Necrotising fasciitis: a fatal case of sepsis and a diagnostic challenge – case report and review of literature

Abstract

BackgroundNecrotising fasciitis (NF) is a severe, devastating soft tissue infection characterised by rapidly progressing tissue necrosis. This rare condition has a high mortality rate and poses diagnostic and management challenges to the clinician. There is usually a history of trauma, which maybe trivial. Some of the premorbid conditions associated with NF are diabetes and or immunocompromised state. It requires prompt recognition and early treatment with intravenous antibiotics and extensive surgical debridement.Case presentationWe describe a 74-year-old lady who presented to our emergency department following 3 days’ history of watery diarrhoea and feeling generally unwell.She had signs of severe sepsis and was started on broad-spectrum intravenous antibiotics and fluids for sepsis with unknown source. She was found to have an area of blackish discolouration on her thigh which was suspected as necrotising fasciitis (NF) and referred to the surgeons. She had no history of trauma or significant comorbidity. She underwent surgical exploration and debridement within few hours of arrival into the emergency department and subsequent further debridement with above-knee amputation of the affected limb.She eventually died after about 48 h of hospital stay despite an early diagnosis and prompt surgical debridement and a multidisciplinary approach.ConclusionsNecrotising fasciitis has been previously reported in literature but we would like to highlight through this case the importance of looking for the source of sepsis by thorough clinical examination and the need to have a high threshold of suspicion for this rare condition and urgent involvement of a surgical team for debridement.

Necrotizing Soft Tissue Infections in the Vasculopathic Patient: Review of Literature

“…59 Thorough clinical examination for sources of sepsis and a low threshold of suspicion for this condition are essential. 5,60 Erythema, warmth, edema, woody induration, pain, and fever may be early signs and can be nonspecific. 51,60 Pain out of proportion and a toxic appearance may be the only distinguishing features at an early stage.…”

“…It incorporates white blood cell count, hemoglobin, C-reactive protein, sodium, glucose, and creatinine for score computation. 5,60 Scores of 8, 6, and 5 are categorized as high, intermediate, and low risk of NSTIs, respectively. 62 A recent prospective study showed that among patients with duration of symptoms .8 hours, a cutoff score of .4 was reasonably effective in distinguishing necrotizing fasciitis from simple cellulitis, with sensitivity of~85% and specificity of 75%.…”

“…It is often preceded by some degree of trauma or result from hematogenous dissemination of pathogenic microorganisms, 1,4 and is associated with chronic conditions including diabetes mellitus, renal impairment, alcohol abuse, and immunocompromised states. 4,5 Vasculopathy is commonly referred to as diseases affecting blood vessels including degenerative, inflammatory, metabolic, and other disorders. 6 For the purposes of this review, we have limited our scope to peripheral arterial disease secondary to atherosclerosis, which is a commonly identified risk factor associated with NSTIs, as well as a poor prognostic indicator for major amputation and mortality.…”

Molecular Methodologies for Improved Polymicrobial Sepsis Diagnosis

“…Bacteria isolated from polymicrobial soft tissue infections such as synergistic gangrene and type I necrotising fasciitis include combinations of Gram-positive cocci, Gram-negative bacilli and anaerobes e.g., Bacteroides sp. [35,36]. These infections can result from factors such as infected surgical wounds, burns and chronic skin ulcers, all of which can rapidly progress to polymicrobial sepsis [35,36].…”

Necrotizing Fasciitis: Expect the unexpected

“…NF may be caused by a single species of bacteria, or by a polymicrobial variety of microrganisms [ 2 ]. A high index of suspicion is essential as aggressive surgical debridement may be necessary to save life [ 3 ]. NF can develop at sites of skin puncture, surgical wounds, chronic ulcers or insect bites [ 2 ].…”