Necrotizing Fasciitis in COVID-19 Patient: A Case Report of Atypical Early Presentation

A 48-year-old male, known to have hypertension (HTN), ischemic heart disease (IHD) post-percutaneous coronary intervention (PCI) before one year, and morbid obesity (BMI: 60), presented to the emergency department complaining of right thigh pain and swelling that started two days before. The swelling got increasingly worsen over the previous days, associated with dyspnea, for which he sought medical attention in another hospital. He was found to have a picture of sepsis where they offered him irrigation and debridement (I&D) but he refused and presented to our institution in a hemodynamically unstable condition. The patient underwent immediate surgery with subsequent intensive care unit (ICU) admission as a case of necrotizing fasciitis complicated by sepsis. Later he was found to have coronavirus disease 2019 (COVID-19) infection.

"Stocking Pattern Metabolic Captivity" of Legs on 18 F-FDG PET-CT in Necrotizing Fasciitis: Potential Complimentary Role in Differential Diagnosis and Assessment of Disease Extent in a Life-Threatening Condition

A rare and fatal life-threatening case of necrotizing fasciitis (initially presenting with skin-deep superficial lesions and clinical suspicion of paraneoplastic syndrome) is described, who was finally diagnosed with the help of fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) as more extensive infectious process. A 36-year-old male presented with bilaterally symmetrical cutaneous lesions involving lower limbs that rapidly progressed to ulcerative lesions and pancytopenia. In view of suspicion of paraneoplastic manifestation, the patient underwent ¹⁸ F-FDG-PET/CT to rule out any underlying malignancy. The FDG-PET/CT findings confirmed hypermetabolism circumferentially along the fasciae of bilateral lower extremities while sparing muscles and subcutaneous fat from below the knee till toe with diffused hypermetabolic marrow, and no evidence of focal disease suggesting malignancy. Biopsy turned out to be superficial necrolytic fasciitis. The patient's condition deteriorated and, 20 days following the scan, the patient succumbed secondary to severe pancytopenia and hypotension. The case raises the importance of high degree of suspicion and prompt diagnosis of this condition, where FDG-PET/CT imaging can play a valuable complimentary role. Such awareness could be lifesaving due to early optimal treatment in the disease course.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.