An 84 y.o. presents from a nursing home with fever and R arm pain
The pt had a new rash which was present for one day
This rash appeared over one day
Our patient had necrotizing fasciitis. This is a soft tissue infection which spreads rapidly. The skin is often purple or blue and patients have severe pain. Often as tissue dies, the lactate is elevated and a sepsis picture results. The key to the diagnosis in this case was the rapid onset and severe acidosis.
fluid and edema along fascial planes
Necrotizing fasciitis has been recognized since the time of Hippocrates although it wasn’t called necrotizing fasciitis until 1952. Risk factors for the disease include: immunosuppression, diabetes, alcoholism ,malignancy and chronic systemic disease.
The infections are divided into several types
TYPE 1: This type is found in about 70% of necrotizing fasciitis. The infections are polymicrobial with Gram-positive cocci( Staph aureus, strep pyogenes) , gram-neg rods (E coli.) and anaerobes (Bacteroides and Clostridium) being the most common.
TYPE 2: This infection accounts for about 20-30% of cases and involves mainly extremities. Strep pyogenes is often found. Strep species produce M protein which can cause an extreme immune reaction precipitating “toxic shock”.
TYPE 3: This is caused by Vibrio vulnificus, and occurs when an injury occurs in salt water. This bacterium enters through a break in the skin.
The diagnosis is often made by the presence of gas in the soft tissue but as in our patient gas may not be present only fascial edema and fluid. In our patient group A strep was cultured from the blood. Surgery offered an arm amputation but informed the family that he had a very grave prognosis and the family chose to proceed with comfort care. The patient died in less than 24 hours in spite of antibiotics and pressors.
The difficulty in diagnosing the disease is that the early stages look like a simple skin infection.
The diagnosis is often made by the presence of gas in the soft tissue but as in our patient gas may not be present only fascial edema and fluid. In our patient group A strep was cultured from the blood. Surgery offered an arm amputation but informed the family that he had a very grave prognosis and the family chose to proceed with comfort care. The patient died in less than 24 hours in spite of antibiotics and pressors.
The difficulty in diagnosing the disease is that the early stages look like a simple skin infection.
Kopari N, Pham R , Evans H. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Current Problems in Surgery 2014. 51(8):344-62.
Cartwright K, Logan M, McNulty C, et al. A cluster of cases of streptococcal necrotizing fasciitis in Gloucestershire. Epidemiology and Infection 115(3):3387-97.
Hua C, Bosc R, Sbidian et al. 2018 Interventions for necrotizing soft tissue infections in adults. The Cochrane Database of Systematic Reviews. 5:CD011680.