Necrotizing Soft Tissue Infection: A Clinical Case Report

Introduction Necrotizing soft tissue infection (NSTI) involves the subcutaneous tissue, superficial and deep fascia and it is considered as a medical emergency due to its high mortality rates ranging from 6% to 34% (1,2,3,4) Emergency department (ED) staff are faced with making the correct diagnosis in a limited amount of time, since the best outcomes are reported if a patient receives adequate treatment in the first 12 hours (1,3). Case Presentation A 67 year old man presented to the ED with pain and swelling of the right leg after trauma, 2 days ago fell while trying to get out of the bath. Later a family member added that some abscess was seen on the knee, which was drained by themselves. Vitals at arriving: respiratory rate - 25 bpm, heart rate - 42 bpm, blood pressure - 127/78 mmHg. Diagnostic tests : X-Ray of the right knee, head CT, CBC (Hb - 140, WBC - 9.9, NE# - 9.3, PLT - 184), arterial blood gasses ( metabolic acidosis - pH 7.1, pCO2 and HCO3 unmeasured, Lactates 18 ) CRP - 294, procalcitonin - 50, deep vein ultrasound of the right leg - no signs of DVT. After 9 hours, bluish discoloration of skin, hemorrhagic bullae formation, spreading redness of right thigh was noted, surgeons immediately informed. Antibiotic therapy with ceftriaxone and metronidazole started, 2 hours later an urgent fasciotomy of involved tissue was performed, it was delayed due to unavailability of surgeons. After, the patient was transferred to the ICU, where 2 days later the patient passed away. Blood and pus culture revealed s. pyogenes as the causative agent. Discussion Patients with NSTIs present with fever, tachycardia, pain, erythema and swelling at the site of infection, serous or hemorrhagic bullae formation, crepitus (5,6,7). Gold standard management is aggressive surgical debridement of affected tissue (3,8) in addition with antibiotic therapy. Difficulty in diagnosing arises if the presentation is atypical - fever might be missing, cutaneous manifestations can be absent, pain and systemic symptoms might be attributed to other causes [8]. Which happened in this case, as the anamnesis was unclear, typical signs of NSTI appeared 9 hours after admission to ED, preliminary diagnosis was cellulitis. Conclusions This case perfectly depicts the rapid progression and the severity of the disease. It proves that early recognition and sufficient management is needed to give the patient the best chance of survival.