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A Case of Necrotizing Fasciitis Caused by Finegoldia Magna in a Patient with Type 2 Diabetes Mellitus

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A Case of Necrotizing Fasciitis Caused by Finegoldia Magna in a Patient with Type 2 Diabetes Mellitus Le Infezioni in Medicina, n. 4, 359-363, 2018 CASE REPORTS 359 A case of necrotizing fasciitis caused by Finegoldia magna in a patient with type 2 diabetes mellitus Margherita Scapaticci1, Sabina Marchetto2, Andrea Nardi2, Maira Zoppelletto3, Andrea Bartolini3 1Laboratory Medicine Department, San Camillo Hospital, Treviso, Italy; 2Diabetic Foot Surgery Department, San Camillo Hospital, Treviso, Italy; 3Laboratory Medicine, San Bassiano Hospital, AULSS 7 Pedemontana, Bassano del Grappa, Italy SUMMARY Diabetes mellitus is one of the serious conditions the appropriate antibacterial agents. Hence the key associated with necrotizing fasciitis, a severe bac- to successful management is an early and accurate terial skin infection that spreads quickly and is diagnosis. We report a case of necrotizing fasciitis characterized by extensive necrosis of the deep and caused by Finegoldia magna in a patient with type 2 superficial fascia resulting in devascularization diabetes mellitus. and necrosis of the associated tissues. In addition to debridement and aggressive surgery procedures, Keywords: necrotizing fasciitis, type 2 diabetes mellitus, the effectiveness of therapy depends on choosing diabetic foot ulcers, anaerobes, GPACs. n INTRODUCTION lesion caused by a trauma, frequently trivial [4]. Symptoms include red or purple skin in the affect- iabetic foot ulcers are one of the main caus- ed area, severe pain, fever, and vomiting [5]. The Des of hospitalization and the major cause of major causative organisms include Streptococcus morbidity in individuals suffering from diabetes pyogenes, Staphylococcus aureus, anaerobic bacteria and, if not properly treated, can need amputation. and intestinal flora [4,6]. Diabetic patients may be The effectiveness of therapy depends on choos- predisposed to necrotizing fasciitis by the tissue hy- ing the appropriate antibacterial agents, and for poxia caused by arteriosclerosis and the immuno- this reason the key to a successful management is deficiency associated with poor glycemic control. an early and accurate diagnosis. When signs of a Accurate diagnosis with an early and aggressive clinical infection and gradual tissue necrosis with surgical debridement of all involved tissues, com- progressive cutaneous changes over the affected bined with prompt intravenous broad-spectrum site are present, necrotizing fasciitis should be sus- antibiotic treatment are important to stopping this pected, and an immediate intervention of surgical severe kind of infection that could rapidly pro- debridement and empiric antibiotic therapy could gress to disseminated vascular coagulation, septic be useful to prevent amputation [1-3]. Necrotizing shock and death [5, 7]. We herein report a case of fasciitis is a deep and devastating soft tissue infec- necrotizing fasciitis caused by Finegoldia magna in a tion that often develops as an extension from a skin patient with diabetes mellitus type 2. n CASE REPORT Corresponding author Andrea Bartolini A 56-year-old male with type 2 diabetes melli- E-mail: [email protected] tus with several complication including hyper- 360 M. Scapaticci, S. Marchetto, A. Nardi, et al. Figure 1 - Patient at admission presented necrotizing fascii- tis of the forefoot, anterior (A) and posterior view (B). tension, dyslipidemia and mild chronic kidney X-ray, that showed thickening of soft tissues, foot disease (CKD) was admitted to Diabetic Foot drainage, including debridement procedure (Fig- Surgery Department of San Camillo Hospital in ure 2A, 2B), was immediately performed and two Treviso with acute diabetic foot infection of right samples of purulent secretion were aseptically forefoot. collected from the wound and sent to Laborato- At the admission the patient, that had started an- ry Department for microbiological investigations. tibiotic therapy with ciprofloxacin(500 mg orally Further imaging investigations were not per- every 12 hours) from one week before, present- formed considering the severity of the infection, ed hyperpyrexia from 10 days and right foot tu- that made necessary an immediate medical inter- mefaction and edema with purulent secretions vention [8]. (Figures 1A, 1B). The blood tests revealed a white Calculated LRINEC (Laboratory Risk Indicator blood cell (WBC) count of 13,530/mm3, haemo- for Necroziting Fasciitis) score was 7, indicating globin (Hb) of 11.3 g/dL, platelets (PLTs) count of that the patient had an intermediate risk for ne- 278,000/mm3, glucose of 179 mg/dL, creatinine crotizing soft-tissue infections [9]. At the same of 2.22 mg/dL, urea of 29 mg/dL, moreover he time an empiric therapy with piperacillin-tazo- presented a concentration of C-reactive protein bactam i.v. (4.5g x 3) and clindamycin i.v. (600 mg of 22.95 mg/dL (normal value: 0.00 - 0.33 mg/ x 3) was started in substitution to current antibiot- dL). Due to the fever, three sets of blood cultures ic therapy. A lower dosage of therapy was due to were immediately collected and sent to Laborato- mild CKD of the patients (eGFR, mL/min per 1.73 ry Department for microbiological analysis. After m2: 39.56). After two days from drainage, despite Figure 2 - Debridement proce- dure was undertaken on first hospital day , anterior (A) and posterior view (B). Necrotizing fasciitis by Finegoldia magna 361 the improvement of general clinical conditions of ples were also inoculated in thioglycolate broth the patient and fever disappearance, an interven- and incubated at 37°C for 5 days. After 48 hours tion of surgical amputation was necessary for the the appearance of turbidity at the bottom of thio- evolution to gangrene of second and third toes. glycolate broth and presence of colonies on COS During surgery procedure, gray necrotic tissue, and Schaedler agar plates indicated growth of noncontracting muscle and a positive “finger strictly anaerobic bacteria. Colonies grown on test” result were found and two samples of bone agar plates were identified as Finegoldia magna af- fragments were aseptically collected and sent to ter biochemical identification with Vitek®2 ANC Laboratory Department for microbiological diag- ID card and confirmed by matrix-assisted laser nostic procedure. desorption ionization-time of flight mass spec- trometry (MALDI-TOF MS) (MALDI Biotyper, Microbiological test results Bruker). Antimicrobial susceptibility testing was The three sets of blood cultures were incubated carried out with broth microdilution method us- into BACT/ALERT® 3D System (bioMérieux). ing Sensititre™ Anaerobe MIC Plate AN02B panel After an incubation time of 5 days all blood (ThermoScientific), that provide results related to samples were negative, excluding bacteremia. the minimum inhibitory concentration (MIC). All Gram stained smear of pus from debridement MIC values were evaluated with EUCAST Clini- showed presence of numerous leukocytes and of cal Breakpoint for bacteria (v 8.0) [10]. The strain Gram-positive cocci. Samples were inoculated di- was susceptible to all tested antimicrobials (peni- rectly on Chocolate agar + PolyViteX (bioMérieux) cillin, ampicillin, piperacillin/tazobactam, imipe- at 37°C in 5% CO2 atmosphere, on Columbia agar nem, clindamycin, vancomycin and metronida- + 5% sheep blood (COS) and Schaedler agar +5% zole) confirming the efficacy of the empiric antibi- sheep blood agar (bioMérieux) at 37°C in anaero- otic therapy that remained unchanged. From the biosis, on MacConkey Agar and Sabouraud Gen- day after amputation, the patient showed a rapid tamicin Chloramphenicol 2 agar (bioMérieux) at improvement of health conditions and became 37°C in O2 atmosphere. Purulent secretion sam- afebrile, declaring progressive subjective well-be- Figure 3 - Amputation was needed on fourth hospital Figure 4 - Postoperative anterior view of patient foot day (anterior view). on the fourth postoperative month. 362 M. Scapaticci, S. Marchetto, A. Nardi, et al. ing. Leukocyte count decreased to 6,620/mm3, putation [5,19]. In our case, the patient came to C-reactive protein decreased to 5.89 mg/dL and the hospital ten days after the fever appearance creatinine to 1.87 mg/dL. After eight days of post- and, at the admission, he reported that some days operative care, the patient was discharged with before he caused a small incision at his right fore- well granulating post-surgical wound (Figure 3) foot with a nail-clipper scissors. Delay in hospi- and complete remission of signs of total inflam- talization could be explained by the fact that ne- mation. Also, the two cultures of bone fragments crotizing fasciitis is a deep-seated infection where samples, collected after surgery, were positive for the epidermidis is minimally involved at initial F. magna. presentation, and, even if localized pain is a clue Antibiotic therapy was continued with amoxicil- to the disease, certain patients, notably those with lin (500 g x 2) and clindamycin (300 g x 3) orally diabetic neuropathy with loss of sensation, can for other 20 days. The patient was followed-up experience minimal pain, resulting in a missed weekly by physicians as outpatient and, after one diagnosis [1]. month from the surgery, he underwent to dermal F. magna is one of the most common anaerobic substitution grafting that permitted a complete pathogens, but sometimes it is forgotten as a re-epithelization (Figure 4). cause of infection in the bones and joints, prob- ably because anaerobic bacteria culture is often time-consuming [20]. n CONCLUSIONS Physician should be suspect infection by GPACs F. magna is a Gram-positive anaerobic coccus in
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