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 Introduction
Necrotizing fasciitis is a rare life-threatening infection
resulting in necrosis of the skin, subcutaneous tissue, and
fascia (1). Even with increased knowledge in the diagnosis
and management of this disease process, mortality is still
between 24% and 34% percent (2). It is perhaps the most
severe form of soft tissue infection (3). The problem with this
disease is that it may resemble simple cellulitis for which the
patient may be given treatment and discharged home. The
emergency physician should have a high index of suspicion
to reach a timely diagnosis in these cases (8), especially if
there are associated risk factors for this condition. The risk
factors are: conditions of decreased immunity (chronic
illnesses, use of corticosteroids), Diabetes Mellitus,
peripheral vascular diseases, varicella infection, chronic
alcohol ingestion, and it may follow childbirth (4,5,6). There
is no race predilection but there is a tendency toward
extremes of age (7).
The causative organisms are usually mixed and the most
virulent and serious infections are caused by group A beta
hemolytic streptococci (GABHS) and methicillin resistant
staphylococcus aureus (MRSA) (8). The condition if not
treated properly, and promptly, may advance to systemic
toxicity, sepsis and septic shock with associated high
morbidity and mortality outcomes (9). The diagnosis of
necrotizing fasciitis should be based on history and clinical
examination. Plain X-ray of the organ affected may be useful
in revealing gas in the soft tissue which, if present and
accompanied by a crepitus sensation, is pathognomonic of
necrotizing fasciitis. Gas in soft tissue is present in only 30-
50% of cases. Magnetic resonance imaging is more sensitive
in identifying necrotizing skin and soft tissue infections and
the extent of involvement (10,11,12).
.
Case
A thirty-two year old Indian male presented to the
Emergency Department (ED) of Hamad General Hospital
complaining of an inability to walk due to pain in his right
thigh.
The problem arose from an incident which happened two
months earlier when he injured his hand at work. As he was
a manual labourer he was prescribed a course of IM tetanus
toxoid. Fifteen days after the second injection, while he was
outside of Qatar, he sought medical attention for pain in the
right gluteus area. The man was examined and an MRI was
done which revealed myositis of the gluteus minims muscle
(the report was with the patient when he presented to the
ED in Qatar). Oral antibiotics (unknown by the patient and
there was no medication report) were given and then he
was discharged. There was no chronic illness.
He was traveling home when his plane stopped in Doha
airport for a transit stop. The patient could not leave the first
plane to board another one. Patient was seen in the airport
clinic and transferred urgently to the ED.
On arrival to the ED the patient looked tired and pale, vital
signs were: temperature.: 36.7o C, Pulse Rate: 124b/m,
Respiratory Rate: 20/min, and BP: 90/60mmHg. There was
diffuse swelling of both thighs but more so in the right
thigh where there was prominent swelling in the posterior
and medial aspects, associated with tenderness and mild
swelling of the left thigh. There was no crepitus on clinical
examination.
Necrotizing fasciitis of both limbs was suspected and
emergency management was started with IV fluid via 2 lines
(Ringer’s lactate, 2 liters, fluid challenge, then continued
at 125cc/hour as maintenance), oxygen therapy (100%
12 l/min), antibiotics (Pipracillin 4.5 gm iv stat dose given
after blood cultures were taken). The surgical specialist was
contacted upon the clinical suspicion.
Investigations were done and revealed WBC count: 15.6 x
103/ul. Hemoglobin level: 8.4gm/dl, serum calcium: 1.8,
Glucose level was within normal limits: 5.2mmol/l, Urea
Nitrogen: 13.3mmol/l, Serum Creatinine: 75umol/l (normal
level), serum myoglobin: 527.8 ng/ml (normal level 28 – 72
ng/ml), CPK was not done in the ED or in the surgical ward.
Blood cultures for aerobic and anaerobic bacteria were done
before giving the antibiotics (both of them were negative).
Patient had hypo-proteinemia: 46g/l (normal 60-80 g/l) and
elevated serum lactic acid level: 3.35 mmol/l (normal 0.5
– 2.2)
Plain X-ray of both thighs did not show any gas, it showed
only soft tissue swelling. An urgent MRI with and without
contrast was done and the report was: “Findings are highly
impressive of bilateral necrotizing fasciitis, being more
extensive in the right gluteal region and the right thigh “.
The patient was admitted to the surgical ward. The general
surgical team on call did an urgent operation with excision
of the necrotic tissue and removal of more than 2 liters of
pus from both thighs and both gluteal areas. Culture and
sensitivity of the evacuated pus was done and revealed
moderate growth of Staphylococcus aureus sensitive to
clindamycin, erythromycin, and oxacillin. The surgeons
report did not mention necrotic tissue or myositis but tissue
from the right thigh was sent for histopathology which
revealed necrotizing inflammation.
Postoperatively, the patient was operated upon a second
time after 4 days for suspicion of a pelvic collection but only
adherent intestinal loops were found.
Because the patient was immobile and there was severe
infection in both lower limbs there was a very high
risk of deep vein thrombosis (DVT) in this patient and
he was put on prophylaxis therapy (fragmin 5000 unit
subcutaneously [s/c] OD). In spite of this, he developed a
DVT on the 15th postoperative day. Consultation with the
medical department was done and a decision was made to
discontinue fragmin and start clexan 60 mg s/c BID (twice
daily). Two weeks post-operatively the patient developed
a swelling on the left side of his chest. This complication
was treated by antibiotics and aspiration of the collection,
which proved to be of inflammatory origin and no bacterial
growth.
The patient improved after that and was finally discharged
27 days after admission. He continued his journey to his
home This case is reported as a rare case of necrotizing fasciitis
after intramuscular injection in a young adult patient having
no risk factor or co-morbidity for that disease. .
Discussion
Diagnosis of necrotizing fasciitis needs a high index of
suspicion (8) as it may start as simple cellulitis, or myositis,
with non-specific symptoms of muscle pain and generalized
weakness (13,14). If not treated quickly, the disease may
progress rapidly and the patient may develop complications
(15,16). There are several points that need to be discussed in
this case:
In general, our patient was a young man without any risk
factors or any co-morbidity. This may explain why he had
an unusually long history in a disease which normally
progresses rapidly (3,20).
In the history: on the patient’s first visit to the doctor
(outside Qatar) the diagnosis was myositis of the gluteus
minims muscle (diagnosis made by MRI imaging). Since
the patient was a young man and the condition was not
severe, the treatment was standard for grade one myositis,
which is antibiotics alone (23). On the other hand, if there is
associated pus in the muscles, in addition to the myositis,
then the standard treatment is surgical exploration and
drainage (17,23).
The long time interval was the likely cause of the extensive
progress of the necrosis from the gluteus minims muscle
(mentioned in the first MRI) to the large distribution in both gluteal regions and both thighs as revealed by the second
MRI.
On admission: The patient was hypotensive when he arrived
at the ED (BP 90/60mmHg, PR 124b/min); he improved on
the fluid challenge. With this improvement, there was no
need to give any additional agents such as hydrocortisone.
In addition, there is a lot of controversy regarding the use of
hydrocortisone, and 2 large clinical trials failed to prove any
clinical benefit for the use of low dose hydrocortisone in the
treatment of septic shock (21).
The laboratory findings were highly indicative of necrotizing
fasciitis: The C-reactive protein was elevated at 185 mg/l. If it
is >150 mg/l it adds 4 points to the risk score of necrotizing
fasciitis (24).
The WBC count was 15,600/ml which raises the suspicion
of necrotizing fasciitis and adds one point to the risk factor
score.
The patient was anemic Hb: 8.4 gm/dl. A serum Hb level
below 11gm/dl adds 2 points for the risks of necrotizing
fasciitis (24).
Serum sodium was 128meq/dl which also earns 2 risk points
(24).
The total risk score for necrotizing fasciitis in this patient
was 9. A score of 6 or above raises suspicion while a score 8
or above is highly suggestive of necrotizing fasciitis (24).
|
Laboratory Risk Indicator
for Necrotizing Fasciitis
score
|
Modified from Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory
Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing
necrotizing fasciitis from other soft- tissue infections. Crit Care Med
2004;32(7):1535–41; with permission
|
Laboratory Risk Indicator for Necrotizing Fasciitis score
and the corresponding risk category and probability of
necrotizing skin and soft-tissue infection
|
Modified from Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory
Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing
necrotizing fasciitis from other soft- tissue infections. Crit Care Med
2004;32(7):1535–41; with permission
The diagnosis was confirmed by MRI with contrast which is
highly sensitive and specific and can reveal the extent of the
necrosis accurately (25).
The early management of patient in the ED: The diagnosis
was suspected early and broad spectrum antibiotics started
directly (after taking blood for culture and sensitivity) in
addition to fluid replacement and 100% O2 therapy. These
are the most important measures in the early treatment
of necrotizing fasciitis (2), and in addition to surgical
debridement they represent the mainstay in management
(18).
The patient did well and his condition stabilized on this
regimen so no immunoglobulin was given to him in the ED.
Immunoglobulin is given if the patient remains unstable
after early measures and it is useful in streptococcal
infections (19). Experimental data supports the use of
immunoglobulin but as yet there are no clinical trials to
support it (22).
Hospital stay: due to the long history of the disease the
patient developed a DVT which was not unexpected with
such severe inflammation in the thigh.
Lastly, being young with no risk factors helped the
patient to pass through this aggressive disease, and all
the complications that accompanied it.. The patient was
discharged home after a long stay in hospital..
References
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