Necrotizing Faciitis Sgim

Atypical Case of Necrotizing Fasciitis Samer Alhindi M.D., Abdul Hamid Alraiyes M.D., M Chadi Alraies M.D., Manju Pillai M.D., Emmanuel Elueze, M.D. Ph.D. FACP. Internal Medicine Residency Program, Department of Internal Medicine St. Vincent Charity Hospital - Case Western Reserve University The Case

CXR and CT of the Chest

Treatment • •

A 55 Year old White-American male with PMH of HTN, ?CHF, RA presented with one week history of dizziness, generalized weakness, fever and chills. He had a history of sore throat 4 weeks ago, and he reported a weight loss over the last 5 month, PT has a prolonged history of NSAIDs use for his joints pain and headache, PT denied any history of travel, sick contact, or any animal contact.

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Emergent surgery: Debridement of the lesions site. Septic Shock: IVF (10 – 20 ) liters. Pressors . Intravenous immune globulin. Hyperbaric oxygen. Antibiotics: See table

PHYSICAL EXAMINATION: VS: T: 38.1oC rectally, BP: 81/51, HR: 110, RR:24, SPOX:96% 2LNC, Wt: 96 kgs. Large black irregular eschar lesion on the left posterior thoracic wall 6-13cm, with underlying softness and surrounding erythema. Left SQ palpable crepitus extending to the scapula, and left deep axiliary adenopathy.

9 cm RT lower lobe mass, Pretracheal adenopathy, Extensive LT posterior SQ gas, not communicate with pleural cavity or abdomen.

Hospital Course Our patient has the overall picture of Group A hemolytic streptococcus necrotizing fasciitis type2 complicated by toxic shock syndrome. He had the preceding history of sore throat, suggestive of pharyngitis with a prolonged use of NSAIDs. He had a history of weight loss and had 9 cm RT lung mass in CT scan with adenopathy, suggestive of malignancy. PT was started on IVF, IV ABx and pressors surgical team consulted. Patient refused the surgery and expired in 4hrs.

Workup Wound Culture: Group A hemolytic streptococcus.

CBCD WBC: 34.4 BAND: 54% Neut: 39% Lymph: 4% HGB: 14.7 HCT: 44.5% MCV: 91 MCH: 30 RDW:15.7 PLT: 246

CMP Na 130 K: 7.4 CL: 92 CO2: 17 GLU: 66 BUN: 149 Cr: 3.8 TP: 5.9 ALB: 1.9 AST: 214 ALT : 101 ALKP: 229 LDH:796 CK:816 BNpep:93.9 Lactic Acid: 5.1

Necrotizing Fasciitis ABG pH: 7.309 PCO2: 26 PO2: 62 HCO3: 12.6 SAT: 85.6% A-a: 61.7

NF Pathogenesis: Severe infection involving the subcutaneous tissue and the deep fascia. Incidence in healthy young adults has increased recently. Most common locations: Perineal region and Extremities. Precipitating factors: Minor trauma (80% of reported cases), Operative wounds, Decubitus ulcers, DM, Severe arteriosclerosis, Poor nutritional status Immunocompromised patients, Obesity, NSAIDs (inhibition of neutrophil function and augmentation of cytokine release) 50% no underlying illness. Type 1 necrotizing fasciitis: A mixed aerobic and anaerobic infection: S. aureus, E. coli, Group A strep, B. fragilis, Peptostreptococcus, and Prevotella. • Risk factors: Recent surgical procedures, DM, • Clinically: Pain often out of proportion to the physical exam. erythema followed by darkening with clear and bloody bullae. Anesthesia. Compartment syndrome, fever, and hypotension. Type 2: Necrotizing Fasciitis: Group A hemolytic streptococcus infection. A history of exposure is often not found, but can follow: Blunt trauma, bug bite, Chickenpox, IVDU, Surgical procedure, Strep throat, NSAIDs. The patient is often immunocompetent and often has no significant past medical history. Clinically: Same as Type 1; Streptococcal toxic shock in 10-20 % of the times, TSS SBP < 90. AND 2 of the following: Renal impairment, platelets < 100,000 OR DIC, Liver involvement, ARDS, Generalized erythematous macular rash, Soft-tissue necrosis.

Discussion Patients with long-standing, severe, erosive rheumatoid arthritis are at increased risk for serious infection and premature mortality. NSAIDs hold great promise for improving the course of rheumatoid arthritis. However, they have powerful anti-inflammatory effects that may mask symptoms of serious infection, 1. Reports suggest that (NSAIDs) increase the risk of developing GAS necrotizing fasciitis, impede its timely recognition and management, and accelerate the course of infection, 2. Although it was not possible to conclude if NSAIDs increase the risk of necrotizing complications in all patients, their use may mask the symptoms and delay diagnosis, 3. There has been a dramatic increase in the number of detected cases of streptococcal TSS as a complication of NF course. There was a wide range of invasive forms of infection, a high fatality rate even in fit young adults, and a rapid course from onset to death. A study showed that (NSAIDs) had been taken around the time of onset of disease by 92% of the patients with TSS4.

References 1. 2. 3. 4.

Fatal sepsis in a patient with rheumatoid arthritis treated with etanercept. Baghai M, Osmon DR, Wolk DM, Wold LE, Haidukewych GJ, Matteson EL. Department of Surgery, Mayo Clinic, Rochester, Minn 55905, USA. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Aronoff DM, Bloch KC. Department of Medicine, University of Michigan Health System, Ann Arbor, USA. Streptococcal toxic shock syndrome: a description of 14 cases from North Yorkshire, UK. Barnham MR, Weightman NC, Anderson AW, Tanna A. Department of Microbiology, Harrogate District Hospital, North Yorkshire, UK. [email protected] Necrotizing cellulitis complicating varicella in two children given nonsteroidal anti-inflammatory drugs] Louis ML, Launay F, Guillaume JM, Sabiani F, Chaumoître K, Retornaz K, Gennari JM, Bollini G