Necrotizing fasciitis (NF) is a life-threatening bacterial infection causing necrosis of the fascia, underlying skin, and vasculature. NF spreads rapidly, making immediate diagnosis important for survival. NF has gained media attention by its rapid progression, frightening 74% mortality, and high-risk of systemic toxicity [1]. Treatment may involve the administration of several broad-spectrum antibiotics, surgical debridement, and skin grafting. Here, we present a case of a 55-year-old patient he presented with bilateral chest swelling and oozing, chest pain, high grade fever and large area of cellulitis 10*10cm. Patient later becomes drawsy, tachypenic, hypotensive and desaturated so rapid elective intubation done after starting vassopressors infusion and patient was connected to mechanical ventilation. He required long time on mechanical ventilation till correction of sepsis, MODs, frequent wound debridement and myopathy.
Abstract
Introduction
Necrotizing
fasciitis (NF), a life-threatening bacterial infection causing necrosis of the
fascia, underlying skin, and vasculature. Typically, the infection begins
innocuously after minor trauma to the skin and may progress so rapidly as to
consume one inch of flesh each hour [2]. Group A Beta hemolytic streptococcus
(GABHS), is frequently identified in NF; however, the infection is commonly
polymicrobial in etiology [3]. After entry, the offending organism secretes
pyrogenic exotoxin A, beginning a cascade of events leading to eventual tissue
destruction. Exotoxin A stimulates the production of cytokines, damaging the
endothelial lining and leaking fluid into the extravascular space causing
diminished blood flow, tissue hypoxemia, and tissue death [4]. As vasculitis
and thrombosis occur in the adjacent tissues, further necrosis occurs involving
the subcutaneous nerves. Untreated, the tissue will become gangrenous within 4
to 5 days, sloughing by the second week and releasing toxins into the
bloodstream leading to sepsis and possible death within 24 to 96 hours. Other
complications adding to morbidity include disseminated intravascular
coagulopathy, respiratory failure, and multisystem organ failure [5].
Case Presentation
A 55-year-old
patient he presented with bilateral chest swelling and oozing, chest pain, high
grade fever and large area of cellulitis 50*30 cm. Later patient became very
critical and unstable (hypotensive, hypoxic, tachycardia and drawsy), immediate
resuscitative work done to stabilize patient condition, IVF, vassopressors and
mechanical ventilation started. On examination, pupils 2 mm reactive, blood
pressure 102/80 - with noradrenaline infusion 25 mcg/min, IVF NS 100 ml/H-
pulse rate 101 per minute SPO2 100%, temperature 39.5 celsius.
Dressing over both nipples with swelling to anterior chest wall. Left and right
upper limb, tense swelling more on the left site, no color change. Laboratory
findings revealed high lactate 8, CRP, PCT are very high aminotransferase,
urea, creatinine, PTT, INR impaired and low albumin level.
Patient underwent
multiple debridement of the chest wound which was deep and large and had
gangarenous tissues. Debridement was done under GA in OT and vaccum dressing
was applied over the wound. The wound improved by time and proper antibiotics
/feeding/ debrdement, the remaining challenge was myopathy which made the
patient to stay longer duration on mechanical ventilation. Weaning done later
successfully and the patient was extubated.
Figure 1: Chest X-Ray.
Figure 2: Bilateral pleural effusion.
Investigations
C-reactive protein
176.5 milligram / Liter, Alkaline Phosphatase 469 units / Liter, Alanine
Aminotransferase 50 units / liter, Aspartate Aminotransferase 146 units /
liter, Urea 22 Millimoles / liter, Creatinine 161 micromole / liter, (PCT)
33.74 microgram / liter, Platelets 137 10^3 / microliter, N-terminal pro B-type
natriuretic peptide (Pro BNP) 2718 pg/mlit, Lactate (lactic acid) 6.67
Millimoles / liter, Culture and Sensitivity specimen (Left breast) showed
moderate growth of Klebsiella pneumonia radiologically. Ultrasound of right and
left breast showed retroareolar edematous breast tissue with increased
vascularity likely to be acute mastitis.
Chest x-ray showed
endotracheal tube and nasogastric tube are seen in situ. Bilateral basal
atelectasis noted. Surgical emphysema is noted in bilateral lower lateral chest
wall.
Management
Patient was
diagnosed to have bilateral breast abscess necrotizing fasciitis, bilateral
pneumonia with respiratory failure, Septic shock, lactic acidosis, MODs and
hypoalbuminemia. Patient underwent wide debridement of the gangrenous tissue
anterior chest wall done under general anesthesia for repeated times. VAC
therapy application done under general anesthesia to facilitate wound healing,
then later removed. He was on mechanical ventilation and weaning was difficult
due to pectoralis muscles involvement bilaterally beside generalized organ
dysfunction, dyselectrolyteamia, and malabsorption.
Patient underwent
wound debridement and secondary closure of the anterior chest wall wounds done
under general anesthesia. Gradual weaning from mechanical ventilation after
wound closure and treatment of sepsis done. Proper nutrition using Parenteral
and enteral feeding modes help to rebuild his muscle tissue again and good
recovery. He stayed for about one weak on CPAP/PS mode before extubating.
Successfully patient extubated and shifted to normal ward for physiotherapy
(chest and limbs).
Psychological Issues
Psychological
consequences of NF result from intense discomfort, painful dressing changes,
and physical disfigurement and include emotions such as anxiety, fear, worry,
guilt, anger, and hopelessness. Nurses must provide holistic care for NF
patients because emotional conditions, such as depression and anxiety
disorders, can slow the healing process and lead to poor management of pain [6].
Patient was on continous remifentanyl infusion during his treatment course till
wound closure [7-11].
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