A 44 y.o was accepted in transfer from Christian NW health care center where he was being treated for cellulitis.

the pt had been in the outside facility for 8 hours awaiting a bed. He was found to be in DKA and complained of discoloration of the arm x two days. He had been on zosyn for 8 hours.

What is the next step? antibiotics were added: clinda and vanc and……..

Our patient has necrotizing fasciitis. This is a bacterial infection, rarely fungal which destroys tissue under the skin. The areas most commonly affected are the limbs and perineum.

CT scan of our patient showing gas in the tissue.

The disease has been described since the time of Hippocrates although the term “necriotizing fasciitis” was first used in 1952. Risk factors for the disease include diabetes, peripheral arterial disease, drug/alcohol use and immunosuppression of any kind. More than 70% of people with the disease have one of these risk factors.

The symptoms of the disease are “pain out of proportion” to skin findings, rash or bullae. The disease progresses very rapidly and the lesion often becomes black in the center due to thrombosis of blood vessels.

While patients are given broad spectrum antibiotics; the treatment remains surgical debridement.

following multiple debridements over one month , the arm was finally amputated.

Necrotizing fasciitis is divided into several types.

TYPE I - consists of mixed bacteria and is the most common type. This comprises 70-80% of cases. Gram negative bacteria, Gram positive bacteria, Clostridia and Bacteroides are including in this group.

TYPE II- consists of Strep pyogenes and comprises 20-30% of cases.

TYPE III- consists of Vibrio Vulnificus- this occurs in wounds occurring in salt water

TYPE IV- are rare fungal infections

This 71 y.o. man was eating raw seafood and contracted Vibrio vulnificus

Remember, the findings can initially be subtle; just a darkening of central skin in a wound. The course over time will determine the outcome.

Hakkaranien T, Kupari N, Pham T , el al. Necrotizing soft tissue infections : review and current concepts in treatment, systems of care and outcomes. Current Problems in Surgery 51(8):344-462.

Pazmaya S, Beltran D, Lamercier P, et al . Necrotizing fasciitis an urgent diagnosis. Skeleta Radiology 43(5): 577-589.

Park J, Lee C. Vibrio vulnificus. NEJM 2018;379-375.