Rough Game of Golf

A 26 year-old morbidly obese otherwise healthy male presents with chief complaint of constipation. The patient states he has been unable to have a bowel movement for the past 5 days nor has been passing gas. He reports taking a couple over-the-counter laxatives as well as Miralax prescribed to him by an urgent care provider 2 days ago but still has not been able to have a bowel movement. He also reports self-induced vomiting 3 days ago in order to "get relief." He denies a history of prior abdominal surgery or prior constipation. 

His other symptoms include mild right upper quadrant pain and worsening shortness of breath with exertion that was especially noticeable during an 18-hole game of golf a week and a half ago. On further questioning he admits that he can no longer walk up a flight of stairs or tolerate lying flat for prolonged periods of time. He denies having any chest pain. He denies fever, chills, cough, swelling, weight changes, or recent travel. 

EXAM

Vital signs: T 37.2 | BP 124/73 | P 105 | R 20 | SaO2 100% on room air 

On exam the patient is a young morbidly obese Caucasian male with moderate diaphoresis of the face and neck and mild tachypnea. Hearts sounds are slightly muffled with no murmurs, gallops or rubs detected. Breaths sounds are clear bilaterally. Abdomen is soft and nontender. Extremities are cool with 1+ peripheral pulses and no evidence of peripheral edema. 

DIAGNOSTIC TESTS

An abdominal series was obtained and is shown below: 

What is the diagnosis?

How would you manage this patient? 

Please leave a comment below and share your thoughts. 

The diagnosis for this case will be posted in approximately 1 week.

Diagnosis: Gas Gangrene

A CT scan with contrast of the patient's left arm showed significant subcutaneous air consistent with diagnosis of acute soft tissue necrotizing fasciitis of the left upper extremity. The patient was started on IV antibiotic therapy including Vancomycin, Zosyn and Clindamycin and an emergent surgical consult was obtained. The patient was rushed to the OR where the diagnosis of necrotizing fasciitis was confirmed.

In the OR the patient underwent extensive excision of skin and subcutaneous tissue with a total area of 220 cm^2 of soft tissue removed. Intra-operative cultures grew Clostridium perfringens susceptible to multiple antibiotics. The patient's antibiotics were tailored to IV Zosyn monotherapy and he did well post-operatively. The patient was discharged in stable condition on hospital day 10 with in-home health wound care services. 

Necrotizing Fasciitis - Rapid Fire 

• Type 1 nec fasc = polymicrobial (most cases) 
• diabetics 
• immunocompromised 

• Type 2 nec fasc = single organsim  
• group A beta-hemolytic strep (most common) aka "flesh-eating bacteria"
• other bugs: Staph aureus, Enterococci, Enterobacteriaceae 
• anaerobes: Bacteroides, Clostridium

• Caused by direct extension from skin in 80% of cases 

• Exotoxins destroy tissue, contribute to shock, cause intravascular hemolysis and DIC

• Fournier's gangrene = nec fasc of perineum
• polymicrobial
• urgent urology consult because infection is rapidly progressive 

• Gas gangrene = clostridial myonecrosis
• crepitus on exam though nonspecific
• traumatic form (more common, think war wounds) 
• spontaneous form (rare) 

• History may include: 
• penetrating trauma
• recent surgery
• IV drug use
• childbirth 

• Presentation
• initial symptoms can be vague (malaise, fever, myalgias, nausea, diarrhea) 
• may appear as simple cellulitis but with pain out of proportion
• skin eventually turns violaceous and ecchymotic (late finding)
• hemorrhagic bulla (late finding)  
• classic "wooden-hard" subcutaneous tissue = deep tissue inflammation

• Lab findings
• hyponatremia and leukocytosis are suggestive but nonsensitive/nonspecific

• Diagnosis 
• for ED MD diagnosis must be clinical 
• pain out of proportion, crepitus, free air on imaging, leukocytosis, etc
• intra-operative evidence of deep tissue infection necessary for official diagnosis

• Management
• urgent surgical consult if suspected
• antibiotic therapy 
• broad-spectrum beta-lactam --> Zosyn, Unasyn, Cefepime
• Vancomycin --> MRSA coverage
• Clindamycin --> disrupts group-A strep exotoxin production 
• definitive management is surgical (fasciotomies, repeated debridement)
• efficacy of hyperbaric oxygen therapy is unclear  

• 20% mortality rate means you can make a difference

References: 

Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 137: Skin and Soft Tissue Infections by Daniel J. Palin and Denise Nassisi

Spider Bite

A 48 year-old male with history of borderline diabetes mellitus presents with chief complaint of left forearm pain and swelling with redness. He reports the pain and redness came on insidiously over the past 4 days and has been getting progressively worse. The patient states he thinks a spider bit him. He became more concerned when he noticed the redness on his arm was spreading over the last 24 hours. He denies having any fevers or chills. He denies any trauma to the area that he can remember. He denies any current or prior history of IV drug use. He denies taking any prescription medications. The patient works as a warehouseman in a shipyard.

Vital signs are stable. On exam the patient appears nontoxic and in no acute distress. Examination of his left proximal forearm reveals a 5x3 cm ovoid area of warm tender erythema and swelling. No fluctuance or crepitus are appreciated. He his able to fully range his left elbow without any pain. 

A CT scan with contrast of the left forearm was obtained. 

What is the diagnosis?

How would you manage this patient? 

Please leave a comment below and share your thoughts. 

The diagnosis for this case will be posted in approximately 1 week.