Severe form of streptococcal necrotizing fasciitis of the upper limb – diagnostic and therapeutic challenge: A case report

Dragan Mikić; Tatjana Takić-Radovanović; Milan Luković; Milomir Košutić; Srdjan Starčević; Zoran Bjelanović; Dragan Djordjević; Darko Nožić

doi:10.2298/6503

Dragan Mikić Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia; †Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Tatjana Takić-Radovanović Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia
Milan Luković Clinic for Orthopedic Surgery and Traumatology, Military Medical Academy, Belgrade, Serbia
Milomir Košutić Clinic for Orthopedic Surgery and Traumatology, Military Medical Academy, Belgrade, Serbia
Srdjan Starčević Clinic for Infectious and Tropical Diseases Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Zoran Bjelanović Clinic for Vascular Surgery, Military Medical Academy, Belgrade, Serbia
Dragan Djordjević Clinic for Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia
Darko Nožić Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia

DOI: https://doi.org/10.2298/6503

Keywords: fasciitis, necrotizing, streptococcus, arm, amputation, anti-bacterial agents,

Abstract

Introduction. Since delay in recognition and effective treatment of necrotizing fasciitis (NF) caused by invasive group A streptococcus increases the mortality and disability, the early diagnosis and management of this disease are essential for a better outcome. We presented a patient with a severe form of streptococcal NF of the left upper limb in whom amputation was performed as a life saving procedure. Case report. A 65-year-old man, previously healthy, suffered an injury to his left hand by sting on a fish bone. Two days after that the patient got fever, redness, swelling and pain in his left hand. Clinical examination of the patient after admission indicated NF that spread quickly to the entire left upper limb, left armpit, and the left side of the chest and abdomen. Despite the use of aggressive antibiotic and surgical therapy severe destruction of the skin and subcutaneous tissues developed with the development of gangrene of the left upper limb. In this situation, the team of specialists decided that the patient must be operated on submited to amputation of the left arm, at the shoulder. After amputation and aggressive debridement of soft tissue on the left side of the trunk, the patient completely recovered. β-hemolytic streptococcus group A was isolated from the skin and tissue obtained during the surgery. Conclusion. In the most severe forms of streptococcal NF of the extremities, adequate multidisciplinary treatment, including limb amputation, can save the life of a patient.

References

Mikić D, Bojić I. Necrotizing fasciitis. Vojnosanit Pregl 2000; 57(3): 339−45. (Serbian)

Wong C, Chang H, Pasupathy S, Khin L, Tan J, Low C. Necrotiz-ing fasciitis: clinical presentation, microbiology, and determi-nants of mortality. J Bone Joint Surg Am 2003; 85-A(8): 1454−60.

Lancerotto L, Tocco I, Salmaso R, Vindigni V, Bassetto F. Necrotiz-ing fasciitis: classification, diagnosis, and management. J Trauma Acute Care Surg 2012; 72(3): 560−6.

Bair M, Chi H, Wang W, Hsiao Y, Chiang R, Chang K. Necrotizing fasciitis in southeast Taiwan: clinical features, microbiology, and prognosis. Int J Infect Dis 2009; 13(2): 255−60.

Donaldson PM, Naylor B, Lowe JW, Gouldesbrough DR. Rapidly fa-tal necrotising fasciitis caused by Streptococcus pyogenes. J Clin Pathol 1993; 46(7): 617−20.

Mikic D, Bojic I, Djokic M, Milanovic M. Streptococcal toxic shock syndrome. Vojnosanit Pregl 2000; 57(5): 585−9. (Serbian)

Ozalay M, Ozkoc G, Akpinar S, Hersekli MA, Tandogan RN. Ne-crotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality. Foot Ankle Int 2006; 27(8): 598−605.

Martin J, Murchan S, O'flanagan D, Fitzpatrick IF. Group A streptococcal disease in Ireland, 2004 to 2010. Euro Surveill 2011; 16(41): pii: 19988.

Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can im-prove survival: an observational intensive care unit cohort study. ANZ J Surg 2013; 83(5): 365−70.

Lamagni TL, Neal S, Keshishian C, Powell D, Potz N, Pebody R, et al. Predictors of death after severe Streptococcus pyogenes in-fection. Emerging Infect Dis 2009; 15(8): 1304−7.

Wong C, Wang Y. The diagnosis of necrotizing fasciitis. Curr Opin Infect Dis 2005; 18(2): 101−6.

Stoneback JW, Hak DJ. Diagnosis and management of necrotizing fasciitis. Orthopedics 2011; 34(3): 196−202.

Machado NO. Necrotizing fasciitis: The importance of early di-agnosis, prompt surgical debridement and adjuvant therapy. North Am J Med Sci 2011; 3: 107−18.

Anaya DA, Dellinger PE. Necrotizing soft-tissue infection: di-agnosis and management. Clin Infect Dis 2007; 44(5): 705−10.

Voros D, Pissiotis C, Georgantas D, Katsaragakis S, Antoniou S, Pa-padimitriou J. Role of early and extensive surgery in the treat-ment of severe necrotizing soft tissue infection. Br J Surg 1993; 80(9): 1190−1.

Wong CH, Yam AK, Tan AB, Song C. Approach to debridement in necrotizing fasciitis. Am J Surg 2008; 196(3): e19−24.

Naqvi G, Malik S, Jan W. Necrotizing Fasciitis of the lower ex-tremity: a case report and current concept of diagnosis and management. Scand J Trauma Resusc Emerg Med 2009; 17: 28.

Cheung JP, Fung B, Tang WM, Ip WY. A review of necrotis-ing fasciitis in the extremities. Hong Kong Med J 2009; 15(1): 44−52.

Angoules AG, Kontakis G, Drakoulakis E, Vrentzos G, Granick MS, Giannoudis PV. Necrotising fasciitis of upper and lower limb: A systematic review. Injury 2007; 38(Suppl 5): S19−26.

Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E. Predictors of mortality and limb loss in necrotizing soft tis-sue infections. Arch Surg 2005; 140(2): 151−7.

Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC. Necrotising fasciitis of a limb. J Bone Joint Surg Br 2001; 83(5): 709−14.

Wong C, Khin L, Heng K, Tan K, Low C. The LRINEC (Labora-tory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infec-tions. Crit Care Med 2004; 32(7): 1535−41.

Holland MJ. Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score to patients in a tropical tertiary referral centre. Anaesth Intensive Care 2009; 37(4): 588−92.

Mikić D, Bojić I, Djokić M, Stanić V, Stepić V, Mićević D, et al. Necrotizing fasciitis caused by group A streptococcus. Vojno-sanit Pregl 2002; 59(2): 203−7. (Serbian)

Childers BJ, Potyondy LD, Nachreiner R, Rogers FR, Childers ER, Oberg KC, . Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg 2002; 68(2): 109−16.

Das DK, Baker MG, Venugopal K. Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review. BMC Infect Dis 2012; 12: 348.

Ogilvie CM, Miclau T. Necrotizing soft tissue infections of the extremities and back. Clin Orthop Relat Res 2006; 447: 179−86.

Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 1998; 64(5): 397−400.

Haywood CT, McGeer A, Low DE. Clinical experience with 20 cases of group A streptococcus necrotizing fasciitis and my-onecrosis: 1995 to 1997. Plast Reconstr Surg 1999; 103(6): 1567−73.

Kojic M, Mikic D, Nožić D. Streptococcal necrotizing fasciitis with toxic shock syndrome and rapid fatal outcome. In: Book of Abstracts. 2nd Congress of Infectious Diseases of Serbia with International Participation. Zlatibor; October 15−17, 2013.

Wang T, Hung C. Role of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limbs. Ann Emerg Med 2004;44(3):222-8. PubMed PMID: 15332062

Yen Z, Wang H, Ma H, Chen S, Chen W. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med 2002; 9(12): 1448−51.

Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology 1997; 203(3): 859−63.

Seok JH, Jee WH, Chun KA, Kim JY, Jung CK, Kim YR, et al. Ne-crotizing fasciitis versus pyomyositis: discrimination with using MR imaging. Korean J Radiol 2009; 10(2): 121−8.

Bryant AE, Bayer CR, Chen RY, Guth PH, Wallace RJ, Stevens DL. Vascular dysfunction and ischemic destruction of tissue in Streptococcus pyogenes infection: the role of streptolysin O-induced platelet/neutrophil complexes. J Infect Dis 2005; 192(6): 1014−22.

Coyle EA, Cha R, Rybak MJ. Influences of linezolid, penicillin, and clindamycin, alone and in combination, on streptococcal pyrogenic exotoxin a release. Antimicrob Agents Chemother 2003; 47(5): 1752−5.

Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg 2005; 189(4): 462−6.

Hassan Z, Mullins RF, Friedman BC, Shaver JR, Brandigi C, Alam B, et al. Treating necrotizing fasciitis with or without hyperbaric oxygen therapy. Undersea Hyperb Med 2010; 37(2): 115−23.

Darabi K, Abdel-Wahab O, Dzik WH. Current usage of intrave-nous immune globulin and the rationale behind it: the Massa-chusetts General Hospital data and a review of the literature. Transfusion 2006; 46(5): 741−53.

Schrage B, Duan G, Yang LP, Fraser JD, Proft T. Different prepa-rations of intravenous immunoglobulin vary in their efficacy to neutralize streptococcal superantigens: implications for treat-ment of streptococcal toxic shock syndrome. Clin Infect Dis 2006; 43(6): 743−6.

McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determi-nants of mortality for necrotizing soft-tissue infections. Ann Surg 1995; 221(5): 558−63.