Authors: Pius A et al.
Cureus 18(2): e104399 10.7759/cureus.104399
Summary
This case report describes a 19-year-old woman who developed rapidly progressive bilateral abdominal wall ulceration after bilateral ultrasound-guided transversus abdominis plane (TAP) blocks (30 mL of 0.2% ropivacaine per side) and laparoscopic port-site infiltration with 0.25% bupivacaine.
Initially, postoperative day (POD) 1 findings included ecchymosis at the TAP site. By POD 2, lesions progressed to blistering with violaceous discoloration involving both TAP sites and multiple laparoscopic port incisions. The patient remained afebrile with normal labs. Empiric IV vancomycin was started for presumed cellulitis, but the lesions progressed despite antibiotics. CT imaging showed only superficial inflammatory changes without abscess or deep infection. Blood and wound cultures remained negative.
By POD 5, ulceration with tissue sloughing and undermined borders developed. Surgical exploration revealed superficial necrosis without fascial involvement or purulence. Histopathology showed a dense neutrophilic infiltrate without organisms, vasculitis, or malignancy. The clinical pattern—multifocal, rapid progression, culture negativity, antibiotic non-response, and involvement of multiple procedural sites—raised concern for a sterile neutrophilic dermatosis in the spectrum of pyoderma gangrenosum (PG), likely triggered by pathergy.
The patient ultimately improved with limited debridement and local wound care. No systemic immunosuppression was reported.
Key Points
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TAP blocks are generally safe; common complications include hematoma, infection, or peritoneal injury.
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Rapidly progressive ulcerative lesions at multiple procedural sites with negative cultures and poor antibiotic response should prompt suspicion for sterile autoinflammatory dermatosis (e.g., pyoderma gangrenosum).
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Pathergy (disproportionate inflammatory reaction to minor trauma) is a known trigger for PG and related neutrophilic conditions.
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Local anesthetics may influence neutrophil function and inflammatory signaling; an immune-mediated amplification response is hypothesized but unproven.
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Early dermatology involvement may prevent unnecessary antibiotics and repeated surgical manipulation, which can worsen pathergy-driven lesions.
What You Should Know
From an anesthesia standpoint, this case is important not because TAP blocks are unsafe—but because rare, noninfectious wound reactions can mimic surgical site infections. Red flags include:
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Bilateral or multifocal lesions
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Rapid progression
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Normal leukocyte count and afebrile state
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Negative cultures
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Worsening despite antibiotics
Misdiagnosis as necrotizing infection or cellulitis can lead to repeated surgical debridement, which may exacerbate pathergy in true neutrophilic dermatosis. While causal linkage to ropivacaine/bupivacaine is speculative, clinicians should maintain diagnostic flexibility when postoperative wound appearance does not align with typical infectious patterns.
This report is hypothesis-generating and does not alter the safety profile of TAP blocks, but it reinforces the importance of differential diagnosis in atypical postoperative wound complications.
Thank you to Cureus for allowing us to summarize and share this article.