Monday, December 2, 2013

Fatal necrotizing fasciitis in a Korean man

A while ago, I posted about an unfortunate little girl from Costa Rica who died from necrotizing fasciitis after getting hit in the chest by a soccer ball. Today, I'm going to present a case of necrotizing fasciitis which occurred in Korea and where no clear cause could be found, but a number of known predisposing factors were present.

For those not familiar with this disease - necrotizing fasciitis is an uncommon and extremely dangerous bacterial infection of subcutaneous tissues and fascia (the membranes that cover the muscles).  It can occur after some sort of injury (often as minor as a bruise or cut) and anything that weakens a person's immunity - including immunosuppressant drugs, obviously, but also diabetes, alcohol abuse or simply old age - can be a predisposing factor. Patients initially present with swelling and redness of the affected area and extreme pain; as the disease progresses, purple discoloration, blisters and necrosis (tissue death) occur. The mortality rate of necrotizing fasciitis ranges from 20% to 60%, if the patient receives treatment, that is - untreated, this infection is usually fatal. It is usually caused either by β-hemolytic streptococci or by mixed infections of aerobic and anaerobic bacteria.  

Necrotizing fasciitis of the patient's left leg on admission. Note the diffuse purple spots and blisters.
Image from: Park et al. (2011).

Park et al. have described the case of 62-yr-old man who was hospitalized in Seoul, Korea in March 2010 with a five-day history of pain and swelling in the left lower leg and increasing swelling over the right hand. He had suffered from alcoholic liver cirrhosis for 27 years. One year earlier he was also diagnosed with type 2 diabetes mellitus. Seven days prior to admission, he had eaten some raw sea squirts.

On physical examination. the patient was severely ill, his temperature slightly lower than normal and his blood pressure low.  Laboratory studies showed a very elevated white blood cell count. 9 hours after admission, surgical exploration of the affected left leg and right hand was carried out. It turned out that the patient had extensive soft tissue necrosis, but without pus formation. All the dead tissue was removed and he was placed on high doses of antibiotics. On hospital day 3, cultures of two blood samples and wound aspirates showed S. pneumoniae - an unusual finding, since reports of necrotizing fasciitis due to Streptococcus pneumoniae are exceedingly rare. Despite repeated surgical debridement, the necrosis extended to the other leg. On hospital day 6, a change in the patient's mental status occurred, and on hospital day 8, he died of septic shock and multi-organ failure.
Were the raw sea squirts a factor in this death? Probably not. Did the patient's alcoholism, chronic liver disease, advanced age (over 50) and diabetes play a role? Most probably yes - all these conditions are known predisposing factors to necrotizing fasciitis.

Source: Park SY, Park SY, Moon SY, Son JS, Lee MS (2011) Fatal Necrotizing Fasciitis Due to Streptococcus pneumoniae: A Case Report. J Korean Med Sci. 26(1): 131–134.  

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