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Atypical Case of Necrotizing Fasciitis

Samer Alhindi M.D., Abdul Hamid Alraiyes M.D., M Chadi Alraies M.D., Manju Pillai M.D., Emmanuel Elueze, M.D. Ph.D. FACP.
Internal Medicine Residency Program, Department of Internal Medicine
St. Vincent Charity Hospital - Case Western Reserve University

The Case CXR and CT of the Chest Treatment


• Emergent surgery: Debridement of the lesions site.
• Septic Shock: IVF (10 – 20 ) liters. Pressors . Intravenous immune
A 55 Year old White-American male with PMH of HTN, ?CHF, RA presented with one week
globulin. Hyperbaric oxygen.
history of dizziness, generalized weakness, fever and chills. He had a history of sore throat 4
• Antibiotics: See table
weeks ago, and he reported a weight loss over the last 5 month, PT has a prolonged history of
NSAIDs use for his joints pain and headache, PT denied any history of travel, sick contact, or
any animal contact.

PHYSICAL EXAMINATION: VS: T: 38.1oC rectally, BP: 81/51, HR: 110, RR:24,
SPOX:96% 2LNC, Wt: 96 kgs. Large black irregular eschar lesion on the left posterior
thoracic wall 6-13cm, with underlying softness and surrounding erythema. Left SQ palpable
crepitus extending to the scapula, and left deep axiliary adenopathy.

9 cm RT lower lobe mass, Pretracheal adenopathy, Extensive LT posterior SQ gas, not communicate with pleural cavity or
abdomen.

Hospital Course
Our patient has the overall picture of Group A hemolytic streptococcus necrotizing
fasciitis type2 complicated by toxic shock syndrome. He had the preceding history of sore
throat, suggestive of pharyngitis with a prolonged use of NSAIDs. He had a history of
weight loss and had 9 cm RT lung mass in CT scan with adenopathy, suggestive of
malignancy. PT was started on IVF, IV ABx and pressors surgical team consulted. Patient
refused the surgery and expired in 4hrs.
Workup
Discussion
Wound Culture: Group A hemolytic streptococcus.
Necrotizing Fasciitis Patients with long-standing, severe, erosive rheumatoid arthritis are at increased risk for
CBCD CMP ABG serious infection and premature mortality. NSAIDs hold great promise for improving the
NF Pathogenesis: Severe infection involving the subcutaneous tissue and the deep fascia. Incidence in healthy course of rheumatoid arthritis. However, they have powerful anti-inflammatory effects that
WBC: 34.4 Na 130 pH: 7.309 young adults has increased recently. Most common locations: Perineal region and Extremities. may mask symptoms of serious infection, 1. Reports suggest that (NSAIDs) increase the risk
BAND: 54% K: 7.4 PCO2: 26 of developing GAS necrotizing fasciitis, impede its timely recognition and management, and
Neut: 39% CL: 92 PO2: 62 Precipitating factors: Minor trauma (80% of reported cases), Operative wounds, Decubitus ulcers, DM, Severe accelerate the course of infection, 2. Although it was not possible to conclude if NSAIDs
Lymph: 4% CO2: 17 HCO3: 12.6 arteriosclerosis, Poor nutritional status Immunocompromised patients, Obesity, NSAIDs (inhibition of neutrophil increase the risk of necrotizing complications in all patients, their use may mask the symptoms
HGB: 14.7 GLU: 66 SAT: 85.6% function and augmentation of cytokine release) 50% no underlying illness. and delay diagnosis, 3. There has been a dramatic increase in the number of detected cases of
HCT: 44.5% BUN: 149 A-a: 61.7 streptococcal TSS as a complication of NF course. There was a wide range of invasive forms
MCV: 91 Cr: 3.8 Type 1 necrotizing fasciitis: A mixed aerobic and anaerobic infection: S. aureus, E. coli, Group A strep, B. fragilis, of infection, a high fatality rate even in fit young adults, and a rapid course from onset to
Peptostreptococcus, and Prevotella. death. A study showed that (NSAIDs) had been taken around the time of onset of disease by
MCH: 30 TP: 5.9
• Risk factors: Recent surgical procedures, DM, 92% of the patients with TSS4.
RDW:15.7 ALB: 1.9
• Clinically: Pain often out of proportion to the physical exam. erythema followed by darkening with clear and
PLT: 246 AST: 214
ALT : 101
bloody bullae. Anesthesia. Compartment syndrome, fever, and hypotension. References
ALKP: 229 Type 2: Necrotizing Fasciitis: Group A hemolytic streptococcus infection. A history of exposure is often not found, 1. Fatal sepsis in a patient with rheumatoid arthritis treated with etanercept. Baghai M, Osmon DR, Wolk DM, Wold LE,
LDH:796 but can follow: Blunt trauma, bug bite, Chickenpox, IVDU, Surgical procedure, Strep throat, NSAIDs. The patient is 2.
Haidukewych GJ, Matteson EL. Department of Surgery, Mayo Clinic, Rochester, Minn 55905, USA.
Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by
CK:816 often immunocompetent and often has no significant past medical history. group A streptococcus. Aronoff DM, Bloch KC. Department of Medicine, University of Michigan Health System,
Ann Arbor, USA.
BNpep:93.9 3. Streptococcal toxic shock syndrome: a description of 14 cases from North Yorkshire, UK. Barnham MR, Weightman
Lactic Acid: 5.1 Clinically: Same as Type 1; Streptococcal toxic shock in 10-20 % of the times, TSS SBP < 90. AND 2 of the NC, Anderson AW, Tanna A. Department of Microbiology, Harrogate District Hospital, North Yorkshire, UK.
mike.barnham@hhc-tr.northy.nhs.uk
following: Renal impairment, platelets < 100,000 OR DIC, Liver involvement, ARDS, Generalized erythematous 4. Necrotizing cellulitis complicating varicella in two children given nonsteroidal anti-inflammatory drugs] Louis ML,
macular rash, Soft-tissue necrosis. Launay F, Guillaume JM, Sabiani F, Chaumoître K, Retornaz K, Gennari JM, Bollini G