Management of necrotizing myositis in a field hospital: a case report

Abstract

Necrotizing myositis is a rare and fatal disease of skeletal muscles caused by group A beta hemolytic streptococci (GABHS). Its early detection by advanced imaging forms the basis of current management strategy. Paucity of advanced imaging in field/rural hospitals necessitates adoption of management strategy excluding imaging as its basis. Such a protocol, based on our experience and literature, constitutes: i. Prompt recognition of the clinical triad: disproportionate pain; precipitous course; and early loss of power- in a swollen limb with/without preceding trauma. ii. Support of clinical suspicion by 2 ubiquitous laboratory tests: gram staining- of exudates from bullae/muscles to indicate GABHS infection; and CPK estimation- to indicate myonecrosis. iii. Replacement of empirical antibiotics with high intravenous doses of sodium penicillin and clindamycin. iv. Exploratory fasciotomy: to confirm myonecrosis without suppuration- its hallmark. v. Emergent radical debridement. vi. Primary closure with viable flaps - unconventional, if need be.

Figure 1

Photograph showing the extent of involvement sparing the anterior compartment, with fasciotomies revealing the myonecrosis with conspicuously absent suppuration.

Figure 2

Photograph showing the extent of involvement sparing the anterior compartment, with fasciotomies revealing the myonecrosis with conspicuously absent suppuration.

Figure 3

Outer view of the harvested quadriceps flap.

Figure 4

Inner view of the quadriceps flap showing the femoral vessels.

Figure 5

Post operative photo showing the viable quadriceps flap.

Figure 6

Low power microscopic view depicting leucocytic infiltration of muscles and vessels.

Figure 7

High power microscopic view showing coagulative myonecrosis; absent pus; and dense leucocytic infiltration.

Figure 8

Photograph showing viable lateral flap based on tensor fascia lata.