Case Follow Up Vicky Stahl PGY 1

HPI 43 yo female presented to ED with abdominal pain and nausea for 4-5 days, subjective fever and chills x 2 days, and vomiting for 1 day Takes 50 U of Lantus every morning but missed morning dose due to nausea

Past medical history PMH: DM, HTN, glaucoma PSH: Left TMA 1/2015, Left BKA 4/2015; osteomyelitis 2/2 to diabetic ulcer Social Hx: Denies smoking, alcohol or illicit drug use Family Hx: DM, colon cancer

Review of Systems Constitutional: Fevers and chills HEENT: negative for rhinorrhea, sore throat, ear pain Respiratory: negative for cough, SOB, DIB Cardiovascular: Negative for chest pain, palpitations GI: Nausea and vomiting, negative for diarrhea GU: Negative for dysuria, increased frequency or urgency MSK: Right foot pain Skin: Discoloration of right great and second toe

Physical Exam Vitals: Temp: 37.2 BP 130/90 HR: 126 RR: 21 SpO2: 99 RA Constitutional: No acute distress HEENT: dry mucus membranes Cardiac: Regular rhythm, tachycardic, 1+ DP pulse of right foot Resp: CTA, breath sounds equal bilaterally, no wheezes or crackles GI: Soft, non distended, no pain to palpation MSK: Left BKA, pain to palpation of right foot, no crepitus palpated on right foot Skin: Black discoloration of great and second toe of right foot, erythema and edema from toes to midtarsal of right foot

Pain in 2nd toe for four days. Discoloration started 3 days before Pain in 2nd toe for four days. Discoloration started 3 days before. Denied trauma, cuts, previous infections

Labs BMP: CBC: Lactate: 2.5 Na: 126 WBC: 25.6 CRP: 33.6 K: 4.8 HgB: 9.4 Cl: 86 HCT: 30.1 Urinalysis: HCO3: 17 Plt: 458 >500 glucose, AG: 23 80 ketones BUN: 17 Negative LE and Nitrate Cr: 1.56 Glucose: 616

ED course ED: Attributed air on xray to open wound on plantar surface of second toe. Beside debridement to allow drainage. Started on Vancomycin and Zosyn, scheduled for TMA the following morning Admitted to MICU for DKA and sepsis 2/2 to wet gangrene

Inpatient Course Admission Day 1: CT showed soft tissue emphysema to lateral malleolus. Taken emergently to OR for right Guillotine amputation above the ankle Admission Day 3: Transferred to GPU Admission Day 7: BKA with closure

Importance of diagnosis Mortality rate around 34% Major reason due to delayed recognition 15-34% of discharge diagnosis of necrotizing fasciitis had the same admitting diagnosis “Diabetic patients, especially those presenting with diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic acidosis have higher rates of death and longer lengths of hospital stay. A delay in surgery of more than 24 hours was an independent risk factor for mortality.”

Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC score) However, the LRINEC score was based on retrospective studies of patients with diagnosed or highly suspected NF. It has not been validated in patients for whom the diagnosis of NF is not apparent in the initial assessment.

positive predictive value of 92% and a negative predictive value of 96%.

Etiology Type 1 (Polymicrobial): gram positive cocci, gram negative rods, and anaerobes Immunocompromised hosts; Diabetes and CKD Typically occur in perineum and trunk Normal flora adjacent to site of infection Type 2 (Monomicrobial): beta hemolytic strep or staph Less common form Previously healthy hosts with hx of trauma (usually trivial) Typically found in extremities

Clinical features Stage 1 Stage 2: Stage 3: (Day 3-5) Hard to distinguish from other soft tissue infections Erythema, warmth and tenderness Poorly defined margins and pain extending beyond erythema Stage 2: Ischemia->bullae formation Stage 3: (Day 3-5) Tissue necrosis causing hemorrhagic bullae and gangrene Ischemia of superficial nerves causing anesthesia Blisters and gangrene are most specific clinical sign but not commonly seen

Imaging Xray: CT: 80% sensitive for NF MRI Ultrasound Gas only present on 25% of cases Present with polymicrobial or clostridium infections CT: 80% sensitive for NF Asymmetrical fascial thickening Fat stranding Gas tracking along fascial plane MRI Found to overestimate amount of deep tissue involvement Ultrasound Not well studied in necrotizing fasiciitis

Diagnosis Definitive diagnosis made during surgery Gray necrotic fascia Lack of resistance of normally adherent muscular fascia Lack of bleeding Foul smelling “dishwater pus” Pathognomonic for necrotizing fasciitis is positive finger test 2 cm incision down to fascia Lack of bleeding, dishwater pus and no resistance diagnostic of necrotizing fasciitis

Diagnosis Blood cx: Histopathology: Positive in 60% of type 1 May not reflect all organisms involved Positive in 20% of Type 2 Histopathology: Extensive tissue destruction, thrombosis of blood vessels, bacterial spreading along fascial plans, inflammatory cells Concentration of bacterial and neutrophils may have prognostic importance

Treatment Treatment: Penicillin, high dose clindamycin, and fluroquinolone or aminogycoside for gram negative organisms Vancomycin, daptomycin, or linezolid for possible MRSA Clindamycin for toxin production

QuestionS A 52-year-old diabetic male sustained minor blunt trauma to his left thigh 10 hours prior to presentation. He initially complained of extreme thigh pain with erythema and swelling but rapidly developed bullae and worsening erythema over the affected area along with fever and tachycardia. What clinical factor has been shown to reduce mortality when treating this pathology? A) MRI findings B) Decreasing time from admission to surgery C)Administration of pressors D) Location of injury

Questions A 56-year-old diabetic male presents to the emergency department with high-grade fevers, malaise, and altered mental status. He is found to be hypotensive and initial labs show an elevated WBC with a profound left shift. Skin manifestations confined to the foot at initial presentation. He is started on broad spectrum antibiotics. Upon follow-up exam 3 hours later his clinical condition deteriorates and he is taken to the operating room for surgical debridement. In a bacterial culture, what would be the most common single isolate for this condition? A) Staph aureus B)Group A stept C) Enterobacteriaceae D) Pseudomonas ncluding gram-positive, gram-negative, aerobic, and anaerobic bacteria were found most commonly in necrotizing fasciitis, Group A streptococcus was the most common bacterial isolate. Wong et al also found the most isolated organism to be group A streptococcus.

References Cunha B. 2009. Infectious Disease in Critical Care Medicine Third Edition Pallin D, Nassisi D, 2014. Skin and Soft Tissue infection, Rosens Pasternack M, Swartz N. 1995 (1194-1215). Cellulitis, Necrotizing Fasciitis, and Subcutaneous Tissue Infections . Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases Puvanendran R, Chan Meng Huey J, Pasupathy S. Oct 2009. V 55(10) Necrotizing Fasciitis. Canadian Family Physician Woon, Colin. Feb 2015. Necrotizing Fasciitis. Orthobullets. Wong C, Khin, L, Heng K, etc. 2004. V 32 (7) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Critical Care Medicine http://static1.1.sqspcdn.com/static/f/1250104/25247721/1406515522600/LRINEC+study.pdf?token=X1rXM8yCG3MWT%2B3GvuH1tQP9Eao%3D http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762295/ https://books.google.com/books?id=syasCQAAQBAJ&pg=PA304&lpg=PA304&dq=dishwater+pus&source=bl&ots=ATwxqup_eH&sig=vQhJN3TwjgM8cO2u85ZYTq3VpPY&hl=en&sa=X&ved=0ahUKEwifmfXihLDKAhVBHT4KHbh8BIQQ6AEIQTAI#v=onepage&q=dishwater%20pus&f=false