BMJ 2019;365:l2214 doi: 10.1136/bmj.
l2214 (Published 20 June 2019)
Endgames
CASE REVIEW
An unstable lump in the groin
Zain Sheikh core surgical trainee, Augustine Akali consultant plastic and reconstructive surgeon
Department of Plastic Surgery, Hull Royal Infirmary, Hull, UK
A 49 year old man with type 2 diabetes presented with a three
day history of severe right sided groin swelling and pain, feeling
generally unwell, fatigue, and fever. His medical history
included two myocardial infarctions (11 and 16 years earlier)
and a previous right sided inguinal abscess (two years earlier)
that healed after incision and drainage. A 20×10 cm lump and
skin crepitations were felt in the right groin. Overlying skin
appeared healthy with no evidence of erythema, necrosis, or
pallor. Glasgow coma scale (GCS) was 15, blood pressure 85/64
mm Hg, heart rate 114 beats/min, temperature 38.4°C, oxygen
saturations 98% on room air, and respiratory rate 28 breaths per
minute. Blood test abnormalities are shown in table 1.
The patient required immediate incision and drainage (fig 1).
There was a foul smell after the initial incision but no frank pus.
Findings after the initial incision
Questions
1.What are the differential diagnoses of groin lumps?
2.What is the most likely diagnosis in this patient?
3.Does this patient have sepsis?
Answers
1.
Correspondence to Z Sheikh Zain.sheikh@nhs.net
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 1 of 3
BMJ: first published as 10.1136/bmj.l2214 on 20 June 2019. Downloaded from http://www.bmj.com/ on 20 August 2019 by guest. Protected by copyright.
ENDGAMES
What are the differential diagnoses of groin
lumps?
• Inguinal abscess: painful fluctuant mass of pus which can
recur
• Necrotising fasciitis: necrotic tissue following
untreated/insufficiently treated abscess, trauma, insect bite,
or skin break
• Incarcerated inguinal hernia: protrusion through inguinal
canal
• Inguinal lymphadenopathy: reaction to lower limb
pathology, eg, severe cellulitis, malignancy
• Unstable pseudoaneurysm: pulsatile mass.
2.
What is the most likely diagnosis in this
patient?
Necrotising fasciitis caused by a new or recurrent abscess.
The condition can develop over hours or days. Hallmarks
include1
• Discharge that is foul smelling or with a dishwater
appearance (fig 2)
• Necrotic fascia (fig 2) or lack of bleeding
• No muscular fascia resistance to blunt dissection
• Haemodynamic instability
• Skin crepitations.
After the initial incision, showing hallmarks of necrotising
fasciitis
Subscribe: http://www.bmj.com/subscribe
BMJ 2019;365:l2214 doi: 10.1136/bmj.l2214 (Published 20 June 2019)
Risk factors include previous or recurrent abscesses,
hyperglycaemia, and impaired immune function.
3.
Does this patient meet the qSOFA definition
of sepsis?
Yes, based on his respiratory rate and blood pressure.
Sepsis is suggested by the presence of two or more of the
following parameters from the modified/quick Sequential Organ
Dysfunction Assessment (qSOFA)2:
GCS <15
Systolic blood pressure <100 mm Hg
Respiratory rate >22 breaths per minute.
Of patients with necrotising fasciitis, 16.3% develop sepsis.3
Learning points
• qSOFA scores4 and the TIME5 mnemonic are useful for
suspected sepsis: Temperature: high or low. Infection: look for
signs. Mental decline: confused, sleepy, difficult to rouse.
Extremely ill: severe discomfort/pain, “Feels like I’m dying.”
• Patients with diabetes are at greater risk of amputation in
managing necrotising fasciitis.6
Patient outcome
Extensive debridement was commenced and a resultant wound
of approximately 50×40 cm remained. Microbiology of
intraoperative samples showed mixed gram positive cocci, and
gram positive and negative rods.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 3
ENDGAMES
After 48 hours the patient underwent further debridement and
a period of negative pressure wound therapy to optimise the
wound for a split thickness skin graft.
BMJ: first published as 10.1136/bmj.l2214 on 20 June 2019. Downloaded from http://www.bmj.com/ on 20 August 2019 by guest. Protected by copyright.
The sepsis was managed in line with the sepsis six regime4
(blood cultures, blood lactate levels, urine output monitoring,
antibiotics, intravenous fluids, oxygen) using intravenous
meropenem and clindamycin.
The patient had a successful reconstruction with split thickness
skin graft and has returned to normal life.
Competing interestsThe BMJ has judged that there are no disqualifying financial
ties to commercial companies.
The authors declare the following other interests: none.
Further details of The BMJ policy on financial interests is here: https://www.bmj.
com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-
competing-interests
Provenance and peer review: not commissioned; externally peer reviewed.
Patient consent obtained.
1 Huang KF, Hung MH, Lin YS, etal . Independent predictors of mortality for necrotizing
fasciitis: a retrospective analysis in a single institution. J Trauma 2011;71:467-73,
discussion 473. 10.1097/TA.0b013e318220d7fa 21825948
2 Marik PE, Taeb AM. SIRS, qSOFA and new sepsis definition. J Thorac Dis 2017;9:943-5.
10.21037/jtd.2017.03.125 28523143
3 Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Tantraworasin A.
Clinical predictors for severe sepsis in patients with necrotizing fasciitis: an observational
cohort study in northern Thailand. Infect Drug Resist 2015;8:207-16.26213473
4 Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis
resuscitation bundle: a prospective observational cohort study. Emerg Med J
2011;28:507-12. 10.1136/emj.2010.095067 21036796
5 Alliance S. Sepsis It's About Time Sepsis Alliance Website: Sepsis Alliance; 2018. https:
//www.sepsis.org/itsabouttime/
6 Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes
mellitus. N Engl J Med 1999;341:1906-12. 10.1056/NEJM199912163412507 10601511
Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2019;365:l2214 doi: 10.1136/bmj.l2214 (Published 20 June 2019) Page 3 of 3

ENDGAMES

Table

BMJ: first published as 10.1136/bmj.l2214 on 20 June 2019. Downloaded from http://www.bmj.com/ on 20 August 2019 by guest. Protected by copyright.
Table 1| Blood test abnormalities

Result Normal range

White cell count 18.1×10 /L 4-11×109 /L
9

C reactive protein 311 mg/L 0-10 mg/L

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe