The incidence of wound related complication following total knee arthroplasty is as high as 10%-20%. To perform total knee arthroplasty in a knee with extensive scarring around the knee can be a challenging task. We report a case of 55-year-old diabetic woman, who had total knee arthroplasty, performed two years after she had recovered from necrotizing fasciitis around the right knee. Understanding the vascular anatomy around the knee is of paramount importance in the planning of skin incision to ensure fewer wound related complications.
Necrotizing fasciitis is an aggressive infection involving fascia and subcutaneous tissue thus causing infectious thrombosis of the nutrient vessels to the overlying skin ultimately leading to extensive necrosis. Although necrotizing fasciitis is common in the perineum, abdominal wall and extremities it is relatively uncommon in the head and neck region. This is a case report of a 65 year old female visiting from India who presented with diabetic ketoacidosis precipitated by cervical necrotizing fasciitis. Computed tomography imaging showed involvement of the left parapharyngeal space and there was soft tissue gas present. This patient subsequently underwent an emergency neck exploration and desloughing. Repeated pus culture studies isolated Klebsiella species as the sole pathogen. Our case illustrates that prompt diagnosis and treatment of cervical necrotizing fasciitis can ensure a good outcome.
A case report of a missed appendicitis presenting with abdominal wall necrotising fasciitis which extended up to the right knee. This subcutaneous collection in the prepatella region of the right knee presented as a crepitus and mimicked an intraarticular pathology.
We present a case of cervical necrotising fasciitis in a 56 year old man, secondary to a rare mastoid infection. The patient had coexisting diabetes mellitus and hypertension. He was treated with early surgical debridement followed by neck and chest reconstruction and radical mastoidectomy. Aggressive antibiotic therapy and supportive care was given. He recovered well with minimal residual functional deficit.
Necrotising fasciitis is a life-threatening infection of the soft tissue which can be caused by different microorganisms, but infection caused by Aeromonas spp. or Vibrio spp. is frequently associated with higher mortality rate. Necrotising fasciitis progresses rapidly and often need aggressive surgical intervention. We present a rare case of necrotising fasciitis cause by Aeromonas sobria which mortality was successfully prevented by swift diagnosis and aggressive surgery.
X-linked agammaglobulinemia is a rare primary immunodeficiency due to a BTK mutation. The patients are characteristically deficient in peripheral B cells and serum immunoglobulins. While they are susceptible to infections caused by bacteria, enteroviruses, and parasites, fungal infections are uncommon in XLA patients. Here, we report a boy of Malay ethnicity who suffered from recurrent upper respiratory tract infections and severe progressive necrotizing fasciitis caused by Saksenaea erythrospora. Immunological tests showed a B cell deficiency and hypogammaglobulinemia. Whole-exome sequencing identified a dinucleotide deletion (c.1580_1581del) in BTK, confirmed by Sanger sequencing and predicted to be disease causing by in silico functional prediction tools (Varsome and MutationTaster2) but was absent in the gnomAD database. This mutation resulted in a frameshift and premature termination (p.C527fs), which disrupted the protein structure. The mother was heterozygous at the mutation site, confirming her carrier status. Flow cytometric analysis of monocyte BTK expression showed it to be absent in the patient and bimodal in the mother. This study describes a novel BTK mutation in a defined hotspot and an atypical fungal phenotype in XLA. Further studies are required to understand the pathogenesis of fungal infection in XLA.
Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.
Necrotizing fasciitis (NF) is a life-threatening soft tissue infection that rapidly progresses and requires urgent surgery and medical therapy. If treatment is delayed, the likelihood of an unfavorable outcome, including death, is significantly increased. The goal of this study was to develop and validate a novel scoring model for predicting mortality in patients with NF. The proposed system is hereafter referred to as the Mortality in Necrotizing Fasciitis (MNF) scoring system. A total of 1503 patients with NF were recruited from 3 provincial hospitals in Thailand during January 2009 to December 2012. Patients were randomly allocated into either the derivation cohort (n = 1192) or the validation cohort (n = 311). Clinical risk factors used to develop the MNF scoring system were determined by logistic regression. Regression coefficients were transformed into item scores, the sum of which reflected the total MNF score. The following 6 clinical predictors were included: female gender; age > 60 years; white blood cell (WBC) ≤5000/mm3; WBC ≥ 35,000/mm3; creatinine ≥ 1.6 mg/dL, and pulse rate > 130/min. Area under the receiver operating characteristic curve (AuROC) analysis showed the MNF scoring system to have moderate power for predicting mortality in patients with NF (AuROC: 76.18%) with good calibration (Hosmer-Lemeshow χ2: 1.01; P = .798). The positive likelihood ratios of mortality in patients with low-risk scores (≤2.5) and high-risk scores (≥7) were 11.30 (95% confidence interval [CI]: 6.16-20.71) and 14.71 (95%CI: 7.39-29.28), sequentially. When used to the validation cohort, the MNF scoring system presented good performance with an AuROC of 74.25%. The proposed MNF scoring system, which includes 6 commonly available and easy-to-use parameters, was shown to be an effective tool for predicting mortality in patients with NF. This validated instrument will help clinicians identify at-risk patients so that early investigations and interventions can be performed that will reduce the mortality rate among patients with NF.
This is a presentation of a case of mono microbial necrotising fasciitis due to the unusual organism Salmonella enteritidis. The patient presented with swelling and blistering of the right calf. There are only five other such cases reported in the literature. This was the only case that had positive blood cultures for the organism. Prompt and appropriate treatment was intuited but the patient died because of multi-organ failure.
Subcutaneous emphysema is the presence of gas or air in the subcutaneous tissue plane. The term is generally used to describe any soft tissue emphysema of the body wall or limbs, it can result from benign causes, most commonly secondary to trauma or from a life-threatening infection by gas gangrene or necrotising fasciitis. A case of subcutaneous emphysema involving the upper limb resulting from a trivial laceration to the elbow is reported and the importance of distinguishing between the two causes of subcutaneous emphysema is highlighted.
A 31-year-old Pakistani man was admitted to hospital after sustaining a Grade I compound fracture of the mid-shaft of the left tibia and fibula following a motor vehicle accident. He developed septicaemic shock, acute renal failure and Group A streptococcal necrotizing fasciitis of the left leg. The patient underwent an above knee amputation followed by disarticulation of the left hip with extensive debridement. He was treated with benzylpenicillin, vancomycin, inotropes and continuous haemodialysis and survived without further sequelae. Subsequently, skin grafting was done over the wound site. This case highlights the role of Group A streptococcus as a cause of this rare and life-threatening infection.
Acupuncture is used for some conditions as an alternative to medication or surgical intervention. Several complications had been reported, and they are generally due to physical injury by the needle or transmission of diseases. We report a case of life-threatening necrotising fasciitis that developed after acupuncture treatment for osteoarthritis of the knee in a 55-year-old diabetic woman. She presented with multiple discharging sinuses over the right knee. As the patient did not respond to intravenous antibiotics, extensive debridement was performed. She made a good recovery. Since many old diabetic patients with degenerative joint diseases may consider this mode of treatment, guidelines on cleanliness and sterility of this procedure should be developed and practiced.
An infant, who was born preterm at 36 weeks, presented with fever and ulcer at umbilical region which progressed to necrotising fasciitis of anterior abdominal wall. He was treated with intravenous penicillin, intravenous cloxacillin and local application of medicated honey. Subsequently, he required wound debridement. Postoperatively, he required prolonged invasive ventilation due to poor respiratory effort which was associated with hypotonia and areflexia. Nerve conduction study revealed absent responses. The diagnosis of infant botulism was made based on the clinical presentation, nerve conduction study and his clinical progress. Botulinum immunoglobulin was not available. He was treated with intravenous immunoglobulin and oral pyridostigmine. He was successfully extubated after 37 days, and currently the patient is doing well.
We described a case of 51-year-old female patient presented with a right calf necrotising fasciitis (NF) where osteomyelitis (OM) was suspected. (99m)Tc-hydroxymethane diphosphonate three-phase bone scintigraphy and (99m)Tc-besilosomab scan failed to demonstrate classical features of OM. The final diagnosis was only made by isolating Acinetobacter sp. in both intra-operative bone and tissue cultures from below-knee amputation. As conclusions, the detection of lower limb OM by (99m)Tc-besilosomab scan is not easy when there is concurrence overlying NF. The unusual three-phase bone scan finding of pericortical accumulation of tracer as an early sign of OM is highlighted in this case.
Necrotising fasciitis caused by Community-Acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a new entity. Although it is recognised worldwide, there have been no reported cases to date in Malaysia. We report a case of necrotising fasciitis of the left lower limb in an otherwise healthy 20-year-old man. He presented with septic shock and despite the paucity of clinical signs in the limb, the infection was aggressive. Methicillin-Resistant Staphylococcus aureus (MRSA) was isolated from the deep fascia of the leg. Panton-Valentine leucocidin gene (PVL), which is a stable genetic marker for CA-MRSA strain, was positive in this case. This case of community acquired MRSA necrotising fasciitis is of concern and may herald the emergence of this resistant organism in Malaysia. Vigilant surveillance and microbiological monitoring is needed to follow this CA-MRSA trend.
Necrotizing fasciitis is a life and limb threatening soft tissue infection with a high mortality rate. This study tries to identify the possible risk factors that contribute to mortality in patients with necrotizing fasciitis involving a lower limb. We prospectively reviewed 41 patients that presented with necrotizing fasciitis of the lower limb over a period of one year. Results show that the mortality rate for necrotizing fasciitis of the lower limb is quite high at 19.5%. Comparison among necrotizing fasciitis patients reveals that higher mortality rate is seen among those patients with advanced age and those presented with initial high pre-operative creatinine levels. Sex, pre-morbid diabetes mellitus, duration from initial symptoms to presentation for treatment and presence of streptococcus group A were not associated with an increased mortality rate. Neither were admission vital signs, subcutaneous gas on radiograph, prior antibiotic treatment on admission or clinical note of bullae formation.
Introduction: Diabetic foot infection, a complication which can lead to lower limb amputation, is a major source of morbidity and mortality in Malaysia. The objective of this study was to determine the predictive factors of major lower limb amputation among patients with diabetes mellitus in a cluster of three district hospitals in Pahang, Malaysia. Materials and Methods: This cross-sectional study involved 170 patients who had undergone surgical interventions for diabetic foot infections at three district hospitals from 1st of September 2014 to 31st December 2015. The predictors for major amputation of lower limb were determined using simple logistic regression (LR) and forward LR multiple logistic regression. Results: A total of 21 patients had undergone major amputations of lower limb (15 transtibial and 6 transfemoral). The following factors were associated with major amputation of lower limb; longer duration of disease, age ≥ 60 years, patients from Bentong Hospital, presence of hypertension, presence of fever, history of multiple limb-salvaging surgeries, monomicrobial culture, necrotising fasciitis, anemia and leukocytosis. Upon forward LR multiple logistic regression, only duration of disease, history of more than three previous limb-salvaging surgeries and total white blood cell count ≥15X109/L were found to be significant as predictive factors of major amputation of lower limb. Conclusion: Among the factors analysed in this study, a longer duration of disease, raised total white blood cell count and history of more than three limb-salvaging surgeries were identified as predictors for major amputation of lower limb in diabetic foot infections using stepwise logistic regression analysis.
Necrotizing fasciitis is a severe and progressive infection of deep soft tissues which results in destruction of the fascia and overlying subcutaneous fat. We report a case of a 45-year-old diabetic gentleman who initially presented with left shoulder pain, which was treated symptomatically. Upon representation, he had fever and the pain extended to his left upper back. There was a warm, firm and mildly tender purplish swelling on his mid to the left upper back. Blood tests revealed significantly elevated white cell counts and C-reactive protein. A CT thorax showed extensive soft tissue gas within the deep and superficial fascial layers of his left upper back. Necrotizing fasciitis was confirmed intraoperatively. The diagnosis of this condition is often difficult as early symptoms can be mild and nonspecific. A high Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score may be helpful to rule in this diagnosis and guide further management.
Introduction: Necrotising fasciitis (NF) is a rapidly progressive infection of the subcutaneous tissue and fascia which spreads rapidly. The scoring system of Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) developed by Wong et al has been proposed as a tool for distinguishing NF and other soft tissue infections (STI) in Singapore. We set out to establish whether the LRINEC score is applicable in our Malaysian setting. Materials and Methods: A cross sectional study of all patients admitted to our hospital diagnosed with NF or To Rule Out NF (TRO NF) between January 1st 2016 to 30th June 2016. The sensitivity, specificity, positive and negative predictive values were then calculated for LRINEC score of ≥ 6 and ≥ 8. Results: Fourty-four patients were identified with the diagnosis of NF or TRO NF in the study. Twenty-seven patients (61.4%) were deemed post-operatively as having NF and 17 patients (38.6%) not having NF. A sensitivity of 59.3% and specificity of 47.1% when a LRINEC score of ≥ 6 was taken with positive predictive value (PPV) of 64.0% and the negative predictive value (NPV) of 42.1%. When score ≥ 8 was taken, the sensitivity was 48.1% and specificity of 58.8% with PPV of 65% and NPV of 41.7%. Conclusion: The low sensitivity and low PPV achieved in this study as well as other studies makes the LRINEC score unsuitable to be used solely to distinguish NF with other soft tissue infections.
Necrotizing fasciitis of the head and neck is a rare, rapidly progressive infection involving the skin, subcutaneous tissue and fascia. We report three cases of necrotizing fasciitis that differ in their presentation and outcome. The first case involves a patient who presented with progressively enlarging anterior neck swelling that was later complicated by dehydration and reduced consciousness. The second case is a patient with neck swelling and ipsilateral otorrhea. The third case concerns a patient with a buccal ulcer complicated by ipsilateral facial swelling. All of them underwent a fasciotomy with wound debridement with the addition of a cortical mastoidectomy in the second case. Two of these patients recovered well. Unfortunately, the third case succumbed to death due to airway compromise and septicaemia. We advocate the importance of eradicating the source of infection followed by frequent, meticulous wound dressing and strict blood sugar control to obtain better outcomes in managing necrotizing fasciitis of the head and neck. However, involvement of the airway carries a grave prognosis despite aggressive treatment.