Case 1. A seventy-one-year-old man with a history of gout and
chronic renal insufficiency sought treatment for swelling, erythema, and
tenderness of the right knee, which had lasted for two days. The patient
worked as a farmer, and he recalled an antecedent injury to the right calf two
months previously, which had resulted in a chronic ulcer. On admission to our
emergency department, he was afebrile with a blood pressure of 99/69 mm Hg and
a pulse rate of 103 beats/min. As a smear of the aspirated synovial fluid
demonstrated gram-positive organisms, oxacillin was administered intravenously
to treat suspected septic arthritis. Despite the antimicrobial drug therapy,
the lower-limb infection progressed, with the erythema extending to the right
thigh. The initial hematologic investigation revealed a white blood-cell count
of 8.8 × 109/L with 83% neutrophils. An emergent computed
tomographic scan showed thickening of the right lower limb with fluid
accumulation. A presumptive diagnosis of necrotizing fasciitis was made.
Above-the-knee amputation was suggested as a life-saving measure, but the
patient declined and opted for fasciotomy and débridement only.
Intraoperative findings included necrosis of the subcutaneous fat and the
fascia and loss of resistance to digital dissection of the subcutaneous
planes, as is typical of necrotizing fasciitis. The diagnosis was further
confirmed by pathohistologic examination of the surgical specimens. Once
again, staining of the surgical specimens showed gram-positive cocci, and the
postoperative antibiotic regimen was changed to intravenous penicillin,
clindamycin, and ciprofloxacin. Despite surgical débridement and
antibiotic treatment, the infection progressed to involve the scrotum and the
right flank. More extensive débridement and a transverse colostomy for
stool diversion were performed on the following day. Nevertheless, the patient
died of septic shock and multiple organ failure forty-two hours after
admission. Methicillin-resistant Staphylococcus aureus, which was
sensitive to vancomycin, minocycline, teicoplanin, and gentamicin, grew on
culture of all blood and synovial fluid specimens obtained on admission and on
culture of all surgical specimens.
Case 2. A sixty-three-year-old woman with a history of diabetes
mellitus, chronic renal insufficiency, and hypertension presented to our
emergency department because of dyspnea and abdominal pain of one day's
duration. She had had lower-back pain during the previous two months and had
visited an orthopaedic clinic for the back problem the day before admission.
Two oral medications, a nonsteroidal anti-inflammatory drug (diclofenac
sodium) and a muscle relaxant (baclofen), were prescribed. When the patient
was seen at our emergency department, she was afebrile with a blood pressure
of 80/64 mm Hg and a pulse rate of 118 beats/min. No signs of antecedent
trauma were noted on the body surface, and only mild erythema involving the
lower back was seen. She had a leukocytosis with a white blood-cell count of
11.7 × 109/L with 89% neutrophils.
A tentative diagnosis of intra-abdominal infection with septic shock was
made, and flomoxef was given intravenously on an empirical basis. An emergent
computed tomographic scan showed no intra-abdominal or pelvic lesions, but
edematous changes of the subcutaneous tissue were noted on the back and both
flanks. Six hours later, further investigation of the lower back in the
intensive care unit showed prominent skin erythema with partial necrosis
(Fig. 1). Necrotizing fasciitis
was suspected, and an emergent exploratory operation was performed. On
incision of the skin on the lower back, a foul "dish-water-like"
odor and sanguineous fluid exuded. The subcutaneous fat and fascia appeared
necrotic, but the muscle underneath seemed viable. All necrotic tissue was
extensively débrided, and the wound was packed with
saline-solution-soaked gauze, which was changed every six hours
postoperatively.
Gram-positive organisms were present in the surgical specimens, and the
antibiotic regimen was changed to clindamycin and imipenem. However, the
patient's general condition did not improve, and progressive necrosis at the
wound margins was noted. On the third postoperative day, the patient underwent
further surgical débridement. The necrotic tissue involved the skin,
subcutaneous tissue, and fascia of the whole back and both flank areas. Full
débridement was performed, but profound intraoperative hypotension
followed. The patient died of septic shock fifteen hours after the second
operation. Histological examination of the surgical specimens confirmed the
diagnosis of necrotizing fasciitis. Cultures of blood obtained on admission
yielded no growth, but cultures of surgical specimens from both of the
operations yielded methicillin-resistant Staphylococcus aureus, which
was sensitive to vancomycin, minocycline, and teicoplanin.
Case 3. A seventy-three-year-old man presented to our emergency
department because of progressive painful swelling of the right wrist and
forearm over the previous week. He reported a medical history of hypertension,
liver cirrhosis, and peripheral arterial occlusive disease. He had fallen on
the right hand one week previously, but no evidence of injury to the affected
limb could be seen. On admission, physical examination revealed a temperature
of 37.7°C, a blood pressure of 174/68 mm Hg, and a regular pulse rate of
122 beats/min. Blood analysis showed a hemoglobin level of 74 g/L, and a white
blood-cell count of 23.6 × 109/L with 87% neutrophils.
Cellulitis was suspected, and intravenous flomoxef was given empirically.
However, the erythema and swelling gradually progressed to the right upper arm
over a ten-hour period. An urgent computed tomographic scan of the right upper
limb showed prominent subfascial fluid collection and multiple intramuscular
lesions with rim enhancement. Necrotizing fasciitis and pyomyositis were
highly suspected, and the patient received emergent débridement and a
fasciotomy.
Intraoperative findings such as soft-tissue necrosis and pus accumulation
beneath the fascia were compatible with a diagnosis of necrotizing fasciitis,
and the diagnosis was confirmed by histologic examination of the surgical
specimens. Gram-positive organisms were seen on the smear. Because of our
previous experience with two cases of necrotizing fasciitis caused by
community-acquired methicillin-resistant Staphylococcus aureus,
intravenous vancomycin was included in the postoperative antibiotic regimen,
along with clindamycin and ciproxin. Two days later, cultures of blood
obtained at admission and cultures of surgical specimens confirmed the
pathogen to be methicillin-resistant Staphylococcus aureus, which was
sensitive to vancomycin and teicoplanin only.
The patient underwent another four operations for débridement and
skin-grafting in the following fifteen days, and the infection gradually
subsided. Unexpectedly, massive bleeding of the upper digestive tract
developed twenty-three days after admission. Panendoscopy revealed an
extensive gastric ulcer. Despite aggressive resuscitation, the patient's
condition deteriorated rapidly and he died on the next day.