AHRQ WebM&M: Morbidity and Mortality Rounds on the Web
Cases & Commentaries
Spotlight Case: Pitfalls in Diagnosing Necrotizing Fasciitis
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis. The commentary by Terence Goh, MBBS, of Singapore General Hospital, and Lee Gan Goh, MBBS, of the National University Health System of Singapore, reveals the challenges in diagnosing necrotizing fasciitis and how enhanced awareness and education can prevent errors. (CME/CEU credit available.)
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis. The commentary by Terence Goh, MBBS, of Singapore General Hospital, and Lee Gan Goh, MBBS, of the National University Health System of Singapore, reveals the challenges in diagnosing necrotizing fasciitis and how enhanced awareness and education can prevent errors. (CME/CEU credit available.)
Pitfalls in Diagnosing Necrotizing Fasciitis 
Commentary by Terence Goh, MBBS, and Lee Gan Goh, MBBS
A 49-year-old previously healthy man presented to the emergency department (ED) after falling from his truck at work 3 days before. He had gone to a different ED the day prior with diffuse pain on his left side (the side of his impact) and was given nonsteroidal anti-inflammatory medications and sent home. He presented to this new ED with persistent and worsening left arm, chest, abdomen, and thigh pain.
On physical examination, he was afebrile but tachycardic. He had diffuse, tender ecchymoses involving his left shoulder, upper chest, lateral abdomen, and thigh. Although the ED physicians felt he had simple bruising from the fall, they noted that he was in severe pain requiring intravenous (IV) opiates and that he was unable to independently ambulate. Because of these symptoms, blood tests were obtained and results showed a white blood cell count of 2.8 × 109/L (normal range: 3.5–10.5 × 109/L) and acute renal insufficiency with a creatinine of 1.4 mg/dL (normal range: 0.6–1.2 mg/dL). A computed tomography scan of the abdomen and pelvis showed "induration in the left quadriceps muscle and fluid layering in the abdominal wall." He was seen by the trauma surgical service, who felt the findings were due to diffuse bruising. The patient was admitted to an internal medicine service.
Due to ED crowding, he remained in the ED overnight, receiving only IV fluids and opiates for his pain. Over the course of the night, his pain worsened and he had a persistent tachycardia. Early morning lab results showed a white blood cell count of 1.6 × 109/L, a creatinine of 1.6 mg/dL, a creatine kinase of 2650 U/L (normal range 55–170 U/L) (evidence of muscle breakdown), and a lactate of 6.2 mg/dL (normal range 0.5–2.2 mmol/L) (evidence of tissue hypoxia). He was seen by the internal medicine team mid-morning and diagnosed with rhabdomyolysis from trauma and acute renal failure. He continued to receive IV fluids. His pain had become so severe that he was switched to hydromorphone hydrochloride, administered through a patient-controlled analgesia pump.
Later that day, the patient had progressive respiratory distress and developed septic shock. He was re-evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis. He was urgently taken to the operating room, where he required debridement of 7300 cm/sq (an area roughly 2 ft by 4 ft) of skin and soft tissue from his left arm and axilla, anterior chest wall, abdominal wall, thigh, and leg.
After surgery, he was progressively hypotensive despite multiple vasopressors. He developed multi-organ dysfunction and ultimately, after discussions with his family, care was withdrawn and he died peacefully. He underwent autopsy, which showed necrotizing fasciitis with pyomyositis secondary to methicillin-resistant Staphylococcus aureus.
On physical examination, he was afebrile but tachycardic. He had diffuse, tender ecchymoses involving his left shoulder, upper chest, lateral abdomen, and thigh. Although the ED physicians felt he had simple bruising from the fall, they noted that he was in severe pain requiring intravenous (IV) opiates and that he was unable to independently ambulate. Because of these symptoms, blood tests were obtained and results showed a white blood cell count of 2.8 × 109/L (normal range: 3.5–10.5 × 109/L) and acute renal insufficiency with a creatinine of 1.4 mg/dL (normal range: 0.6–1.2 mg/dL). A computed tomography scan of the abdomen and pelvis showed "induration in the left quadriceps muscle and fluid layering in the abdominal wall." He was seen by the trauma surgical service, who felt the findings were due to diffuse bruising. The patient was admitted to an internal medicine service.
Due to ED crowding, he remained in the ED overnight, receiving only IV fluids and opiates for his pain. Over the course of the night, his pain worsened and he had a persistent tachycardia. Early morning lab results showed a white blood cell count of 1.6 × 109/L, a creatinine of 1.6 mg/dL, a creatine kinase of 2650 U/L (normal range 55–170 U/L) (evidence of muscle breakdown), and a lactate of 6.2 mg/dL (normal range 0.5–2.2 mmol/L) (evidence of tissue hypoxia). He was seen by the internal medicine team mid-morning and diagnosed with rhabdomyolysis from trauma and acute renal failure. He continued to receive IV fluids. His pain had become so severe that he was switched to hydromorphone hydrochloride, administered through a patient-controlled analgesia pump.
Later that day, the patient had progressive respiratory distress and developed septic shock. He was re-evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis. He was urgently taken to the operating room, where he required debridement of 7300 cm/sq (an area roughly 2 ft by 4 ft) of skin and soft tissue from his left arm and axilla, anterior chest wall, abdominal wall, thigh, and leg.
After surgery, he was progressively hypotensive despite multiple vasopressors. He developed multi-organ dysfunction and ultimately, after discussions with his family, care was withdrawn and he died peacefully. He underwent autopsy, which showed necrotizing fasciitis with pyomyositis secondary to methicillin-resistant Staphylococcus aureus.
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