laparotomy. Peri-operative findings showed minimal purulent fluid in the peritoneal cavity. There was extensive necrosis of the retroperitoneum spreading to the left side of the anterior abdominal wall (parietal perito- neum) (Figure 1). A differential diagnosis of necrotizing fasciitis was not initially suspected, thus a laboratory risk indicator for necrotizing fasciitis (LRINEC) score was not calculated pre-operatively. An incidental diagnosis of ret- roperitoneal necrotizing fasciitis was made under observa- tion during laparotomy. Colonic perforation and peri- renal abscess were excluded with findings of normal intes- tines and solid visceral organs including kidneys. Pyelone- phritis was excluded based on the results of urine microbiological examination and culture. Debridement of the necrotic tissue was performed with placement of a corrugated retroperitoneal drain and a pelvic tube drain. Suspecting infection due to pathogens originating from the gastrointestinal tract, we started our patient on intravenous cefoperazone, sulbac- tam and clindamycin to cover anaerobic and Gram- negative enterobacteria. Necrotic tissue and drainage fluid culture revealed Escherichia coli sensitive to cefo- perazone. The same antibiotics were continued post- operatively. Our patient improved with no post-opera- tive complications and was discharged on the 12th post- operative day. Page 2 of 3 Discussion NF is a serious soft tissue infection that causes second- ary necrosis of the soft tissues. We report the case of a patient who developed extensive necrotizing fasciitis of the retroperitoneum. The diagnosis was confirmed intra-operatively with subsequent debridement, and he was treated successfully without complications. Of the reported cases of retroperitoneal necrotizing fasciitis in the literature, most had identifiable sources of infection including chronic pyelonephritis, diverticulitis, peri-anal abscess, colonic cancer, perforation, urinary extravasa- tion and post-hemorrhoidectomy [2,3,5-7]. As with our patient, there have been cases of retroperitoneal necro- tizing fasciitis reported without an obvious source of infection [8-10]. Our patient revealed a history of local trauma three weeks prior, followed by mild loin pain over a few days, that was tolerated by our patient until it subsided. We hypothesize that the patient developed a retroperitoneal hematoma following the traumatic event, which subsequently developed an infection. While retro- peritoneal necrotizing fasciitis is more common in immunocompromised patients [7], our patient had no history or clinical findings suggestive of diabetes melli- tus, chronic renal failure, human immunodeficiency virus or any other obvious immunosuppressed state. Clinically, necrotizing fasciitis presents with a wide range of signs and symptoms, therefore early diagnosis and treatment is a major challenge. Previously reported Figure 1 Peri-operative findings in our patient. Peri-operative findings revealed minimal purulent fluid in the peritoneal cavity, with extensive necrosis of the retroperitoneum spreading to the anterior abdominal wall. The intestine and solid organs including the kidneys were normal.