Necrotizing fasciitis due to Serratia marcescens: case report and review of the literature

Different types of bullae of limbs with necrotizing fasciitis predict different outcome: a prospective study

Study objective

Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment.

Methods

From April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups.

Results

In total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N.

Conclusions

In southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.

Diagnostic Challenge of Necrotizing Soft Tissue Infection in a Patient With B Lymphocytic Leukemia

The necrotizing soft tissue infection is a rare surgical emergency. Early diagnosis and timely treatment can contribute to better survival and the preservation of the limb. Diagnosis of this pathology remains a challenge to the clinician at the initial stage of the disease, especially if the patient is immunocompromised. We present the case of a 75-year-old man with B lymphocytic leukemia who was diagnosed with necrotizing soft tissue infection but failed to exhibit typical clinical and laboratory measurements. This case highlights the difficulty of early diagnosis in hematology patient, altered sensitivity of disease-specific scoring systems, and importance of high clinician awareness.

Severe and Progressive Cellulitis Caused by Serratia marcescens Following a Dog Scratch

Soft tissue infections occur in over 30% of patients with chemotherapy-induced neutropenia. Gram-positive bacterial infections predominate early in neutropenia, and likelihood of infection by resistant bacteria and fungi increases with prolonged neutropenia. Prior infections and exposures influence the risk of rare pathogens. A 55-year-old woman with chemotherapy-induced neutropenia was scratched on her forearm by a dog. She cleaned the wound with isopropanol and was treated empirically with amoxicillin-clavulanate. Over the next 4 days, she developed fever along with erythema, edema, and mild tenderness of the forearm without purulence or crepitus. She was hospitalized and received empiric treatment with intravenous vancomycin, piperacillin-tazobactam, tobramycin, and voriconazole. Despite therapy, her fevers persisted and the cellulitis progressed for over a week. After 10 days of hospitalization, her neutrophil count began to recover and a bulla developed at the wound site. Culture of the bullous fluid grew Serratia marcescens, and antibiotics were switched to cefepime based on susceptibility. She defervesced and showed substantial improvement of cellulitis within 48 hours and was discharged on oral ciprofloxacin. Serratia marcescens skin infections are rare, and this may be the first report of Serratia cellulitis associated with trauma from dog contact. This case highlights the need to consider unusual pathogens based on exposure history and immune status and to obtain cultures from fluid collections or tissue in cases of treatment-resistant soft tissue infections.

An unusual location of squamous cell carcinoma and a rare cutaneous infection caused by serratia marcescens on the tumoral tissue: A case report

RATIONALE

Serratia marcescens (S. marcescens) is an opportunistic pathogen of the Enterobacteriaceae family. Although S. marcescens is known to cause sepsis, meningitis, endocarditis, urinary system and ocular infections, skin infections are sporadic. Squamous cell carcinoma (SCC) is the most aggressive skin cancer type that is often located in the head and neck region, and rarely in the scalp tissue.

PATIENT CONCERNS

An 89-years-old male patient was diagnosed with SCC three years ago. The frontal region of the skull showed an ulcerated tumor, irregular borders, and exophytic growth pattern. The destruction of the frontal bone made the vibrating brain tissue visible, and the lower part had haemopurulent flow.

DIAGNOSES

Gram staining showed the proliferation of gram (-) bacilli. Bacteria were identified as non-pigmented S. marcessens in the wound culture. To the best of our knowledge, there have not been any cases reported with S. marcescens causing cutaneous infections on SCC. Therefore, our report is the first case in the literature.

INTERVENTIONS

According to the culture antibiogram, S. marcescens was ciprofloxacin sensitive. Consequently, 1000 mg/day ciprofloxacin was initiated for 14 days.

OUTCOMES

Purulent exudate in skin cancers may be caused by the nature of carcinoma tissue as well as the colonization of opportunistic pathogen microorganisms as seen in our patient.

LESSONS

Examination of the wound cultures and elimination of infections are critical in these cases.