Journal: BMJ Case ReportsPaper: bcr-2012-007025Title: Necrotising soft-tissue infection The proof of your manuscript appears on the following page(s).
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Miguel F Carrascosa,1 Mariano Pérez Santamaría,2 José-Ramón Salcines Caviedes,1 Department of Internal Medicine, Hospital of Laredo, Laredo, Cantabria, Spain Service of Orthopedic and Traumatologic Surgery, Hospital of Laredo, Laredo, Cantabria, Spain Service of Radiology, Hospital of Laredo, Laredo, Cantabria, Spain Correspondence to Dr Miguel F Carrascosa, miguel.carrascosa@scsalud.es A 55-year-old woman presented with a 3-day history of progressively worsening pain, swelling and ‘unpleasant crackling feeling’ on her left upper limb. These complaints had begun after she noticed a small reddish lesion on her left elbow. The patient had received a diagnosis of sys- temic lupus erythematosus 15 years before coming to us and was taking methylprednisolone and acenocoumarol, the last for previous deep vein thrombosis associated with protein S deficiency. There was history of neither acute or chronic trauma nor diabetes (in the patient or in her family). She was allergic to penicillin. On admission, blood pressure and temperature were normal but heart rate was 99 beats/min. Her left upper extremity showed erythema, an elbow wound (figure 1), and generalised tense oedema and crepitus, the last also being evident on the ipsilateral supraclavicular region. Plain radiographs of the left upper limb and chest identified abundant sub- cutaneous gas (figure 2 and 3), a very specific finding of necrotising soft-tissue infection (NSTI). The patient was immediately started on intravenous clindamycin and vancomycin and then urgent, extensive surgical Plain radiographs revealing the presence of subcutaneous widespread gas in the left upper extremity (white arrows). ‘Dissection’ of muscular and other tissular structures by debridement of the necrotic tissue was performed. She afterwards received hyperbaric oxygen as an adjunct to operative procedure and antibiotics. Culture of several samples obtained from the necrotic tissue grew no micro- organisms. The postoperative course was uneventful and she was discharged on hospital day 11.
NSTI is infrequent but still remains a highly lethal dis- order.1 Some patients seem to be more prone to develop this condition, as those with diabetes mellitus, immuno- suppression, obesity and intravenous drug use.1 2 Other reported risk factors are age greater than 50 years, periph- eral vascular disease and chronic alcoholism.2 3 Although NSTIs are more commonly polymicrobial,1–3 the aetiology may remain unknown in some patients.1 Early and aggres- sive surgical debridement combined with empiric broad- spectrum antimicrobial therapy and physiological support Left elbow appearance on admission showing a are of paramount importance to increase the survival non-exudative, ulcerative lesion (arrow) with surrounded oedema and erythema (suspected portal of entry for the infection). The visible portion of the left upper extremity is swollen and BMJ Case Reports 2012; doi:10.1136/bcr-2012-007025 1. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis 2007;44:705–10.
2. Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med 3. Headley AJ. Necrotizing soft tissue infections: a primary care review.
Plain radiographs revealing the presence of subcutaneous widespread gas in the both ipsilateral hemithorax (thin black arrows) and supraclavicular area (thick black arrows).
Dissection’ of muscular and other tissular structures by the gas This pdf has been created automatically from the final edited text and images.
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Carrascosa MF, Santamaría MP, Caviedes J-RS, Gutiérrez P G. Necrotising soft-tissue infection. BMJ Case Reports 2012; Become a Fellow of BMJ Case Reports today and you can: Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact consortiasales@bmjgroup.com Visit casereports.bmj.com for more articles like this and to become a Fellow BMJ Case Reports 2012; doi:10.1136/bcr-2012-007025

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