Abstract
Background
Myonecrosis can rapidly develop in soft tissue necrotizing infections, often with initial sparing of the skin. Despite the improvements in management of necrotizing soft tissue infections, mortality remains high, according to the location, microbial agents and comorbidities, ranging between 17 and 46 %. A prompt diagnosis represents the greatest challenge for the emergency physician.
Case report
We describe the case of a patient with a history of hypertension and arrhythmia who developed nonclostridial necrotizing fasciitis with extensive myonecrosis, after articular infiltration procedure. A bedside focused ultrasonography (US) revealed disappearance of the regular fibrillar architecture of the long head of biceps muscle, with diffuse abnormal hyperechogenicity assembled in a “clod pattern”. Computed tomography (CT) of the right arm did not depict muscle involvement, but showed a small gas collection around the shoulder, spreading to the subclavian region behind the major pectoral muscle. Necrotizing fasciitis with wide myonecrosis was confirmed by surgical debridement. Microbiological results showed a Staphylococcus aureus infection, managed by a selected antibiotic therapy. The patient was discharged after a small period of mechanical ventilation.
Conclusion
This is the first report of a previously healthy patient developing a nonclostridial necrotizing fasciitis with extensive myonecrosis attributable to infiltrative procedure and detected early by bedside US in emergency department. The role of bedside US in the emergency setting may save time for the prompt management of life-threatening necrotizing infections.
Riassunto
Introduzione
La mionecrosi può rapidamente svilupparsi come conseguenza di un’infezione necrotizzante dei tessuti molli superficiali. Nonostante i miglioramenti nelle cure delle infezioni necrotizzanti dei tessuti molli, la mortalità resta alta (tra il 17% ed il 46%), dipendendo da localizzazione dell’infezione, agenti responsabili e comorbidità. Una diagnosi precoce è il punto chiave e rappresenta una grande sfida per il medico d’urgenza.
Descrizione del caso
Descriviamo il caso di un paziente presentatosi in Pronto Soccorso per febbre e dolore al braccio dx, trattato in precedenza senza beneficio con antiinfiammatori ed infiltrazioni locali, e successivamente con antibiotici. In presenza di segni di infezione dei tessuti molli superficiali, veniva eseguita dal medico d’urgenza un’ecografia clinica (“bedside”), che documentava la scomparsa della regolare architettura fibrillare del muscolo bicipite del braccio destro, con una iperecogenicità anomala e diffusa disomogeneità della ecostruttura, che appariva assemblata a zolle; coesisteva una minima raccolta fluida lungo il piano fasciale distalmente. La TC del braccio destro non mostrava il coinvolgimento muscolare, ma evidenziava una piccola quota di gas intorno alla spalla. Una fascite necrotizzante con estesa mionecrosi veniva confermata dall’intervento chirurgico. L’esame microbiologico documentava infezione da Staphylococcus aureus, per cui si impostava terapia antibiotica mirata. Il paziente veniva dimesso dopo breve ciclo di ventilazione meccanica assistita e ricovero in rianimazione.
Conclusioni
E’il primo caso descritto di un paziente con fascite necrotizzante con mionecrosi non da clostridio, successiva a infiltrazione locale, diagnosticata precocemente tramite un’ecografia “bedside” in Pronto Soccorso. L’ecografia “bedside” si conferma presidio accurato e tempestivo nella gestione di condizioni potenzialmente fatali come le infezioni necrotizzanti dei tessuti molli.
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Conflict of interest
The authors, Americo Testa, Rosangela Giannuzzi, and Valeria De Blasio, declare no competing interest.
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Patient informed consent was received according to ethical standards, and he was assured that all pictures would be anonymized.
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Testa, A., Giannuzzi, R. & De Biasio, V. Case report: role of bedside ultrasonography in early diagnosis of myonecrosis rapidly developed in deep soft tissue infections. J Ultrasound 19, 217–221 (2016). https://doi.org/10.1007/s40477-015-0155-4
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DOI: https://doi.org/10.1007/s40477-015-0155-4