Necrotizing Fasciitis

Abstract

Necrotizing soft-tissue infections (NSTIs) are infrequent but associated with a high mortality grade. An accurate diagnosis is difficult in the early stages, and a high level of suspicion is required.

We present a 45-year-old male that came to the emergency room (ER) due to general malaise and extensive skin injuries in the lower right limb. He mentioned a 3-month-old injury, and self-performed cures were made. He was alert but presented generalized illness (tachycardia, tachypneic, hypotension, and fever) and functional impotence with inflammatory signs of the right inferior limb. The presence of pain, swelling, crepitation. and intense odor caught our attention. Laboratory tests provided data of infection (high procalcitonin and creatinine phosphokinase) with incipient renal failure with lactic acidosis and moderate hyponatremia.

The patient was admitted to the Intensive Care Unit with a preliminary diagnosis of soft tissue septic shock. We initiated intravenous fluid therapy, norepinephrine to maintain MAP around 65 mmHg, shock dose corticosteroid, and empirical antibiotic treatment with Piperacillin-Tazobactam and Clindamycin. Simultaneously we contacted our Traumatology Team who examined the patient. A CT scan of the lower limbs was performed, and an ulcer on the sole of the foot approximately 3 cm deep with intraosseous gas was encountered. Urgent surgical intervention was decided, and a right supracondylar amputation was made. During his admission to ICU, despite the broad specter antibiotic that was changed to Meropenem, Vancomicyn, and Clindamycin, the main problem was a prolonged high fever with negative blood cultures and eventually negative tissue cultures. A tracheostomy was performed on the 28th day, and a total of 8 surgical interventions were made. Eventually, he was decannulated on the 42nd day.

After 44 days of ICU admission, the patient was transferred to a standard-care hospital room and finally was discharged.