Occipital necrotizing fasciitis ‒ a case report of diagnostic and surgical challenges from an atypical anatomical presentation

Introduction and aim. Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high mortality. While most cases involve the extremities or perineum, isolated occipital scalp NF is exceptionally rare, often leading to delayed recognition. We present a case describing its unusual site, diagnostic pitfalls, and surgical challenges. Description of the case. A 48-year-old man presented with one week of progressive swelling and pain following rupture of a boil-like lesion on the occipital region. Examination revealed a 20×20 cm erythematous, tender, and swelling. The primary survey was unremarkable. Laboratory results showed hyperglycemia (490.6 mg/dL), hyponatremia (122.0 mEq/L), and leukocytosis (26.72×10⁹/L). Imaging suggested a localized abscess, initially managed with incision and drainage. Rapid necrosis progression necessitated emergent wide debridement, confirming NF. Intraoperative bleeding complicated tissue assessment. Negative pressure wound therapy was attempted but discontinued due to anatomical limitations. The patient improved with repeated debridements, antibiotics, and reconstructive surgery. Conclusion. This case highlights the rarity of occipital NF and the risk of low clinical suspicion in atypical locations, emphasizing the importance of early recognition and tailored surgical management.