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Susan Dufel, MD, and Margarita Martino, MD Simple cellulitis Associate Professor, Department Trauma and Emergency Medicine, University or a more serious infection? of Connecticut

54-year-old woman was admitted She related to her sisters that she had an to the emergency department with appointment with her gynecologist in the A a swollen right leg, fever, and next few days to have the lesion drained. altered mental status. Her family brought The patient had no fever, chest pain, her in after finding her confused and shortness of breath, nausea, or vomiting. lethargic. She was incontinent of stool and Her medical history included type 2 urine and complained of a rash with blis- diabetes mellitus, hypertension, and corti- ters on her right ®thigh.Dowden The patient Health had cal atrophyMedia with mild mental retardation. noted a pimple in her groin more than 5 She had been living independently in her days earlier; over the past few days she has own apartment, and was last seen by her beenCopyright complainingFor of personal increasing leg usepain. onlysisters 6 days before with no apparent

FIGURE 1 Cellulitis in the leg

FEATURE EDITOR Richard P.Usatine, MD University of Texas Health Sciences Center at San Antonio

C ORRESPONDENCE Susan Dufel, MD, Department Trauma and Emergency Medicine, University of Connecticut, 80 Seymour Street, Hartford CT 06102. The patient’s right leg, showing the extent of her cellulitis. E-mail: [email protected]

396 VOL 55, NO 5 / MAY 2006 THE JOURNAL OF FAMILY PRACTICE

For mass reproduction, content licensing and permissions contact Dowden Health Media.

FIGURE 2 FIGURE 3 Radiograph of thigh and hip area Radiograph of knee

Note the presence of the soft-tissue gas extending into Note the gas tracking down the patient’s leg, past areas FAST TRACK the patient’s pelvis. of obviously clinical celulitis. The patient’s right complaints. She had been wheelchair-bound right upper quadrant incision. Her geni- leg was swollen, for 6 months due to a fractured ankle from tourinary exam revealed a purulent had a brownish- which she has not been able to completely drainage in the groin near her vulva. red discoloration rehabilitate. Her right leg was markedly swollen, The medications she was taking includ- erythematous, and had a brownish-red from groin ed glyburide, raloxifene (Evista), and discoloration that extended from her to knee, and had furosemide (Lasix). Surgical history was groin circumferentially to her knee. The a “woody” feel significant only for a cholecystectomy. She skin had a “woody” feel when palpated when palpated did not smoke or drink alcohol. Upon pres- and large bullae were present (FIGURE 1). entation to the ED she appeared ill, with a The decision to obtain x-rays of her blood pressure of 124/50 mm Hg, pulse pelvis and femur was made to assess the 110, respiratory rate 18, and temperature extent of her infection (FIGURES 2 AND 3). of 102°F. Her fingerstick blood sugar was 573. She was able to answer simple ques- tions but was not oriented to time or place. T What is the differential Her skin was hot and dry. Chest exam diagnosis for this patient? revealed clear lungs with tachypnea and a 2/6 systolic murmur. Her abdomen was T What tests might help slightly obese, soft, and nontender with delineate the extent normal bowel sounds and a well-healed of her infection?

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DS N

OU T Diagnosis: Acute single organism. In immune-compromised R necrotizing fasciitis patients, Pseudomonas spp and gram- O T The patient was diagnosed with acute negative enteric organisms can be found. O

H necrotizing fasciitis, a rare, often fatal, The organisms isolated most often in P soft-tissue bacterial infection. According to polymicrobial necrotizing soft-tissue infec- the Centers for Disease Control and tions are combinations of staphylococci Prevention, only 500 to 1500 cases of (especially Staphylococcus epidermis with necrotizing fasciitis are diagnosed each beta-hemolytic streptococcus), enterococ- year in the US.1 ci, Enterobacteriaceae spp (commonly Escherichia coli, Proteus mirabilis, Epidemiology Klebsiella pneumoniae, and Pseudomonas Peripheral vascular disease, diabetes, and a aeruginosa), streptococci, Bacterioides pre- compromised immune system are signifi- votella spp, anaerobic gram-positive cocci, cant risk factors for necrotizing fasciitis.2 and Clostridium spp.6 Diabetes is present in 18% to 60% of cases;1,3 in addition, 19% to 77% of Patient presentation patients use intravenous drugs.1,3,4 Other The clinical history and a meticulous significant predisposing factors include physical examination are essential in alcohol abuse (9%–31%),1,4 obesity,1,4 and establishing an early diagnosis of necro- malnutrition.3 Although risk factors are tizing infections.5 Necrotizing fasciitis can numerous, half of all cases of streptococcal be easily misdiagnosed as only cellulitis. necrotizing fasciitis occur in previously Most often, a patient with necrotizing healthy individuals. Pathogenic agents can fasciitis appears ill, with constitutional be introduced as a result of minor trauma, symptoms of fever, chills, hypotension, insect bites, or surgical incisions. dehydration, and rapid heart rate. You In this case the patient noted a “pim- can also see erythema with bullae forma- ple” in the groin area and complained of tion, serosanguineous fluids drainage, pain for 5 days. By the time she reached induration, and violaceous discoloration. FAST TRACK the hospital she had mental status changes, Pain and crepitation may be noted.3,5,7 Rapid progression fever, appeared toxic, and had signs of Rapid progression of edema and pain out early septic shock. We can identify in this of proportion to examination is seen in of edema and pain case the probable port of entry as the the early stages. The parts of the skin out of proportion lesion in the groin that was visualized on affected by the disease can become numb to exam is seen in physical exam to be draining pus. with progression of the infection; this is thought to be due to infarction of the the early stages; Pathophysiology cutaneous nerves located in necrotic sub- parts of the skin Necrotizing fasciitis involves the superficial cutaneous fascia and soft tissue.5 may become numb layer of skin, subcutaneous tissues, and fas- Causative factors in this patient with progression cia. The infection spreads rapidly along included diabetes and obesity. Diabetic these layers, causing edema and compres- neuropathy may have also delayed presen- sion of vasculature, which rapidly progress- tation and dulled her perception of pain. es to tissue necrosis and sepsis. Even with Diabetic microvascular disease may also new broad-spectrum antibiotics, mortality have contributed to a faster progression of can be as high as 75% in patients who tissue hypoxia. become septic and develop renal failure. Necrotizing fasciitis occurs when a mixed variety of organisms, both aerobic T Diagnostic methods: and anaerobic, invade the subcutaneous Lab tests, biopsy, x-rays tissue and fascia.5 Most necrotizing soft- Laboratory testing for necrotizing fasciitis tissue infections are polymicrobial, with is thought by most experts to be non- only a small percentage involving a specific. Another investigative team found

398 VOL 55, NO 5 / MAY 2006 THE JOURNAL OF FAMILY PRACTICE

Simple cellulitis or a more serious infection? L

that 76% of patients with necrotizing or another aminoglycoside for Entero- soft-tissue infections had low platelet bacteriaceae. Imipenem or meropenem count or PT and PTT with higher than can be used as the initial agent for high normal values; prolonged PT is associated beta-lactamase resistance, wide-spectrum with increase mortality.6 Hypocalcemia, efficacy, and inhibition of endotoxin hypoproteinemia, anemia, and acidosis release from aerobic bacilli. Tetanus pro- have also been noted. phylaxis with absorbed tetanus toxoid Diagnosis must be considered early and passive immune coverage with when necrotizing fasciitis is suspected. tetanus hyperimmune globulin is indicat- Although the gold standard for diagno- ed for a patient whose history of immu- sis is biopsy or wound exploration and nization is unclear or unavailable.6 surgical debridement,6 diagnosis can be made early when necrotizing fasciitis is Surgery suspected. Urgent surgical consultation is necessary. The role of soft-tissue radiographs in Early recognition and prompt aggressive the diagnosis of necrotizing fasciitis is debridement of all necrotic tissue is critical unclear. Plain films can provide informa- for survival—in fact, it is the only therapy tion such as soft-tissue thickening and demonstrated to improve the rate of sur- internal gas formation. Unfortunately, vival.7 Necrotic tissue serves as a culture plain radiographs typically show no spe- medium and creates an anaerobic environ- cific abnormality until the necrotizing ment, which hinders an adequate immune process is well advanced. response. Sufficient debridement consists of exposure to all margins of viable tissue. Antibiotics are important but are second- T Treatment of necrotizing ary to urgent removal of the toxic tissue. fasciitis Resuscitation Hyperbaric oxygen therapy Adequate fluid resuscitation and stabiliza- All necrotizing infections are associated tion of any patient suspected of having with ischemia, reduced tissue oxygen ten- FAST TRACK necrotizing fasciitis is the first line of ther- sion, and a decrease in host cellular Urgent surgical apy. Large-bore IV lines or a central line immunity. The physciological rationale may be necessary. Adequate monitoring for increasing oxygen is that tension consultation should include a Foley catheter and pulse ischemia may be reversed and host is needed— oximetry. Correction of any metabolic defense mechanisms improved. Hyper- prompt, agressive abnormalities needs to be addressed. baric oxygen is generally considered an important adjunct in the treatment of debridement of Antibiotics clostridial myonecrosis or gas gangrene. necrotic tissue Antibiotic treatment should be started as Studies have failed to show statistical- is critical soon as possible, although no study has ly significant outcome differences with for survival shown antibiotics to significantly alter respect to mortality and length of hospi- mortality. A Gram stain of the infected talization.3 Some studies show improve- material would be helpful to guide further ment of survival rates or limb salvage; antibiotic choices. However, initial thera- others show no difference in outcomes py should be directed at both aerobic and with hyperbaric oxygen. Note that these anaerobic organisms. studies show no consistency in patient Triple therapy is recommended: population or number of visits to the penicillin or ampicillin for Clostridia, operating room. More evidence is needed, Streptococci, and Peptostreptococcus; preferably by way of randomized con- clindamycin or metronidazole for anaer- trolled trials, before routine or wide- obes, Bacteroides fragilis, Fusobacterium, spread use of hyperbaric oxygen can be and Peptostreptococcus; and gentamicin recommended.

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PHOTO ROUNDS Register onlineat www.APCToday.comRegister T A PLUS REclinical resource for your staff FREE A oday’s information for advanced practice clinicians PC M M M E-newsletters National and local conference alerts Online continuing education credits Peptostreptococcus. later was madecomfortable;shedied12hours pelvectomy. Theydeclined.Thepatient approach, ahipdisarticulationorhemi- ed concerningamoreradicalsurgical pubis totheknee.Thefamilywasconsult- to once-viabletissuefromthesymphysis operating room—theinfectionhadspread Eighteen hourslatershereturnedtothe entire medialthighduringthefirstsurgery. ic musclesandskininherperineum debrided herskinandremovedallnecrot- laboratory tests. tion, theysentforbloodculturesandother an urgentsurgicalconsultation.Inaddi- tiated intravenousantibioticsandobtained The emergencydepartmentphysiciansini- T Enterococcus, Staphylococcus Proteus vulgaris,Coryne-bacterium, and outcome The patient’s treatment In theoperatingroom,surgeons T . Herwoundcultur oda pr evidence-basedHigh quality, informationfor advanced M M M and nurse-midwives clinical specialists, nurse assistants, T articles byarticles advanced practice clinicians. Accepting submissions for “From the Field,” ARNP RN, Led by Editor-in-Chief MS, Wright, Wendy L. C Featuring timely and relevant from articles act HE ONTEMPORARY ice cl J UNLOF OURNAL ,FNP ncas—nrepattoes physician practitioners, nurse — inicians ,FAANP e latergrew S F y.com URGERY AMILY and adistinguished Editorial Board , P p,and spp, OBG M , RACTICE E coli, and C , ANAGEMENT RE .HalyA.Necrotizing Headley fasciitis:AJ. care review. aprimary 6. .Kni J iluA tHl R Necrotizing soft-tissue St Hill infec- CR. Tillou Kuncir EJ, A, 3. 5 .Cidr J oynyL,Ncrie ,e l Necrotizing et al. Nachreiner R, Potyondy LD, Childers BJ, 2. .BshrtT,HnesnV,OgnC r Necrotizing Jr. CH Organ VJ, Henderson Bosshardt TL, 4. .FuhrL,Mri E dla S ta.Burncenter et al. Edelman LS, Morris SE, Faucher LD, 1. .Ci-oWn,HwCogCag PasupathyS. Haw-ChongChang, Chin-Ho Wong, 7. aek ,Jh FJ.Necrotizing soft tissue John infections: JFJr. a Majeski J, . URRENT FERENCES so determinants of mortality. microbiology, Necrotizing fasciitis: clinical presentation, 2003; 96:900–906. (8):1454–1460. t in unburned patients. management of necrotizing soft-tissue surgical infections Fam Phys patients. fasciitis: a fourteen-year retrospective study of 163 g ions. uide to early diagnosis and initial therapy. ft-tissue infections. , E merg Clin Med North Am P Am Surg SYCHIATRY 2003; 68:323–328. 2002; 68:109–116. Am JSurg Arch Su J Bone Joint Surg rg 1 2001; 182:563–569. 2 996; 131:846–854. 003; 21:1075–1087. S outh MedJ 2003; 85A Am & certi NPs The mostpra www. online , P APC As, fie d nu od To clini ctic ay rse- nica . com al midwives — l nur plac se s e t for thi 245, Acc o rea s new the peci ess 375 ad a spe ch ali pot tate-of- cia vanced sts enti lty

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