The Case

A 60-year-old male with past medical history of anxiety and depression presented to the emergency department via EMS with complaints of pain in the left upper extremity after falling. The patient stated he recently moved into a new apartment, and he tripped and fell forward onto a carpeted surface three days ago. He then developed pain and swelling to the left hand/arm and left eye. He reported loss of consciousness for some time and denied any alcohol or drug use or abuse. The patient noted the redness to his left hand yesterday, and it progressively worsened and started to develop blisters (see Figures 1 and 2). The patient also noted swelling to the left eye upper and lower eyelids and a rash to the left upper abdomen similar in appearance to his hand (see Figures 3 and 4). He admitted to significant pain and stated he could not straighten his fingers. He denied fever, chills, nausea, vomiting, chest pain, shortness of breath, or similar symptoms in the past. He hadn’t taken anything for pain.

Figure 2: Rash and blisters on the patient’s left hand.

Based on his history and physical exam, a CT of the head, maxillofacial, and left hand without contrast were ordered because of concern for necrotizing fasciitis and compartment syndrome. His chemistries were significant for sodium 126 mEq/L, potassium 6.4 mEq/L, blood urea nitrogen 77 mg/dL, creatinine 6.85 mg/dL, glucose 109 mg/dL, total creatinine phosphokinase 11,000 U/L, aspartate aminotransferase 871 U/L, alanine aminotransferase 972 U/L, white blood cell count 13.5 k/mm3 with left shift, hemoglobin 15.2 g/dL, and C-reactive protein (CRP) 249.2mg/L.

The head CT was negative for acute findings. The maxillofacial CT was significant only for soft tissue swelling. The CT of the left hand was notable for osteoarthritis of the left trapezium and first and second metacarpals with some soft tissue swelling with blebs in subcutaneous soft tissues. Plain radiographs of the hand were significant for flexion deformities of the distal phalanges. However, no subcutaneous air or acute fracture or dislocations were noted. X-rays of the right hip and chest were negative for acute findings.

Over the course of his ED visit, the patient became more uncomfortable, and the pain and functionality of his left hand worsened since his arrival. Reexamination showed numbness to the left hand and forearm and a weak radial pulse, both of which were concerning signs for compartment syndrome. Orthopedic surgery was consulted, and the patient was emergently taken to the operating room (OR) for debridement and fasciotomy of the left hand and forearm. Compartment pressures were not measured as the patient exhibited clinical signs of compartment syndrome and delaying definitive treatment to measure compartment pressure is contraindicated. The patient was started on clindamycin, Zosyn, and vancomycin. He was taken to the OR the following day for a second debridement, and a muscle biopsy was performed of the left volar region, identifying viable skeletal muscle tissue with mild reactive changes. The patient underwent hemodialysis for acute renal failure secondary to rhabdomyolysis. The patient had a long, complicated hospital course. Ultimately, he improved and was discharged to a rehabilitation facility on day 20.

Figure 3: Swelling on the patient’s left eye upper and lower eyelids.

Figure 4: Rash on the patient’s left upper abdomen, similar in appearance to the one on his hand.

Background

Necrotizing fasciitis is a category of soft tissue infection that is described as fulminant deep tissue destruction with systemic signs of toxicity and a high mortality rate.^1,2 There are two types of necrotizing fasciitis: polymicrobial (anaerobic and aerobic) and group A Streptococcus.¹ Patients typically present with erythema, swelling, pain out of proportion to the exam, crepitus, and skin breakdown with bullae that can begin acutely and rapidly progress and spread.^1-3 Risk factors include immunosuppression, drug use, recent surgery, liver disease, traumatic wounds, and diabetes.^1-3

(click for larger image) Table 1: LRINEC Scoring System⁶

In patients who present to the emergency department with these symptoms and risk factors, it is also important to consider other similarly presenting complications such as acute compartment syndrome (ACS). ACS occurs when fascial compartment pressures surpass capillary perfusion pressures, leading to tissue ischemia and necrosis. ACS is a limb-threatening diagnosis that can occur acutely after fracture or soft tissue injury and requires immediate clinical suspicion and intervention. Both necrotizing fasciitis and ACS are rare diagnoses, and a few case studies have shown that they can occur simultaneously in patients who present with severe extremity pain and signs of a systemic inflammatory response.

To help providers better recognize necrotizing fasciitis in the emergency department, the laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring system was developed based on six laboratory results: total white cell count, hemoglobin, sodium, glucose, serum creatinine, and CRP (see Table 1). Patients with a score of 6 or above should be seriously considered for necrotizing fasciitis.^4,5 For example, in the case presented above, the patient’s LRINEC score was 8 for elevated CRP, hyponatremia, and elevated creatinine, which reinforced our suspicion for necrotizing fasciitis and need for emergent treatment.

CT scan is the most helpful imaging modality for detecting necrotizing fasciitis in the deeper soft tissue layers in the emergency department in a timely manner.^1,7 However, the only way to definitively diagnose necrotizing fasciitis is surgical exploration and early wound debridement of necrotic tissue.^1,7 Surgical exploration should not be delayed, and wound cultures should be obtained. The wound should also be evaluated 24 hours later in the OR and aggressively debrided again if necrotic tissue is present. Broad-spectrum antibiotic therapy should be started and continued until no additional debridement is needed and the patient’s condition improves.⁷

Necrotizing fasciitis is associated with a high mortality rate and should be treated immediately upon identification in the emergency department. Patients may present with different clinical histories and physical exam findings, but it is important that necrotizing fasciitis be ruled out in cases of rapidly progressive soft tissue infections.

Dr. Peña is an emergency medicine resident at St. Joseph’s University Medical Center in Paterson, New Jersey.

Dr. Bella is an emergency medicine resident at Morristown Medical Center in Morristown, New Jersey.

References

1. Stevens DL, Baddour LM. Necrotizing soft tissue infections. UpToDate. Accessed September 27, 2018.
2. Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1): e119-125.
3. Wong CH, Chang HC, Pasupathy S, et al. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of morality. J Bone Joint Surg Am. 2003;85-A(8):1454-1460.
4. Neeki MM, Dong F, Au C, et al. Evaluating the Laboratory Risk Indicator to differentiate cellulitis from necrotizing fasciitis in the emergency department. West J Emerg Med. 2017;18(4): 684-689.
5. Wong CH, Khin LW, Heng KS, et al. Clinical relevance of the LRINEC (Laboratory Risk Index for Necrotizing Fasciitis) score for assessment of early necrotizing fasciitis. Crit Care Med. 2005;32(7):1535-1541.
6. Panesar K. Necrotizing soft-tissue infections: “flesh-eating bacteria.” US Pharm. 2013;38(4):HS8-HS12.
7. Misiakos EP, Bagias G, Papadopoulos I, et al. Early diagnosis and surgical treatment for necrotizing fasciitis: a multicenter study. Front Surg. 2017;4:5.
8. Kleshinski J, Bittar S, Wahlquist M, et al. Review of compartment syndrome due to group A streptococcal infection. Am J Med Sci. 2008;336(3):265-269.
9. Johnson P, Ocksrider J, Silva S. Update and review of acute compartment syndrome and necrotizing fasciitis. Intern Med Rev. 2017; 3(2).