Necrotizing fasciitis--a diagnostic dilemma: two case reports

Abstract

Introduction: Necrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality.

Case presentation: Two case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days.

Conclusions: Necrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.

Figure 1

Initial clinical presentation and surgical intervention. The two top images depict the various healed and recent injuries sustained by the patient. The image in the middle shows a laterally rotated swollen left thigh and lower limb. The bottom image depicts necrotic muscle on surgical debridement of the left thigh.

Figure 2

X-ray imaging of left thigh and abdomen. Image on the left is an X-ray of the left thigh; it failed to demonstrate presence of gas. Image on the right is an X-ray of the abdomen in supine position which demonstrates dilated large bowel loops favoring the clinical picture of intestinal obstruction.

Figure 3

Magnetic resonance imaging of the left lower limb. Row 1: T2-weighted sagittal and axial view magnetic resonance imaging cuts of the left thigh demonstrate loss of normal architecture and edema of the muscle of the adductor compartment and numerous cystic areas. Row 2: Fat-suppressed T1-weighted image on the left, and T2-weighted image on the right, both axial magnetic resonance imaging cuts at the knee level demonstrate presence of gas with knee joint effusion.

Figure 4

Clinical deterioration and progression of necrotizing fasciitis. Image depicts necrotizing fasciitis ascending to involve the chest and left upper limb.

Figure 5

Superficial skin manifestations of necrotizing fasciitis. Image on the left shows early skin involvement of the left medial aspect of the thigh and bullae formation of the calf, which is more clearly demonstrated on the image on the right.