Case of necrotizing soft tissue infection
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?
I agree that gram negative myositis is very unusual except where there is a GI source of contamination such as a Fournier’s Gangrene. Have you tapped the ascites?
I am surprised that there was dead muscle and no elevation of the CPK.
I recently had a case of right flank necrotizing fasciitis that arose from an appendiceal abscess. The patient who was HIV positive presented with confusion and a picture of an ileus versus bowel obstruction. He had absolutely no localized tenderness. CT showed a RLQ abscess which was percutaneously drained. 48 hours later he developed a gram negative fasciitis of the right flank. At first I thought it was seeding from the drain, but in retrospect, the CT showed inflammatory changes along the tissues of the right flank before the drain was placed. He did well with aggressive debridement of the right flank. As an aside, I wonder what others on the list would feel about doing an interval appendectomy in this patient.
Given your patient’s cogagulopathy and myositis, amputation of the involved limbs as a lifesaving maneuver would be a consideration. But with his underlying liver disease, I think it would be appropriate not to be aggressive.
I have not been impressed with the data on the use of hyperbaric oxygen in this setting. In our experience it often turns into a logistical nightmare, especially with the unstable patient.
In 2006 I had this run of Group A beta hemolytic strep necrotizing fasiitis. I was averaging one to two cases a month. In one weekend I had admitted three patients with this type of infection including the most severe case of craniocervcial necrotizing fasiiitis that you can ever imagine. (I will be presenting this case as a separate post now that the legal smoke has cleared).
During the last half of 2006 and most of 2007, I saw one or two cases of very mild necrotizing cellulitis. I was begining to worry until last week when I was called to see two more cases with one of them in septic shock. The last patient was transferred from Kauai. In Kauai, they are experiencing such a significant ourbreak, that they have done screening nasal swabs of all the school children with the thought that the children are acting as a resevoir of the more virulent strains of this strep.
No but the patient died this morning and will undergo autopsy to clear that point. Preoperative abdominal exam revealed moderate ascitis with no tenderness.
CPK were initially normal but elevated to 2700 12 hours after the patient arrived.
When in front of a necrotizing fasciitis, you can’t go in a shy way. Only fasciotomy is not enough op, do you think there is any difference to do a fasciotomy or a resection?. All the dead tissue must be resected, ALL, with all the neccessary incisions and drains. What do you think is going to happen with the dead tissue in situ? just to keep the infection and spread it to the next healthy tissues. This, Martel, must be clear, you must take your patient to the OR, the sooner the better. Otherwise, he won’t have any hope. About the use of Hyperbaric oxygen, try it!, but never instead of resection, but plus resection. The use of HO must be in several sessions, how many?, it depends on the response. The gold standard must be to resect until you see only healthy tissues, and to review the lessions once or twice a day or all the times it may be neccessary.
What a pity! when I read your first message I responded it inmediately in order to try to help, and eventhough I thought it was a very poor risk pt. What is worthy for you from this pt? May be you must be more aggressive. Never leave dead tissues. NEVER. Dead tissues will never revitalize and on the other hand will be good for the bacteries. From this cases one learns more than a hundred classes.
Forget the hyperbaric O2–it is unproven–it is certainly no substitute for getting rid of the septic focus–in this case, debriding the dead muscle–oxygen can’t magically bring back to life tissue that is dead.
The only known management of necrotising fasciitis is an aggresive surgical excision,there is no place for incisions,drainage or decompression. The timing of surgery is the key to outcome,early diagnosis and prompt management may save lifes. The aim of surgery is to excise all necrotic and infected tissue leaving clean,viable tissue only. Excision of large areas of skin,dead muscles,and amputations should be curried out if you are aiming for any chance for survival,the wounds should be reveiwd 4-6 hourly for further debridment if needed,failure to implement complete excision of all infected tissue will bring chances of survival to 0%. While I was writing this letter I knew that your patient died,amputations may not have changed the outcome in a very sick Child Pugh C liver cirrhosis patient,but I think it is the proper line of management as long as the patient have been taken to theater.
I’m surprised you are giving an advice in order to “not to be aggressive” in a severe case of necrotizing fasciitis. Why? which are your arguments to not to be aggressive. Leave dead tissues is more aggressive than to resect it, cause it is aggressive and life threatening to the patient. Please, light my darkness, for I’d been resecting all dead tissues all my surgical life, and if I see one more I should do the same, so please let me know I’m wrong and I’ll soon learn to leave dead tissues in situ in a necrotizing fasciitis, send me your evidences and where I can read about this different way. Otherwise, you must detract and accept it was a wrong advice. Don’t forget that there are thousand surgeons( old, mediums and young ) reading our messages.
A necrotizing infection in a Child C cirrhotic patient is bad news. Any infection is a bad news in Child C patient.
There are three components essential to the therapy of this condition: Resection, re-resection, and re-resection. All the rest are gimmick. Jorge mentioned drains??? what drains, where and why?
Five years ago I was called to operate on a leukemic patient with necrotizing myositis of lumbar pre-vertebral muscles; I approached it extra-periotoneally via a loin incision- the patient died. No port of entry noticed; must be hematogenic seeding in immunocompromised host.
All evidence on this topic is level 5. One may decide to believe in it… as some believe in many other gimmicks.
As a footnote: the classification of necrotizing soft tissue infections is complicated and controversial but to me does not make sense as the treatment is simple: resect anything which stinks even if it is a whole limb.
At the time we saw our unfortunate patient, we probably should have amputated both his left arm and leg (and very high because the swelling extended up to his inguinal fold and to the axilla) and debrided his right calf to get a chance of cure. We thought he was too sick to survive such an operation and were afraid he would bleed to death. But he wouldn
On this case, I think everyone would agree that thorough debridement or amputation if necessary was the only hope for this gentleman, but I agree that his chance of surviving a Pseudomonas necrotizing muscle infection while awaiting liver transplant for end stage liver disease was negligible if not 0, even with appropriate debridement.
A Child’s C patient on the liver tranplant list with the infection described (myosotis and septic shock) is probably in my opinion not salvagable. His only chance of survival would be a major amputation of all involved extremities. My advice “not to be aggressive” meant that it would be reasonable in my opinion to make the decision that this was an incurable process and to let the patient die with his limbs intact (assuming the family was agreeable).
Very unusual case with both an arm and a leg involved at the same time. It is also unusual because it was first thought to be streptococcal fasciitis which suggest there were obvious skin manifestations, BUT at operation, you write, there was dead muscle, meaning a myositis. Finally, it is very unusual for the relatively non-invasive pseudomonas to cause myositis. It is more common, but still unusual, that pseudomonas is involved with the subcutaneous infection of fasciitis. A case of Child C cirrhosis associated with simultaneous arm and leg myofasciitis caused by pseudomonas. Write it up for the JCC.