First case of necrotizing soft tissue infection is a 48 year-old man with hepatitis C cirrhosis, Child Pugh C, on the waiting list for liver transplant. He came to the Hospital in the morning with left leg and arm swelling and pain both of which were very tender on palpation and on passive mobilisation with initially no neurologic involvement. No history of trauma nor diabetes. No fever, HR 96, BP over 110. Moderate ascitis with no abdominal symptoms. No leucocytosis . CPK normal. Platelets 15 000, INR 1.9.
He was admitted by the Hepatologist, put on Peni/Clinda for suspected Strept A necrotizing fasciitis by the end of the afternoon. Because of communication problems, we, the surgeons, were aware of this consultation only around 7 PM. By this time, the patient had developped important swelling with frank compartment syndrome of both arm and leg, he also complained of pain in the right calf which was tender on palpation and mobilisation. He was obnubilated but had been on Morphine 20-30 mg every 2-3 hours to control the pain. Then, Temperature 37,9, HR 110, BP still OK. CPK 2000.
He was taken to the OR for fasciotomies only, his liver disease with coagulopathy and the extent of the infection kept us from doing more extensive debridement of the dead muscles we saw. Gram staining showed Gram negative bacilli. Patient is now in ICU on ventilator and levophed for septic shock.
- Has anyone seen such an agressive gram negative myositis arising spontaneously with no history of trauma or diabetes?
- Would you have been anymore agressive in the management of this case?
- Do you believe in hyperbaric oxygen for such a case?