Correspondence
Clinical Problem-Solving: Necrotizing Fasciitis
N Engl J Med 1994; 331:279-280July 28, 1994
- Article
To the Editor:
Magnetic resonance imaging (MRI) of the extremity can be particularly useful in delineating a collection of inflammatory fluid at the interface of muscle and fascia in areas of necrosis. Why was MRI not performed in the patient described in the March 3 Clinical Problem-Solving article,1 especially since the information obtained might have allowed earlier treatment with less tissue loss? The patient had cellulitis in the calf, according to the description. If it remained below the knee, why did the surgeon not consider an open, below-knee amputation with debridement of necrotic fascia? In some cases of sepsis of the leg, it is possible to salvage the knee for a functional amputation by delaying wound closure of debrided muscle over the tibia, with skin grafting of the stump. The description of the vascular supply to the calf suggests that if the fasciitis did not involve the main neurovascular bundles of the leg, this might have been an option.
1 ReferencesJeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 011991
Thibault GE . Desperate appliance. N Engl J Med 1994;330:623-626
Full Text | Web of Science | Medline
To the Editor:
The Clinical Problem-Solving feature in the March 3 issue came at an opportune time for a renal-transplant recipient of ours.
A 64-year-old man was receiving immunosuppressive therapy after having received a cadaveric renal transplant in 1987. In April 1994 he presented with fever, chills, pain, and tenderness in the left calf, along with a thin erythematous area over the anterior aspect of the same calf. Within 12 hours, the patient was in shock and his calf had become exquisitely tender, edematous, and gangrenous to an area just below the knee. All pulses were palpable. At this stage the diagnosis was uncertain, but fortunately one of us had seen the description of necrotizing fasciitis in the Journal article and called it to the attention of the others. The article stressed the need for early and aggressive surgical therapy, in combination with appropriate antibiotic therapy.
Twelve hours later the patient's leg was worse, with spread above the knee. Blood cultures grew group A streptococcus, and there was laboratory evidence of disseminated intravascular coagulation. The patient's hemodynamic status improved overnight, and a decision was made to amputate the leg above the knee. We thought that to perform debridement and possibly fasciectomy and myectomy in this immunosuppressed patient was to invite secondary infection. One day after operation, the patient was much improved. His blood pressure was normal, and the stump looked healthy. Despite persistent hypoalbuminemia (1.6 g per deciliter) and acute pulmonary congestion 10 days after amputation, the patient is feeling stronger every day. Histopathological examination of the amputated leg revealed large numbers of gram-positive cocci, separation between the epidermis and the dermis, severely edematous fascia, widespread myolysis, and small-vessel thrombi. We hope that our patient will recover fully and succeed in a rehabilitation program in the near future. The Clinical Problem-Solving article and the reading it generated made a very difficult decision easier for us, and the Journal thus served one of its primary purposes.
Asher Korzets, M.B., B.S.
Eytan Cohen, M.D.
Izhar Zahavi, M.D.
Hasharon Hospital, Petah-Tiqva 49372, IsraelAuthor/Editor Response
Dr. Thibault replies:
To the Editor: Dr. Kaufman makes pertinent observations about the management of necrotizing fasciitis of the lower extremity. MRI was not available in the institution where the patient was cared for, and his condition was deemed too unstable to allow transfer. By the time of surgery the necrotic area had extended above the knee; hence, a higher level of amputation was required. The point raised by Dr. Kaufman is that the sooner a diagnosis is made in the course of an illness, the better the surgical result -- both in terms of mortality and preservation of function.
With regard to the experience of Dr. Korzets and his colleagues, I am delighted that the description and analysis of our patient led to appropriate and timely action in theirs.
George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132- Citing Articles (1)
Citing Articles
1
Richard F. Edlich, Catherine L. Cross, Jill J. Dahlstrom, William B. Long. (2010) Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis. The Journal of Emergency Medicine 39:2, 261-265
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