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Necrotizing fasciitis (NF) is a life threatening rapidly progressive soft tissue infection that carries a high mortality rate. There are approximately 500-1,500 cases per year in the United States with a mortality rate of up to 18-20%. Without surgical intervention, the mortality rate is near 100%. NF can be characterized by tissue involvement, polymicrobial or monomicrobial etiology, or site of infection. The most common risk factor includes diabetes (reported in up to 60% of cases), IV drug use history, malnutrition, and chronic alcohol abuse. In about 50% of group A streptococcus cases, there is an associated streptococcal toxic shock syndrome with multiorgan system failure. Early recognition and prompt surgical intervention is key in improving mortality and amputation rates.
We present a case of a 64-year old male with history of severe malnutrition, chronic bilateral deep vein thromboses on apixaban, and chronic pancytopenia who presented with rapidly worsening right leg pain. He was afebrile on arrival with a blood pressure of 70/40 mmHg and heart rate of 90 bpm. Clinically he appeared cachetic and chronically ill with appreciable anasarca. His right lower extremity exhibited significant pitting edema with multiple hemorrhagic and flaccid bullae, areas of open weeping wounds with surrounding erythema, and severe tenderness to palpation. Initial labs showed leukopenia to 1.5k, thrombocytopenia to 107k, lactate of 3.2, procalcitonin of 152, and CRP of 21.9. 3-view X-ray of his right ankle showed diffuse soft tissue swelling without findings concerning for osteomyelitis or acute osseous abnormality. He had poor response to IV fluids and was found to be in septic shock. The physical exam findings and evidence of systemic involvement prompted a high suspicion for necrotizing fasciitis. He was started on broad spectrum antibiotics and eventually needed the support of multiple pressors. Urgent surgical consultation was obtained and transferred to a larger multispecialty hospital center. The patient hesitated about proceeding with surgery but ultimately decided to proceed after 24 hours when he then underwent debridement of his entire right leg. He ended up on three pressors and continuous renal replacement therapy for two weeks. He eventually needed a tracheostomy and transferred to a long term acute care facility only to be readmitted two weeks later for worsening infection. He was found to be bacteremic with streptococcus pneumoniae and underwent a right leg above-the-knee amputation. He ultimately succumbed to his infection and died approximately 3 weeks after readmission.
This case highlights the importance of both early clinical recognition and surgical intervention of necrotizing fasciitis due to its extremely high morbidity and mortality rate. Despite concerted efforts to get this patient into surgery, even a few hours of delay worsened the already poor prognosis. Especially as primary care physicians, prompt recognition and decisive action to get the patient appropriate care is crucial to improving overall outcomes. In addition, having clear goals of care discussions between PCPs and their patients who are most at risk for hospitalizations can aid in making difficult time sensitive medical decisions.
Graduate Medical Education
Conference / Event Name
Academic Achievement Day, 2020
Providence Oregon Family Medicine Residency, Milwaukie, OR
Sun, Jeffrey and Kim, Edward, "Necrotizing Fasciitis – Time is of the Essence" (2020). Milwaukie Family Medicine 2020. 2.