Case history
Case history
A 35-year-old woman is admitted to hospital because of pain and swelling of the right thigh. The patient was well until the morning before admission, when she observed a spot on her right thigh. During the course of the day, the lesion enlarged, with increasing pain, swelling, and erythema, and was accompanied by nausea, vomiting, and delirium. Her temperature is 37.5°C (99.5°F), pulse is 128 bpm, and respirations are 20 breaths/minute. BP is 85/60 mmHg. On physical examination, the patient appears unwell and in pain. A small, indurated area of skin breakdown with surrounding erythema and warmth is present on the right thigh; no fluctuance is detected. She is unable to flex or extend the right hip without severe pain and reports pain on passive extension of the right ankle. Her temperature soon rises to 38.4°C (101°F), and BP drops to 70/40 mmHg. Haematocrit is 42, WBC count 5.9 x 109/L (with 64% neutrophils, 19% band forms), serum creatinine 168 micromol/L (1.9 mg/dL), and serum urea 7.8 millimol/L (22 mg/dL). Contrast-enhanced computed tomography shows a diffuse, non-enhancing, honeycomb pattern within the subcutaneous tissue of the right thigh. Subcutaneous stranding and thickening of the skin are prominent in the posterolateral aspect of the thigh; there is also thickening of the posterolateral deep fascia.
Other presentations
Necrotising fasciitis should be considered in a patient with cellulitis who also has systemic symptoms and signs such as hypotension, tachycardia, tachypnoea, nausea, vomiting, or delirium. The area of cellulitis may be either severely and constantly painful (disproportionately to skin findings) or, conversely, anaesthetic. Examination of the skin overlying the area of cellulitis may reveal underlying induration extending beyond the area of cellulitis, ecchymoses, vesicles, bullae, greyish discoloration, or oedema extending beyond erythema. Crepitus may be noted on examination. Rapid extension of cellulitis despite the use of appropriate antibiotics should also raise suspicion for a necrotising process. About half of cases occur in the extremities, with the remainder affecting the perineum, trunk, or head and neck.[1][2][3][4][5][16][19][20]
Atypical presentations include necrotising fasciitis that occurs without an obvious overlying skin lesion (approximately 20% of cases), or that arise from a Bartholin gland or perianal abscess. Fournier's gangrene is a form of type I necrotising fasciitis that occurs in the perineum.[1][16]
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