What's the diagnosis? By Dr. Caroline Blatcher
A 52 you male PMH of uncontrolled DM presents with four days of left arm pain. Exam significant for foul odor, tissue necrosis, crepitus over clavicle and shoulder, decreased ROM. An x-ray is shown. What's the diagnosis? Scroll down for answer.
A CT was obtained as well
Answer: Necrotizing fasciitis, extensive subcutaneous air within tissue
- Risk factors: DM, ETOH abuse, peripheral vascular disese, immunodeficiency, IV drug abuse, penetrating trauma
- Up to 75% of infections are polymicrobial (aerobic and anaerobic bacteria)
- Infection can spread rapidly, usually presents over hours
- Exam: erythema, edema, severe pain out of proportion to external findings, fever, less commonly crepitus and skin bullae / necrosis
- Treatment involves prompt surgical debridement, antibiotics alone are ineffective.
- ED management: stat surgical consult, IV fluid resuscitation, broad spectrum IV antibiotics to cover gram positive, gram negative and anaerobic bacteria - for example piperacillin-tazobactam plus vancomycin plus clindamycin for it's antitoxin effects
Kelly, E., & Magilner, D. (2016). Soft Tissue Infections. In Tintinalli's emergency medicine: A comprehensive study guide. New York, NY: Mc Graw-Hill Education.