Necrotizing fasciitis is a rare but life-threatening soft tissue infection. Its presentation is characterized by rapidly spreading inflammation and resultant death both of the surrounding soft tissue and fascial planes. Prompt recognition and aggressive treatment is paramount in order to avoid fatality. Often times, symptoms may overlap in their presentations so one must maintain a high index of suspicion and a multidisciplinary approach facilitated appropriate imaging studies and resulted in a diagnosis of necrotizing fasciitis.
While manning the orthopedic floor, I received a call from the ED attending who was caring for a 60-year-old lady and was concerned about an infectious process going on in her left hip. After inquiring about her case, I learned that the patient had a three-day history of increased lethargy, general malaise, decreased appetite as well as left hip and thigh pain. The patient denied any recent trauma to her leg or falls. Her only medical problems included Lyme disease as a child, asthma, high cholesterol, and seasonal allergies. She underwent an invasive dental procedure in preparation for a root canal three weeks prior to presentation.
Once I saw her at bedside, I knew there was a big problem. She looked sick. She was in septic shock. The skin overlying her left hip and thigh was grossly unremarkable. No obvious signs of infection or erythema were noted besides an area of warmth isolated to the lateral aspect of her left thigh. She was able to flex her left hip approximately thirty degrees and only complained of pain to the lateral aspect of her upper leg with passive internal and external rotation. She was unable to put weight on the leg because of pain. The right lower extremity was unremarkable.
Imaging studies included conventional radiographs of her pelvis and left hip which showed soft tissue swelling but no boney abnormalities. There was no evidence of subcutaneous gas seen. Her WBC count was normal yet her ESR and CRP were mildly elevated. She continued to decline. Given the clinical picture of possible septic arthritis, a magnetic resonance imaging scan of her left hip and thigh was performed without contrast. Extensive edema was noted diffusely throughout her left gluteus medius muscle and vastus lateralis muscle. No fluid collection was noted. The left hip was free of any fluid collection, thus the diagnosis of septic arthritis was essentially ruled out. Computed tomography ruled out any fluid collection in her pelvis and abdomen.
While in the ED she was started on vasopressor support. Antibiotic therapy was started with vancomycin. She was subsequently brought to the operating room where her vital signs decompensated further. After being positioned on the operating table, the lateral aspect of her left thigh was found to have a well demarcated area of redness. Palpable subcutaneous crepitus was noted in the surrounding areas. Surgery was performed under general anesthesia while maintaining her vasopressor support. Multiple incisions were made to allow drainage of the purulent fluid. Digital dissection was performed without any resistance along the fascial planes. Cultures were obtained and penrose drains were placed and the wounds were loosely approximated. Sterile dressings were applied and the patient was transferred to the surgical intensive care unit and remained intubated. On postoperative day number one, she returned to the operating room for further examination and debridement. All surgical wounds were again copiously irrigated and dressed sterilely.
She was continued on an antibiotic regimen of vancomycin, clindamycin and zosyn (piperacillin-tazobactam). Gradually her vasopressor support was reduced and respiratory support weaned until both were finally discontinued on postoperative day two. Negative pressure wound VAC therapy was applied to the left thigh and was maintained for one week. The patient’s operative cultures were positive for group A Streptococcus pyogenes. Upon discharge, her antibiotic regimen was adjusted and limited to augmentin until completion. After a two-week hospitalization, the patient was transferred to an acute rehabilitation facility in stable condition; she remained there for one week before being discharged.
Discussion
Originally described by Hippocrates, in the 5th century, as a complication of erysipelas, necrotizing fasciitis later became known as the malignant ulcer. It was subsequently described in the United States by Joseph Jones in 1871. The name of the disease was modified from hospital gangrene to its current name in 1952.
Today, necrotizing fasciitis is an uncommon disease process yet one that must be recognized and dealt with rapidly. If not treated promptly and aggressively, the virulent and toxin-producing bacteria, most commonly group A Streptococcus pyogenes, will cause severe systemic toxicity which may lead to death. Common risk factors include diabetes mellitus, immunocompromised states, peripheral vascular disease, cardiac disease, obesity, intravenous drug use, alcohol use, malnutrition, smoking as well as corticosteroid use and chronic use of non-steroidal anti-inflammatory drugs. Despite the large number of predisposing factors that have been identified, half of all cases of necrotizing fasciitis occur in healthy individuals. Early surgical intervention preventing a delay of more than twenty-four hours prevented an adverse outcome. In our case, the patient was in the operating room within 10 hours from initial presentation.
This case demonstrated a true surgical emergency; one that was appropriately managed with a multi-disciplinary team approach. A high index of suspicion by the examining ED staff and surgical consultants led to supportive measures maintaining the patient’s vital signs and ultimately her life. Despite having no clear etiology for the cause of necrotizing fasciitis, it is possible that this may have resulted from her prior dental work. Although there is no causal relationship, reports suggest that NSAIDs may prevent prompt recognition and accelerate the infection by altering its initial presentation. In this case, she reported no recent use of anti-inflammatory medication in association with her pain.
This case also showed the importance of urgent magnetic resonance imaging. Besides helping to exclude other diagnoses involving the hip joint, the imaging study provided a roadmap for debridement of active infection. The test eliminated the need to explore the left hip joint as well as the risk of seeding a sterile space.
In conclusion, I highlight this case to ensure that all members of the healthcare team maintain a high degree of vigilance when patients present with sepsis. Orthopedic and general surgeons must maintain a high index of suspicion when asked to evaluate a patient with generalized limb and joint complaints. This case may not have ended as satisfactorily as it did were it not for the meticulous preoperative management and surgical debridement of the ED physicians and surgeons, respectively, who cared for the patient.
Adam Bitterman is a physician.
