Necrotizing Fasciitis Case Study

Teri Billings, William Claytor, Krista Gagnon

Introduction

C. S. is a 33-year-old, married, African American male who presented to the ED for progressively worsening body aches, abdominal pain, and swelling and draining in the peri-rectal and perineal area. Patient stated he “developed a pimple on his buttocks a week ago and it broke open today”. Patient also stated his “weakness and pain have been worsening over the past week”. The only medical history consisted of hypertension and insulin dependent diabetes diagnosed four years ago, but patient reports he has not been taking insulin for at least one week. Patient is employed full-time and denies any family medical history, allergies, or alcohol, tobacco, or drug use. Patient was diagnosed with diabetic ketoacidosis (DKA) and peri-rectal abscess. Upon medical workup, patient was found to have necrotizing fasciitis / Fournier’s gangrene, so both infectious diseases and general surgeon were consulted.

Question 1: Explain the pathophysiology of necrotizing fasciitis? Give details about the cells involved. (4 points)

Question 2: Why is diabetes in the patient’s history a risk factor for necrotizing fasciitis, and how does diabetes compound the problem? (3 points)

Question 3: What is the probable cause of the chief complaint of abdominal pain? Think about edema and the mediators released during inflammation and incorporate into your answer. (3 points)

Physical Assessment and Diagnostics

Review of Systems

C. S. complains of fever and chills. He denies sore throat, nasal drainage or visual changes. He denies chest pain or palpitations. He denies any cough, wheezing or shortness of breath. C. S. does complain of abdominal pain, but denies any nausea, vomiting, diarrhea, black or bloody stools. He denies hematuria or dysuria. He also denies any rashes or easy bruising. C.S. does complain of swelling, pain, and redness in the perineal area. He denies any headache, syncope, near syncope or focal weakness. He denies any psychiatric or musculoskeletal problems. The remainder of a complete and careful review of systems is entirely negative and within normal limits.

Physical Exam

C. S. vital signs upon admission were: temperature 101.8, pulse 117, respirations 16, blood pressure 125/67, and oxygen saturation is 99% on room air. The patient’s general appearance is a well developed, well-nourished African American male in no apparent distress. His head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular motion is intact. There is no sclera icterus. Oropharynx is clear without lesion or exudates. Mucous membranes are moist. His neck is supple without mass, lymphadenopathy or JVD. His lungs are clear to auscultation bilaterally, without wheezes or crackles. His heart is regular, with tachycardia. No murmurs, gallops or rubs are noted. His abdomen is soft, nontender, with positive bowel sounds. His rectal/GU area revealed the presence of a left-sided peri-rectal wound with purulent drainage and confluent tenderness to palpation along theperineal area. His extremities are without clubbing, cyanosis, or edema. His skin is warm and dry, withoutrash or bruising. No neurological deficits are present. Patient moves all extremities. His speech is intact. Patient is awake and alert, somewhat flat affect, pleasant and cooperative.

Question 4: What is causing the fever and what are the systemic physiological effects of fever on the body? (3 points)

 

 Lab Results

Table 1

C. S.’s Abnormal Lab Results

 Test Result

WBC H 20.18

Hgb L 11.7

Hct L 35

Neutrophils % H 95

Lymphocytes % L 3

Neutrophil-Absol H 19.15

LymphocytesAbsolute

 

L 0.55

Sodium L 128

Carbon Dioxide L 21

Glucose H 485

FiO2 arterial 21 (room air)

pH arterial H 7.46

PCO2 arterial L 29

PO2 arterial L 76

HCO2 arterial L 21

O2 saturation 96%

Creatinine H 2.02

eGFR L 46

Hgb A1C H 12.2

CRP H 8.6

 

Clinical Course

Upon receiving the CT results, C. S. was taken for emergent surgery for debridement of peri-anal abscess and multiple intravenous antibiotics were administered. Two days later the patient was taken back to surgery for another debridement and creation of transverse, loop colostomy since the abscess had spread into the rectal tissues. He was then treated with hyperbaric oxygen therapy. During his third treatment of hyperbaric oxygen, within the first 24 hours, he experienced a rapid increase in heart rate, but no shortness of breath or physical complaints. An EKG was performed after the treatment and he was found to be in supraventricular tachycardia. After cardiac consult and echocardiogram, patient was found to have a patent foramen ovale. Furthermore, after returning to his room on the unit the patient’s wife reported the patient having mental status changes. A CT of the head was performed and discovered a left thalamic lacunar infarct. A patent foramen ovale is the number one cause of stroke in patients under the age of 55. On the third day of admission C. S. did go into renal failure from acute tubular necrosis possibly from sepsis, hypotension, and/or antibiotics. Patient therefore was placed on hemodialysis.

Question 5: What is your analysis of these abnormal lab results in relation to the pathophysiology of the patient’s disease process? What findings confirm necrotizing fasciitis? (3 points)

Question 6: Based on lab findings, what other complications need to be monitored? Why? (3 points)

Question 7: What is the standard treatment for necrotizing fasciitis? (3 points)

Question 8: Why is hyperbariatric therapy used for the treatment of necrotizing fasciitis? Explain the physiology and potential side effects of treatment. (3 points)

 

 Patient Response to Medical Intervention

The wound responded well to treatments. The wound bed was pink and granulating without signs of infection after debridements. Initial wound measurements per the surgeon were 20cm by 15cm. Upon discharge to the patient’s home, the wound measured 12cm by 5cm by 0.2cm. The patients WBC was  20.18 on admission and 11.55 at discharge. Neutrophil percentage dropped from a high of 95% to 79% at discharge. These findings indicate the patient is responding well to antibiotic therapy. His glucose went from a high of 485 mg/dl to a 143 mg/dl at discharge. BUN is stable at 18 and creatinine remains high at 5.22 mg/dl, however is down from 9.78 mg/dl from hemodialysis. The patient will remain on dialysis for an indeterminate amount of time.

Question 9: What wound care orders would be expected for home care? Incorporate knowledge from your lectures/readings on wounds to answer this question. (3 points)

 

Question 10: What discharge instructions should be given to facilitate a positive outcome? (2 points)

Attachments:

• 1505889081-Necrotizing Fasciitis Case Study.docx