Case history

Case history

A 35-year-old woman is admitted to the hospital because of pain and swelling of the right thigh. The patient has been in excellent health until the morning before admission, when she observed a pimple 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 99.5°F (37.5°C), pulse is 128 bpm, and respirations are 20 breaths/minute. BP is 85/60 mmHg. On physical examination, the patient appears ill 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 because of pain and reports pain on passive extension of the right ankle. The temperature soon rises to 101°F (38.4°C), and the BP drops to 70/40 mmHg. Hematocrit is 42, WBC count 5900/mm³ (with 64% neutrophils, 19% band forms), serum creatinine 1.9 mg/dL, and BUN 22 mg/dL. Contrast-enhanced computed tomography shows a diffuse, nonenhancing, 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

Necrotizing fasciitis should be considered in a patient with cellulitis who also has systemic symptoms and signs such as hypotension, tachycardia, tachypnea, nausea, vomiting, or delirium. The area of cellulitis may be either severely and constantly painful (disproportionate to skin findings) or, conversely, anesthetic. Examination of the skin overlying the area of cellulitis may reveal underlying induration extending beyond the area of cellulitis, ecchymoses, vesicles, bullae, grayish discoloration, or edema extending beyond erythema.[3]​ Crepitus may be noted on exam. Rapid extension of cellulitis despite the use of appropriate antibiotics should also raise suspicion for a necrotizing process. About half of cases occur in the extremities, with the remainder concentrated in the perineum, trunk, and head and neck areas.​​[1]​​​​​​[2][3][4][16]​[19]​[20]​

Atypical presentations include necrotizing fasciitis that occurs without an obvious overlying skin lesion (approximately 20% of cases), or that arise from a Bartholin gland or perianal abscess. Fournier gangrene is a form of type I necrotizing fasciitis that occurs in the perineum.​​​[1]​​​[5]​​[16]​

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