Multifocal cellulitis and polymicrobial infection in a patient with a perforated duodenal ulcer: a case report and literature review.

INTRODUCTION: Perforated peptic ulcer (PPU) is a critical surgical emergency associated with high mortality rates, typically requiring immediate surgical intervention. Helicobacter pylori infection and misuse of nonsteroidal anti-inflammatory drugs are common causes. Salmonella, a Gram-negative bacterium, is usually acquired through foodborne or fecal-oral exposure and most commonly causes gastroenteritis, bacteremia, or focal infection. Cellulitis, a bacterial infection involving the deep dermis and subcutaneous tissue, remains primarily a clinical diagnosis because no definitive gold-standard diagnostic test is currently available. CASE PRESENTATION: A 41-year-old man, who had a long-term history of taking unidentified analgesics for chronic left groin pain, presented to the hospital with fever, diffuse abdominal pain, and both legs were red and painful. Initial evaluation suggested a perforated peptic ulcer and cellulitis of both legs and scalp, and emergency exploratory laparotomy and abscess drainage were performed simultaneously, revealing a duodenal perforation. Notably, blood cultures were positive for Salmonella, while wound cultures from the scalp and leg abscesses identified Staphylococcus aureus. The patient received intravenous antibiotics and nutritional support, leading to a full recovery. DISCUSSION: The relationship between Salmonella bacteremia, duodenal perforation, and analgesic use cannot be proven from a single case. These findings are best interpreted as an unusual association in which several factors may have contributed to disease severity. CONCLUSION: This case highlights the importance of cautious etiologic interpretation, early source control, culture-directed antibiotics, and individualized postoperative nutritional management in complex perforated ulcer disease with multifocal infection.