Determinants of mortality for necrotizing soft-tissue infections

Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study

Background

New biomarkers are needed to assess the severity of necrotizing soft tissue infection (NSTI) at an early stage and to individualize treatment strategies. We assessed pentraxin-3 (PTX3) as a marker of disease severity and risk of death in patients with NSTI.

Methods

We conducted a prospective, observational study in the intensive care unit at Copenhagen University Hospital, where treatment of NSTI is centralized at a national level. We compared PTX3, procalcitonin and C-reactive protein in septic shock versus nonshock patients and in amputated versus nonamputated patients using the Mann-Whitney U test. The prognostic value of the markers for 180-day mortality was assessed using Cox regression analyses.

Results

Patients with NSTI (n = 135) were included over 25 months with up to 2.5-year follow-up; 71 % had septic shock, amputation was undertaken in 20 % and the 180-day mortality was 27 %. Baseline plasma PTX3 level was significantly higher in patients with septic shock (67.3 versus 24.6 ng/mL, p < 0.0001) and in patients who underwent amputation (118.6 versus 43.6 ng/mL, p = 0.019). No significant differences in baseline procalcitonin or C-reactive protein levels were found according to amputation (25.2 versus 7.0 μg/L, p = 0.060 and 202 versus 225 mg/L, p = 0.123), respectively. Baseline PTX3 level above the median was associated with death (p = 0.009, log-rank test) and the univariate Cox regression analysis revealed a significant association between PTX3 level upon admission and 180-day mortality (hazard ratio 2.60 (95 % confidence interval 1.28–5.29), p = 0.008). When adjusted for age, sex, chronic disease and Simplified Acute Physiology Score II, no significant association was found.

Conclusions

High PTX3 level is associated with septic shock, amputation and risk of death in patients with NSTI, but it is not an independent predictor of 180-day mortality in this patient group.

Trial registration

ClinicalTrials.gov Identifier: NCT02180906. Date of registration: June 29, 2014.

Liver cirrhosis as a real risk factor for necrotising fasciitis: a three-year population-based follow-up study

INTRODUCTION

Necrotising fasciitis (NF) is often found in patients with diabetes mellitus, chronic renal failure, alcoholism, malignancy or liver cirrhosis. However, it remains unknown whether liver cirrhosis is an independent risk factor for the occurrence of NF. This study aimed to determine whether liver cirrhosis is an independent risk factor for the occurrence of NF, and to identify the relationship between severity of liver cirrhosis and occurrence of NF.

METHODS

The National Health Insurance Research Database, maintained by Taiwan's National Health Insurance programme, was retrospectively analysed, and the hospitalisation data of 40,802 cirrhotic patients and 40,865 randomly selected, age‑ and gender‑matched non‑cirrhotic control patients was collected. The medical records of all patients were individually followed for a three‑year period from the patients' first hospitalisation in 2004.

RESULTS

During the three‑year follow‑up period, there were 299 (0.7%) cirrhotic patients with NF and 160 (0.4%) non‑cirrhotic patients with NF. Cox regression analysis showed that liver cirrhosis was a risk factor for the occurrence of NF during the study period (hazard ratio 1.982; p < 0.001). Among cirrhotic patients, those with complicated liver cirrhosis had a higher risk for the occurrence of NF than patients with non‑complicated liver cirrhosis (hazard ratio 1.320; p = 0.028).

CONCLUSION

Cirrhotic patients had a higher risk for the occurrence of NF than non‑cirrhotic patients, and the risk for NF was especially high among patients with complicated liver cirrhosis.

Management of Necrotizing Fasciitis and Its Surgical Aspects

Necrotizing fasciitis (NF) is a severe and rapidly progressive infectious disease that attacks superficial an as well as deep fascia, subcutaneous fat tissue, and muscle. Although the incidence is of relatively low frequency, the median mortality is high. NF is a great burden to patients and hospitals. The most common cause of NF is trauma injuries, followed by other conditions with comorbidity. A classification for NF was presented concerning microbial cause, depth of infection, and anatomy. But the value of classification is not convincing. Early diagnosis of NF is essential and still to be realized by far. Information from clinic or laboratory might contribute to the purpose. Surgery is used in exploration debridement and tissue reconstruction as the main method with NF. Negative pressure wound therapy has proved to be useful in improving wound bed preparation and healing.

Clinical Characteristics and Risk Factor Analysis for Lower-Extremity Amputations in Diabetic Patients With Foot Ulcer Complicated by Necrotizing Fasciitis

Patients with diabetes are at a higher risk of having diabetic foot ulcers (DFUs) or necrotizing fasciitis (NF). The present study aims to examine the clinical characteristics and associated risk factors for lower-extremity amputation (LEA) in patients with DFU complicated by NF.We retrospectively reviewed patients treated at a major diabetic foot center in Taiwan between 2009 and 2014. Of the 2265 cases 110 had lower-extremity NF. Limb preservation outcomes were classified as major LEA, minor LEA, or limb-preserved. Clinical characteristics, laboratory data, and bacterial culture results were collected for analysis.Of the 110 patients with NF, 100 had concomitant DFUs (NF with DFU) and the remaining 10 had no DFU (NF without DFU). None of the NF patients without DFU died nor had their leg amputated. Two NF patients with DFU died of complications. The amputation rate in the surviving 98 NF patients with DFU was 72.4% (46.9% minor LEA and 25.5% major LEA). Seventy percent of the NF patients without DFU had monomicrobial infections (60% with Streptococcus species), and 81.4% NF patients with DFU had polymicrobial infections. Anaerobic organisms were identified in 66% of the NF patients with DFU. Multinomial logistic regression analysis revealed an association between high-grade Wagner wound classification (Wagner 4 and Wagner 5) and LEA (adjusted odds ratio [aOR] = 21.856, 95% confidence interval [95% CI] = 1.625-203.947, P = 0.02 and aOR = 20.094, 95% CI = 1.968-205.216, P = 0.01 for major and minor LEA, respectively) for NF patients with DFU. In addition, a lower serum albumin level was associated with major LEA (OR = 0.066, P = 0.002).In summary, once DFUs were complicated by NF, the risk of amputation increased. Empirical treatment for NF patients with DFU should cover polymicrobial infections, including anaerobic organisms. The high-grade wound classification and low serum albumin level were associated with LEA.

Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality

Background

Necrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients.

Methods

Detailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality.

Results

There were 84 patients (51 %) with diabetes. The overall case fatality rate was 29.7 %, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95 % confidence interval, 1.2 to 4.02; P = 0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95 % confidence interval, 1.66 to 32.54; P = 0.009).

Conclusions

Diabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.

Predictors of Monomicrobial Necrotizing Soft Tissue Infections

BACKGROUND

Broad-spectrum antibiotic therapy is critical in the management of necrotizing soft tissue infections (NSTI) in the emergency setting. Clindamycin often is included empirically to cover monomicrobial gram-positive pathogens but probably is of little value for polymicrobial infections and is associated with significant side effects, including the induction of Clostridium difficile colitis. However, there have been no studies predicting monomicrobial infections prior to obtaining cultures. The purpose of this study was to identify independent predictors of monomicrobial NSTI where the use of clindamycin would be most beneficial. We hypothesized that monomicrobial infections are characterized by involvement of the upper extremities and fewer co-morbid diseases.

METHODS

We reviewed all cases of potential NSTI occurring between 1996 and 2013 in a single tertiary-care center. The infection was diagnosed by the finding of rapidly progressing necrotic fascia during debridement with positive cultures of tissue. Univariable analysis was performed using the Student t-, Wilcoxon rank sum, χ2, and Fisher exact tests as appropriate. Multivariable logistic regression was used to identify independent variables associated with outcomes.

RESULTS

A group of 151 patients with confirmed NSTI with complete data was used. Of the monomicrobial infections, 61.8% were caused by Group A streptococci, 20.1% by Staphylococcus aureus, and 12.7% by Escherichia coli. Of the polymicrobial infections, E. coli was involved 13.7% of the time, followed by Candida spp. at 12.9%, and Bacteroides fragilis at 11.3%. On univariable analysis, immunosuppression, upper extremity infection, and elevated serum sodium concentration were associated with monomicrobial infection, whereas morbid obesity and a perineal infection site were associated with polymicrobial infection. On multivariable analysis, the strongest predictor of monomicrobial infection was immunosuppression (odds ratio [OR] 7.0; 95% confidence interval [CI] 2.2-22.3) followed by initial serum sodium concentration (OR 1.1; 95% CI 1.0-1.2). Morbid obesity (OR 0.1; 95% CI 0.0-0.5) and perineal infection (OR 0.3; 95% CI 0.1-0.8) were independently associated with polymicrobial infection.

CONCLUSION

We identified independent risk factors that may be helpful in differentiating monomicrobial from polymicrobial NSTI. We suggest empiric clindamycin coverage be limited to patients who are immunosuppressed, have an elevated serum sodium concentration, or have upper extremity involvement and be avoided in obese patients or those with perineal disease.

Differentiating between red legs and cellulitis and reviewing treatment options

Red legs (RL) is a chronic inflammatory condition often misdiagnosed as cellulitis. Antibiotic therapy is not required and does not resolve the symptoms. The main causes of RL are chronic dermatological and venous disease, including chronic oedema. Raising awareness of this condition among health professionals could prevent misdiagnosis and unnecessary costly and potentially harmful antibiotic therapy. The aim of this paper is to highlight the differential diagnoses and management of red legs, and the author also includes an example through a case history.

Necrotizing Fasciitis and The Diabetic Foot

Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.

Prognostic factors in necrotizing soft-tissue infections (NSTI): A cohort study

BACKGROUND

Necrotizing soft-tissue infection (NSTI) is uncommon but life-threatening. A recent meta-analysis estimated the overall mortality at 23.5%.

OBJECTIVE

We sought to identify risk factors associated with mortality in a cohort of patients with NSTI in a tertiary care center.

METHODS

We identified 512 patients with NSTI between 1996 and 2012 in the national hospital database Program for Medicalization of Information Systems and examined risk factors of mortality with NSTI by univariate and multivariate analysis.

RESULTS

We included 109 patients with a confirmed diagnosis of NSTI; 31 (28%) died at a median follow-up of 274 days (range 2-6135 days). On multivariate analysis, independent risk factors of mortality were age older than 75 years (hazard ratio [HR] 4.4, 95% confidence interval [CI] 1.8-10.3), multifocal NSTI (HR 5.9, 95% CI 1.9-18.5), severe peripheral vascular disease (HR 5.1, 95% CI 1.5-17.0), hospital-acquired infection (HR 3.9, 95% CI 1.4-10.7), severe sepsis (HR 7.4, 95% CI 1.7-33.1), and septic shock on hospital admission (HR 13.9, 95% CI 3.8-50.4).

LIMITATIONS

This was a retrospective cohort, which disallows a precise record of the delay between diagnosis and surgery.

CONCLUSION

Our findings for this robust cohort of patients with a definite diagnosis of NSTI could help clinicians stratify NSTI severity at clinical course onset.

Lower Extremity Wounds in Patients With Idiopathic Thrombocytopenic Purpura and Systemic Lupus Erythematosus

Infections in lower extremities are sometimes concerned with systemic immunological disorders such as idiopathic thrombocytopenic purpura and systemic lupus erythematosus, which are treated with systemic steroids. Steroid therapy impairs the epithelial wound healing and with systemic condition, especially with systemic lupus erythematosus, the wound is susceptible for infection. Even a pyoderma gangrenosum sometimes occurs in a patient with idiopathic thrombocytopenic purpura with an incisional wound of hernia. The severe signs and symptoms are the deep skin and soft tissue infections, mainly caused by group A streptococcus, composed of necrotizing fasciitis and muscle necrosis. Medically suspected necrotizing fasciitis patients should be empirically and immediately administered with broad-spectrum antibiotics, which may cover the common suspected pathogens. In type I (polymicrobial) infection, the selection of antimicrobial should be based on medical history and Gram staining and culture. The coverage against anaerobes is important in type I infection. Metronidazole, clindamycin, or beta-lactams with beta-lactamase inhibitor or carbapenems are the treatment of choice against anaerobes, while early surgical debridement-wide enough and deep enough-is the core treatment of necrotizing fasciitis and results in significantly better mortality compared with those who underwent surgery after a few hours of delay. When necrotizing fasciitis is considered and the patient is brought to the operation room, aggressive and extensive surgical debridement is explored. Tissue involved should be completely removed until no further evidence of infection is seen. When further debridement is required, the patient must return to the operating room immediately. In this context, the temporal coverage using the artificial dermis after debridement is useful because there is no loss of the patient's own tissue and yet it is easier for "second-look" surgery or secondary reconstruction, and extensive enough debridement is always the mainstay of the therapy.

Necrotizing Fasciitis in Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, progressive, and life-threatening hematopoietic stem cell disorder characterized by complement-mediated intravascular hemolysis and a prothrombotic state. Patients with PNH might have slightly increased risk of infections due to complement-associated defects subsequent to CD59 deficiency. Here, we report a rare case of a 65-year-old male patient with necrotic ulcers on both legs, where the recognition of pancytopenia and microthrombi led to the diagnosis of PNH based on FLAER (FLuorescent AERolysin) flow cytometric analysis. He was subsequently started on eculizumab therapy, with starting and maintenance doses set as per drug labelling. Progression of the patient's leg ulcers during follow-up, with fulminant tissue destruction, purulent discharge, and necrotic patches, led to a later diagnosis of necrotizing fasciitis due to Pseudomonas aeruginosa and Klebsiella pneumonia infection. Courses of broad-spectrum antibiotics, surgical debridement, and superficial skin grafting were applied with successful effect during ongoing eculizumab therapy. This case highlights the point that it is important to maintain treatment of underlying disorders such as PNH in the presence of life-threatening infections like NF.

The Prediction Predicament: Rethinking Necrotizing Soft Tissue Infections Mortality

BACKGROUND

Our study sought to identify independent risk factors predisposing patients with necrotizing soft tissue infections (NSTIs) to mortality from among laboratory values, demographic data, and microbiologic findings in a small population. To this end, a retrospective review was conducted of the medical records of all patients with NSTI who had been treated at our institution from 2003 to 2012 (n=134).

METHODS

Baseline demographics and comorbidities, clinical and laboratory values, hospital course, and the microbiologic characteristics of surgical incision cultures were recorded. Each variable was tested for association with survival status and all associated variables with p<0.15 were included in a logistic regression model to seek factors associated independently with mortality.

RESULTS

Surprisingly, no demographic or pre-existing condition proved to be a predictor of mortality. Two laboratory values had an inverse correlation to mortality: High C-reactive protein (CRP) and highest recorded CRP. Of surgical incisions that grew bacteria in culture, 33.6% were polymicrobial. Mortality rates were highest with Enterococcus-containing polymicrobial infections (50%), followed by those containing Pseudomonas (40%), and Streptococcus spp. (27%). Understanding why so many studies across the literature, now including our own, find such disparate results for correlation of NSTI mortality with patient data may lie in the fundamentally dynamic nature of the organisms involved.

CONCLUSIONS

This study suggests that no single factor present on admission is a robust predictor of outcome; it is likely that survival in NSTI is predicated upon a complex interaction of multiple host and microbial factors that do not lend themselves to reduction into a simple formula. It is also abundantly clear that the well-established principles of NSTI surgery should continue to be followed in all cases, with an emphasis on early debridement, irrespective of apparent severity of initial presentation.

Necrotizing fasciitis: 11-year retrospective case review in South Auckland

BACKGROUND

The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile.

METHODS

A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed.

RESULTS

Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval (CI) 13.9%-28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71-0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002-July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens.

CONCLUSION

This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality.

Clinical predictors for severe sepsis in patients with necrotizing fasciitis: an observational cohort study in northern Thailand

Background

Necrotizing fasciitis (NF) is a life-threatening infection of skin and fascia. Its progress is extremely fast, with extensive necrosis. Delay in treatment, with subsequent huge soft tissue loss and associated severe sepsis, remains a major cause of death in the management of NF.

Objective

The aim of this study was to explore clinical characteristics that may be used to predict severe sepsis in patients with NF, in the context of routine clinical practice in northern Thailand.

Methods

A retrospective observational cohort study was conducted. The patient cohort in this study consisted of all patients who were diagnosed with NF by surgical or pathological confirmation. The follow-up period started with the admission date and ended with the discharge date. The clinical variables were collected from patients registered at three provincial hospitals in northern Thailand from 2009 to 2012. The clinical predictors for severe sepsis were analyzed using multivariable risk regression.

Results

A total of 1,452 patients were diagnosed with NF, either with severe sepsis (n=237 [16.3%]) or without severe sepsis (n=1,215 [83.7%]). From the multivariable analysis, female sex (relative risk [RR] =1.51; 95% confidence interval [CI] =1.04–2.20), diabetes mellitus (RR =1.40; 95% CI =1.25–1.58), chronic heart disease (RR =1.31; 95% CI =1.15–1.49), hemorrhagic bleb (RR =1.47; 95% CI =1.32–1.63), skin necrosis (RR =1.45; 95% CI =1.34–1.57), and serum protein <6 g/dL (RR =2.67; 95% CI =1.60–4.47) were all predictive factors for severe sepsis.

Conclusion

The clinical predictors for severe sepsis in patients with suspicion of NF included female sex, diabetes mellitus, chronic heart disease, hemorrhagic bleb, skin necrosis, and serum protein <6 d/dL. The risk ratio was much higher in patients with total protein less than 6 g/dL, which is associated with malnutrition. Therefore, provision of sufficient nutritional support and close monitoring for these clinical predictors may be beneficial to reduce morbidity and mortality.

Necrotizing soft tissue infections after injection therapy: Higher mortality and worse outcome compared to other entry mechanisms

OBJECTIVES

Necrotizing Soft Tissue Infections represent a rare entity of infection associated with a high mortality. The aim of this retrospective study was to analyze patients with an iatrogenic etiology of injection or infiltration to compare the outcome with other etiologies.

METHODS

The study group consisted of 21 patients treated with a Necrotizing Fasciitis caused by injection or infiltration. Risk factors and outcome were compared to 134 patients with a Necrotizing Fasciitis caused by other entry mechanisms.

RESULTS

Overall mortality in our study group was 14 of 21 (67%) with an amputation rate of 11 of 15 (73%) if an extremity was involved. The survival rate was significantly worse after injection or infiltration (p < 0.001) as was the amputation rate (p = 0.013), the percentage of patients requiring intensive care (100% vs. 83%, p = 0.038) and vasopressors (81% vs. 54%, p = 0.02). Injection or infiltration therapy proved to be the strongest prognostic factor (p = 0.003) besides the known risk factors obesity (0.007) and renal insufficiency (0.025).

CONCLUSIONS

Our results demonstrate that patients with a Necrotizing Soft Tissue Infection after injection or infiltration therapy have a significantly worse prognosis.

Extensive cervical necrotizing fasciitis of odontogenic origin

Necrotizing fasciitis (NF) is an uncommon infection, but potentially lethal, especially when associated with systemic disorders such as diabetes. The authors report a case of necrotizing fasciitis from odontogenic origin in a patient with uncontrolled diabetes mellitus. The initial diagnosis was based on clinical information, in which multiple necrosis areas in cervical and thoracic regions were observed. Wide antibiotic therapy was applied, followed by surgical drain age and debridement. Culture was positive for methicillin-resistant Staphylococcus aureus. Although the treatment is established, the patient dies after sepsis and failure of vital organs. Clearly, the morbidity associated to this infection, even in diabetic patients, can be minimized if an early diagnosis and effective debridement are done.

Fatal Necrotizing Fasciitis following Episiotomy

Introduction. Necrotizing fasciitis is an uncommon condition in general practice but one that provokes serious morbidity. It is characterized by widespread fascial necrosis with relative sparing of skin and underlying muscle. Herein, we report a fatal case of necrotizing fasciitis in a young healthy woman after episiotomy. Case Report. A 17-year-old primigravida underwent a vaginal delivery with mediolateral episiotomy. Necrotizing fasciitis was diagnosed on the 5th postpartum day, when the patient was referred to our tertiary care medical center. Surgical debridement was initiated together with antibiotics and followed by hyperbaric oxygen therapy. The patient died due to septic shock after 16 hours from the referral. Conclusion. Delay of diagnosis and consequently the surgical debridement were most likely the reasons for maternal death. In puerperal period, a physician must consider necrotizing fasciitis as a possible diagnosis in any local sings of infection especially when accompanied by fever and/or tenderness. Early diagnosis is the key for low mortality and morbidity.

Necrotizing Fasciitis of the Abdominal Wall Caused by Serratia Marcescens

In this article, we present the first case of necrotizing fasciitis affecting the abdominal wall caused by Serratia marcescens and share results of a focused review of S. marcescens induced necrotizing fasciitis. Our patient underwent aorto-femoral bypass grafting for advanced peripheral vascular disease and presented 3 weeks postoperatively with pain, erythema and discharge from the incision site in the left lower abdominal wall and underwent multiple debridement of the affected area. Pathology of debrided tissue indicated extensive necrosis involving the adipose tissue, fascia and skeletal muscle. Wound cultures were positive for Serratia marcescens. She was successfully treated with antibiotics and multiple surgical debridements. Since necrotizing fasciitis is a medical and surgical emergency, it is critical to examine infectivity trends, clinical characteristics in its causative spectrum. Using PubMed we found 17 published cases of necrotizing fasciitis caused by Serratia marcescens, and then analyzed patterns among those cases. Serratia marcescens is prominent in the community and hospital settings, and information on infection presentations, risk factors, characteristics, treatment, course, and complications as provided through this study can help identify cases earlier and mitigate poor outcomes. Patients with positive blood cultures and those patients where surgical intervention was not provided or delayed had a higher mortality. Surgical intervention is a definite way to establish the diagnosis of necrotizing infection and differentiate it from other entities.

Necrotizing fasciitis in patients with head and neck cancer

Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 patients with head and neck cancers who developed necrotizing fasciitis during the postoperative period.

Necrotizing soft tissue infections in intravenous drug users: a vascular surgical emergency

OBJECTIVE

To assess the short and long-term outcomes of necrotizing soft tissue infection (NSTI) in intravenous drug users (IVDU) in a regional vascular centre.

METHODS

This was a retrospective analysis of all IVDUs with NSTI admitted to the regional vascular surgical unit between January 2009 and July 2014. Clinical outcome measures were interval between admission and surgery, length of ITU/HDU and hospital stays, post-operative complications, in hospital and one year mortality.

RESULTS

25 patients were admitted. The median age was 39 years (range 30-53 years) with a female to male ratio of 1:3.3. The median interval between admission and surgery was 23 hours (range 2-195 hours), however, this was significantly less when the admitting specialty was directly to vascular surgery (median 4 hours, range 2-7) compared with other specialties (median 38 hours, range 7-195 hours). Ten patients required HDU/ITU care with a median duration of 4 days (range 1-12 days). Five patients (20%) required amputation, of whom two (40%) had a prosthetic limb fitted. There was one in hospital death (4%). Another patient died while awaiting limb fitting 4 months post discharge, giving a 1 year mortality of 8%.

CONCLUSIONS

NSTI in IVDUs carries high risk of amputation with a very low rate of limb fitting. Intervention is significantly delayed when the admitting specialty is not vascular surgery, and half of these patients require HDU/ITU care, with significant morbidity and mortality. Early diagnosis and referral to vascular surgery is crucial in management of these patients.

Necrotising soft tissue infection in a UK metropolitan population

INTRODUCTION

Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice.

METHODS

Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated.

RESULTS

Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality.

CONCLUSIONS

In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.

Bromine, bear-claw scratch fasciotomies, and the Eagle effect: management of group A streptococcal necrotising fasciitis and its association with trauma

Necrotising fasciitis is a rare, but potentially fatal, soft-tissue infection. Historical depictions of the disease have been described since classical times and were mainly recorded in wartime reports of battle injuries. Although several different species of bacteria can cause necrotising fasciitis, perhaps the most widely known is group A streptococcus (GAS). Infection control, early surgical debridement, and antibiotic therapy are now the central tenets of the clinical management of necrotising fasciitis; these treatment approaches all originate from those used in wars in the past 150 years. We review reports from the 19th century, early 20th century, and mid-20th century onwards to show how the management of necrotising fasciitis has progressed in parallel with prevailing scientific thought and medical practice. Historically, necrotising fasciitis has often, but not exclusively, been associated with penetrating trauma. However, along with a worldwide increase in invasive GAS disease, recent reports have cited cases of necrotising fasciitis following non-combat-related injuries or in the absence of antecedent events. We also investigate the specific association between GAS necrotising fasciitis and trauma. In the 21st century, molecular biology has improved our understanding of GAS pathogenesis, but has not yet affected attributable mortality.

Severe monobacterial necrotizing soft tissue infection by group A Streptococcus: A surgical emergency

Eight percent of necrotizing soft tissue infections (NSTI) are attributable to group A Streptococci (GAS), and among these, 50% develop streptococcal toxic shock syndrome. The reported mortality associated with NSTI reaches 32%. We present cases of two healthy individuals with minor GAS skin infection which developed to a rapidly progressed NSTI and sepsis despite of the antibiotic treatment, aiming to discuss the lessons learned from the course and management of these patients.

Necrotizing fasciitis caused by perforated appendicitis: a case report

Acute appendicitis is one of the most common causes of acute abdominal pain. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in diagnosis or treatment may result in increased risks of complications, such as perforation, which is associated with increased morbidity and mortality rates. Necrotizing fasciitis caused by perforated appendicitis is extremely rare. We herein report a case of 50-year-old man presenting with an appendiceal abscess in local hospital. After ten days of conservative treatment with intravenous antibiotics, the patient complained about pain and swelling of the right lower limb and computed tomography (CT) demonstrated a perforated appendix and gas and fluid collection extending from his retroperitoneal cavity to the subcutaneous layer of his right loin and right lower limb. He was transferred to our hospital and was diagnosed with necrotizing fasciitis caused by perforated appendicitis. Emergency surgery including surgical debridement and appendectomy was performed. However, the patient died of severe sepsis and multiple organ failure two days after the operation. This case represents an unusual complication of a common disease and we should bear in mind that retroperitoneal inflammation and/or abscesses may cause necrotizing fasciitis through lumbar triangles.

Necrotizing fasciitis: risk factors of mortality

BACKGROUND

Necrotizing fasciitis (NF) is a serious infection of skin and soft tissues that rapidly progresses along the deep fascia. It becomes a fatal soft tissue infection with high mortality rate if treatment is delayed. Early diagnosis for emergency surgical debridement and broad-spectrum antibiotic therapy were the optimal treatments to reduce the mortality rate of NF.

OBJECTIVE

The aim of this study was to identify risk factors that increased the mortality rate in patients with NF under routine clinical practices.

METHODS

A retrospective cohort study was performed at three general hospitals located in northern Thailand. All medical records of patients with surgically confirmed NF treated between January 2009 and December 2012 were reviewed. Clinical predictors for mortality were analyzed using multivariable risk regression analysis.

RESULTS

Of a total of 1,504 patients with a diagnosis of NF, 19.3% (n=290) died in hospital and 80.7% (n=1,214) survived. From multivariable analysis, being female (risk ratio [RR] =1.37, 95% confidence interval [CI] =1.01-1.84); age >60 (RR=1.39, 95% CI =1.25-1.53); having chronic heart disease (RR=1.64, 95% CI=1.18-2.28), cirrhosis (RR =2.36, 95% CI=1.70-3.27), skin necrosis (RR =1.22, 95% CI=1.15-1.28), pulse rate >130/min (RR =2.26, 95% CI=1.79-2.85), systolic BP <90 mmHg (RR =2.05, 95% CI =1.44-2.91), and serum creatinine ≥1.6 mg/dL (RR=3.06, 95% CI=2.08-4.50) were risk factors for mortality.

CONCLUSION

Prognostic factors for mortality in NF patients included being female; age >60; or having chronic heart disease, cirrhosis, skin necrosis, pulse rate >130/min, systolic BP <90 mmHg, and serum creatinine ≥1.6 mg/dL. Thus, disease progression to mortality may occur in such patients presenting one of these risk factors. Further examination or close monitoring for systemic involvement may be advantageous to reduce morbidity and mortality.

Adjunctive hyperbaric oxygen for necrotizing fasciitis

BACKGROUND

Hyperbaric oxygen therapy (HBOT) involves the therapeutic administration of 100% oxygen in a pressure chamber at pressures above one atmosphere absolute. This therapy has been used as an adjunct to surgery and antibiotics in the treatment of patients with necrotizing fasciitis with the aim of reducing morbidity and mortality.

OBJECTIVES

To review the evidence concerning the use of HBOT as an adjunctive treatment for patients with necrotizing fasciitis (NF). Specifically, we wish to address the following questions.1. Does administration of HBOT reduce mortality or morbidity associated with NF?2. What adverse effects are associated with use of HBOT in the treatment of individuals with NF?

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid (1966 to September 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Ovid (1982 to September 2014); EMBASE Ovid (1980 to September 2014); and the Database of Randomised Controlled Trials in Hyperbaric Medicine (DORCTHIM, M Bennett) (from inception to September 2014). In addition, we performed a systematic search of specific hyperbaric literature sources. This included handsearching of relevant hyperbaric textbooks; hyperbaric journals (Hyperbaric Medicine Review, South Pacific Underwater Medicine Society Journal, European Journal of Underwater and Hyperbaric Medicine, Aviation Space and Environmental Medicine Journal); and conference proceedings of the major hyperbaric societies (Undersea and Hyperbaric Medical Society, South Pacific Underwater Medicine Society, European Underwater and Baromedical Society, International Congress of Hyperbaric Medicine).

SELECTION CRITERIA

We included all randomized and pseudo-randomized trials (trials in which an attempt at randomization has been made but the method was inappropriate, for example, alternate allocation) that compared the effects of HBOT with the effects of no HBOT (no treatment or sham) in the treatment of children and adults with necrotizing fasciitis.

DATA COLLECTION AND ANALYSIS

We planned independent data collection by two review authors using standardized forms.

MAIN RESULTS

We found no trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

This systematic review failed to locate relevant clinical evidence to support or refute the effectiveness of HBOT in the management of necrotizing fasciitis. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of individuals with necrotizing fasciitis.

Necrotising soft-tissue infections of the upper limb: risk factors for amputation and death

Necrotising soft-tissue infections (NSTIs) of the upper limb are uncommon, but potentially life-threatening. We used a national database to investigate the risk factors for amputation of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination database on 116 patients (79 men and 37 women) who had a NSTI of the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis of in-hospital mortality showed that the significant variables were age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction (P < 0.001), altered consciousness (p = 0.049), and sepsis (p = 0.021). Logistic regression analysis showed that the factors associated with death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95% confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction (OR 15.4; 95% CI 3.8 to 62.8; p < 0.001). Univariate analysis of limb amputation showed that the significant variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001). Multivariable logistic regression analysis showed that the factors related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0; p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p = 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction are both associated with a higher rate of in-hospital mortality. Sepsis and diabetes mellitus are both associated with a higher rate of amputation.

World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections

Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.

Predictors of Mortality in Necrotizing Soft Tissue Infection

Necrotizing soft tissue infections (NSTIs) are a major source of morbidity and mortality, yet predictors of mortality for these critically ill patients remain poorly characterized. The aim of this study was to identify risk factors for mortality in patients with NSTI. We performed a retrospective review of all patients presenting with an NSTI to our county-funded, academic medical center between 2008 and 2013. Admission characteristics, comorbidities, laboratory values, time to operation, and perioperative cultures were assessed to identify predictors of mortality. During the 5-year study period, 138 patients were admitted with a NSTI; 20 (14.5%) of the patients died. Univariate predictors of mortality included bandemia, elevated creatinine, low bicarbonate, elevated lactate, a lower admission temperature, and shorter duration of presenting symptoms. Using Classification And Regression Tree analysis and subsequent logistic regression, bands greater than 25 per cent (odds ratio [OR], 8.0; 95% confidence interval [CI], 2.7 to 24.1; P = 0.0002), duration of symptoms less than 3.5 days (OR, 4.0; 95% CI, 1.2 to 13.9; P = 0.03), and temperature 37°C or less (OR, 3.6; 95% CI, 1.1 to 11.8; P = 0.03) were found to be independent predictors of mortality. Awareness of these predictors should prompt aggressive management of this at-risk population.

Fournier's Gangrene: A Model for Early Prediction

Early diagnosis remains the cornerstone of management of Fournier's gangrene. As a result of variable progression of disease, identifying early predictors of necrosis becomes a diagnostic challenge. We present a scoring system based on objective admission criteria, which can help distinguish Fournier's gangrene from nonnecrotizing scrotal infections. Ninety-six patients were identified, 38 diagnosed with Fournier's gangrene and 58 diagnosed with scrotal cellulitis or abscess. Statistical analyses comparing admission vital signs, laboratory values, and imaging studies were performed and Classification and Regression Tree analysis was used to construct a scoring system. Admission heart rate greater than 110 beats/minute, serum sodium less than 135 mmol/L, blood urea nitrogen greater than 15 mg/dL, and white blood cell count greater than 15 x 103/mL were significant predictors of Fournier's gangrene. Using a threshold score of two or greater, our model differentiates patients with Fournier's gangrene from those with nonnecrotizing infections with a sensitivity of 84.2 per cent. Only 34.2 per cent of patients with Fournier's gangrene had hard signs of necrotizing infection on admission, which were not observed in patients with nonnecrotizing infections. Objective admission criteria assist in distinguishing Fournier's gangrene from scrotal cellulitis or abscess. In situations in which results of the physical examination are ambiguous, this scoring system can heighten the index of suspicion for Fournier's gangrene and prompt rapid surgical intervention.

View from the front lines: an emergency medicine perspective on clostridial infections in injection drug users

Injection drug use (IDU), specifically non-intravenous "skin-popping" of heroin, seems to provide optimal conditions for Clostridial infection and toxin production. IDU is therefore a major risk factor for wound botulism and Clostridial necrotizing soft tissue infections (NSTI) and continues to be linked to cases of tetanus. Case clusters of all 3 diseases have occurred among IDUs in Western U.S. and Europe. Medical personnel who care for the IDU population must be thoroughly familiar with the clinical presentation and management of these diseases. Wound botulism presents with bulbar symptoms and signs that are easily overlooked; rapid acquisition and administration of antitoxin can prevent neuromuscular respiratory failure. In addition to Clostridium perfringens, IDU-related NSTIs can be caused by Clostridium sordellii and Clostridium novyi, which may share a distinct clinical presentation. Early definitive NSTI management, which decreases mortality, requires a low index of suspicion on the part of emergency physicians and low threshold for surgical exploration and debridement on the part of the surgeon. Tetanus should be preventable in the IDU population through careful attention to vaccination status.

Management of necrotizing skin and soft tissue infections

Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.

Klebsiella pneumoniae necrotizing fasciitis of the leg in an elderly French woman

Klebsiella pneumoniae necrotizing fasciitis is a rare infection in regions outside of Asia. Here, we present a case of necrotizing fasciitis of the leg caused by K. pneumoniae in a 92-year-old French woman hospitalized in a geriatric rehabilitation unit. The patient initially presented with dermohypodermitis of the leg that developed from a dirty wound following a fall. A few hours later, this painful injury extended to the entire lower limb, with purplish discoloration of the skin, bullae, and necrosis. Septic shock rapidly appeared and the patient died 9 hours after the onset of symptoms. The patient was Caucasian, with no history of travel to Asia or any underlying disease. Computed tomography revealed no infectious metastatic loci. Blood cultures showed growth of capsular serotype K2 K. pneumoniae strains with virulence factors RmpA, yersiniabactin and aerobactin. This rare and fatal case of necrotizing fasciitis caused by a virulent strain of K. pneumoniae occurred in a hospitalized elderly woman without risk factors. Clinicians and geriatricians in particular should be aware of this important albeit unusual differential diagnosis.

Necrotizing fasciitis in a young patient with acute myeloid leukemia - a diagnostic challenge

Background

Necrotizing fasciitis is characterized by a fulminant destruction of the soft tissue with an alarmingly high mortality rate. One of the main reasons for the continued high mortality is due to the challenge to punctual recognize and diagnose this disease, as specific cutaneous signs can vary or even be missing early in its evolution – especially in case of simultaneous first manifestation of an acute leukemia.

Case presentation

An untypical case of necrotizing fasciitis disease in a young patient with the first diagnosis of acute myeloid leukemia is presented. After her induction chemotherapy the only presenting clinical sign was fever in the presence of severe neutropenia without an evident infectious focus. After a few days a painless confluent, erythematous, pustular skin rash with a central necrosis on lateral thigh appeared. Escherichia coli was isolated from blood cultures. Surgical debridement was performed and showed subcutaneous tissue, fascia and underlying muscle around the site of initial cutaneous manifestation with typical necrosis on exploration. But, initially taken skin biopsy did not show any typical histopathological findings like bacteria or inflammatory cells confirming necrotizing fasciitis. Nevertheless, the intraoperative findings were impressive and highly indicative for a necrotizing soft tissue infection, so that the patient was treated according to clinical guidelines with extensive recurrent surgical debridement, broad-spectrum antibiotics and intensive care therapy. After recovering from NF, she successfully underwent further chemotherapy and stem cell transplantation.

Conclusion

The presented case highlights the risk of potential misinterpretation, delayed diagnosis and treatment of necrotizing fasciitis in patients presenting with an untypical clinical and histopathological manifestation of necrotizing fasciitis as a result of severe neutropenia following chemotherapy for acute myeloid leukemia.

Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections

BACKGROUND

The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities.

METHODS

We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n=14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression.

RESULTS

There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p<0.01) and fewer deaths (4% vs. 23%; p<0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1).

CONCLUSION

At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft-tissue infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) represent a devastating spectrum of disease with high case mortality and resource intensive care. Treatment consists of wide surgical debridement and often prolonged periods of intensive care unit care. Major complications are common. The severity of the disease and the aggressive treatment requirements put survivors at risk for significant long-term sequelae related to the trauma of both disease and treatment. Information about the postdischarge impact of NSTIs on survivors is extremely limited. Qualitative approaches are typically used to explore new phenomena and to capture individuals' thoughts, feelings, or interpretations of meaning and process. Therefore, qualitative methods are ideally suited for hypothesis generation to guide future quantitative study and ensure measured outcomes are patient-centered.

MATERIALS AND METHODS

Semistructured interviews were conducted with survivors of NSTIs from a single regional referral center. Stratified purposive sampling was used to select interview candidates based on severity of illness. Descriptive thematic analysis was performed to identify major themes described by the patients.

RESULTS

Interviews with 18 survivors identified three primary domains of experience: (1) individual factors, (2) relational factors, and (3) societal factors. These domains were split into the following two categories: factors effecting the disease process and recovery, and factors that were outcomes of the disease process. Each category yielded between one and seven themes. Themes identified included physical, psychological, relationship, and employment aspects.

CONCLUSIONS

Patient's reported quality of life was significantly affected by their disease and recovery. The results demonstrate that many outcomes of importance for patients are not easily assessed by traditional measures of outcomes. This work illustrates the multidimensional nature of recovery from critical illness, and shows that it represents a massive transition period in the lives of survivors that affects the patient, their family, and the patient's ability to interact with society. Interviews with survivors ensure that the patient voice is heard before developing tools to assess long-term outcomes.

Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death

Background

Subcutaneous emphysema is an uncommon clinical finding associated both with benign sources and potentially deadly necrotizing infections. Wide ranges of causes exist including trauma, iatrogenic injuries, factitious disorders and necrotizing infections.

Case presentation

A 49-year old male presented to the emergency room with extensive subcutaneous emphysema following blunt trauma. The orthopaedic surgery service was consulted for treatment of suspected necrotizing fasciitis due to his subcutaneous emphysema. A careful patient history and physical examination correlated with laboratory and radiographic findings revealed rib fractures and a long-standing, undiagnosed pneumothorax as the cause for emphysema. Treatment of the underlying condition with chest tubes led to eventual resolution of the emphysema, though multisystem organ failure ultimately resulted in patient death.

Conclusion

This case illustrates the importance of rapidly and appropriately evaluating trauma patients, and in this case specifically diagnosing and treating the underlying cause of subcutaneous emphysema. The late diagnosis of pneumothorax resulted in delayed definitive treatment, which may have contributed to the patient’s ultimate demise. In acute and sub-acute trauma situations a high level of suspicion for life threatening injuries must be maintained. Decision making for initial treatment should be based on the basic tenants of Advanced Trauma Life Support to primarily address these injuries and help prevent further disability or death.