Clinical evolution, management, and resolution of type II necrotizing fasciitis

Abstract

A 60-year-old woman with a history of pre-diabetes and hyperlipidemia, presented to a local hospital with severe left flank pain and skin discoloration on the same area for 2 days. She had been taking care of her grandson who was diagnosed with streptococcal sore throat. On examination, the patient was hypotensive and tachycardic. There was a large grayish blue area over the left flank, extending to the left lower back (Fig. 1a, b). This area was very tender to palpation. There were no bullae, crepitus, or external drainage. A CT scan of the abdomen revealed a diffuse inflammatory process within the skin and soft tissue without any gas in the adjacent area. A diagnosis of necrotizing fasciitis was pursued. Broad-spectrum intravenous antibiotics (vancomycin, piperacillin-tazobactam, and clindamycin), and vasopressors were initiated, and she was transferred to our institution for further management. Upon arrival, she was immediately taken to the operating room for surgery. The operative findings showed there were extensive soft tissue necrosis and edematous fascial layers. A full-thickness debridement of skin and subcutaneous tissue of the left flank (24 cm 9 21 cm 9 1.5 cm) was performed (Fig. 1c). The tissue culture was positive for group A b-hemolytic Streptococcus (Streptococcus pyogenes). The pathogen was sensitive to penicillin (minimal inhibitory concentration, MIC 0.032 mg/L), ceftriaxone (MIC 0.064 mg/L), vancomycin (MIC 1.0 mg/L), and clindamycin (MIC not reported). Blood cultures were negative throughout the admission. Antibiotics were tailored to intravenous penicillin and clindamycin.Despite appropriate antimicrobial therapy, on day 3 of hospitalization, there were new areas of purplish red discoloration changes noted around the edge of the wound (Fig. 1d). She underwent additional debridement of skin and subcutaneous tissues (Fig. 1e). A day later (day 4 of hospitalization), it was again noted that the infection was extending upward to the left axilla at which point further debridement was undertaken (Fig. 1f). On day 6 of admission, extension of bluish gray skin changes occurred medially towards the suprapubic region (Fig. 1g), requiring an additional large area (20 cm 9 11 cm 9 2 cm) of surgical debridement (Fig. 1h). The negative pressure wound therapy devices were applied to the wounds, and the wound dressings were regularly changed under anesthesia. Vasopressors were successfully weaned off, and she continued to improve. On day 20 of hospitalization, the patient was eventually discharged home with negative pressure wound therapy. Approximately 2 months after the initial hospitalization, the abdominal and axillary wounds were found to be sufficiently granulated (Fig. 1i). She underwent definitive wound closure with split-thickness skin grafts harvested from the left thigh. One month post-skin graft follow-up (day 84 from the first hospitalization), skin grafts were taken very well without further complications (Fig. 1j).J. Makadia and Z. Min equally contributed to this manuscript.