Carlos J. Roldan, MD, FAAEM

J Emerg Med.  2008;34(4):457-458.  ©2008 Elsevier Science, Inc.

Case Report

A 72-year-old man presented to the Emergency Department (ED) with altered mental status. His neighbors had called Emergency Medical Services after not seeing him for the prior 2 days. No further information could be obtained.

Emergency Medical Services found an ill-appearing elderly man who was very confused, hypotensive, tachypneic, and cold to the touch. Intravenous fluids and oxygen were provided during transportation.

In the ED, the physical examination revealed abnormal vital signs including: blood pressure 90/62 mm Hg, pulse weak at a rate of 104 beats/min, respiratory rate 24 breaths/min, rectal temperature 36.2آ°C, and pulse oximetry of 97% with supplemental oxygen at 3 L per nasal cannula. A fingerstick glucose test was 180 mg/dL. The patient looked pale, emaciated, and in mild distress. He was making poor eye contact, and was confused and unable to provide any relevant information. The initial physical examination revealed dryness of the oral mucosa. The neck was supple without masses. The lungs were clear to auscultation. The heart was hyperdynamic with no obvious murmurs. There were no signs of dyspnea despite the fast respiratory rate. The abdomen was flat and soft without mass or organomegaly. The neurologic examination did not reveal meningeal signs or motor deficits. Lower extremity examination revealed an erythematous, warm area in the antero-lateral aspect of the left leg including the knee, and the dorso-lateral aspect of the foot. There were no signs of fluid collection, but diffuse crepitation was palpable all across the compromised area. The range of motion of the involved joints was limited, and accompanied by increased discomfort. A sutured 2-cm wound in the plantar aspect of the foot was noted with putrid purulent discharge and friable appearance. Initial treatment included intravenous fluids, thiamine, and oxygen. Preliminary workup was initiated including blood cultures, blood cell count, chemistry, urinalysis, lactic acid, liver function tests, cardiac enzymes, and a portable chest X-ray study.

The white blood cell count was 19,000/cc with 92% neutrophils and an 11% bandemia. Serum lactate was 4.2 mmol/L, bicarbonate 13 mEq/L, glucose 220 mg/dL, sodium 132 mmol/L, and creatinine 2.1 mg/dL. Review of the previous medical record indicated that the suturing of the described laceration had occurred 20 h after stepping on a piece of broken glass while gardening at home 2 days before the current ED visit.

The management at this point included intravenous Imipenem, vasopressors, and urgent surgical evaluation. Foot and leg X-ray studies were obtained (Figure 1). Hyperbaric oxygen therapy was not an option in this institution. The patient was taken to the operating room for an above-the-knee amputation. He had a very lengthy course of recovery in the intensive care unit and surgical wards. Blood cultures grew out group A Hemolytic Streptococci, in addition to Clostridium Perfringens, and Proteus species isolated in the tissue sample. The patient was eventually discharged to a physical rehabilitation facility on day 53.

     

Discussion

Necrotizing fasciitis (NF) is a rare surgical emergency that involves primarily the fascia and the subcutaneous tissue as well as the cutaneous microcirculation followed by a rapid compromise of the deep fascial planes and the systemic circulation. NF, although rare in children, affects people of a wide range of ages.^[1] NF is mostly found in immunocompromised patients such as those with diabetes mellitus, cancer, alcoholism, chronic liver disease, vascular insufficiency, organ transplantation, human immunodeficiency virus, malnutrition, and neutropenia from any origin.^[2,3]

NF is a polymicrobial infection commonly initiated by group A Hemolytic Streptococci or Staphylococcus Aureus, acting synergistically with anaerobic organisms including Bacteroides, Clostridium, and Peptostreptococcus, as well as Enterobacteriaceae, Coliforms, Proteus, Pseudomonas, and Klebsiella.^[2] Necrotizing fasciitis due to Clostridium species including Clostridium Sordellii as well as wound botulism due to Clostridium Botulinum, and tetanus due to Clostridium Tetani, has been reported in intravenous drug users, and has been attributed to contaminated black tar heroin injected subcutaneously or intramuscularly ("skin popped"). The patients often present with marked leukocytosis, hemoconcentration, and fulminant shock.^[4]

Growing evidence includes Vibrio vulnificus as a cause of NF in patients with chronic liver disease after warm sea water exposure or after raw seafood ingestion.^[3,5-7] Local crepitation as a manifestation of subcutaneous gas is present in more than half of the patients; it also can be found distant from the original wound site. The radiographic presence of gas in the soft tissues is highly suggestive of gas-producing bacteria and most likely of NF.^[2]

NF requires aggressive management started in the ED, which includes resuscitation with fluids and pressors if necessary, immediate surgical evaluation, and intravenous antibiotics. If available, hyperbaric oxygen is an important adjunct in the treatment of NF.

Seal DV. Necrotizing fasciitis. Curr Opin Infect Dis. 2001;14:127-132. Wong C-H, Chang H-C, Pasupathy S, Khin L-W, Tan J-L, Low C-O. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85:1454-1460. Taviloglu K, Cabioglu N, Cagatay A, et al.. Idiopathic necrotizing fasciitis: risk factors and strategies for management. Am Surg. 2005;71:315-320. Kimura AC, Hilga JI, Levin RM, Simpson G, Vargas Y, Vugia DJ. Outbreak of necrotizing fasciitis due to Clostridium sordellii among black-tar heroin users. Clin Infect Dis. 2004;38:87-91. Tsai Y-H, Hsu RW-W, Huang K-C, Chen C-H, Cheng C-C, Peng K-T, et al. Systemic Vibrio infection presenting as necrotizing fasciitis and sepsis (A series of thirteen cases). J Bone Joint Surg Am. 2004;86:2497-2502. Oliver JD. Wound infections caused by Vibrio vulnificus and other marine bacteria. Epidemiol Infect. 2005;133:383-391. Elliot D, Kufera JA, Myers RA. The microbiology of necrotizing soft tissue infections. Am J Surg. 2000;179:361-366.

Reprint Address

Carlos J. Roldan, MD, Department of Emergency Medicine, University of Texas Health Science Center at Houston, 6431 Fannin Street, JJL 445, Houston, TX 77002