Images in Clinical Medicine
Severe Soft-Tissue Infection
N Engl J Med 2008; 358:940February 28, 2008
- Article
A 65-year-old woman with a 15-year history of diabetes presented with fever (temperature, 38.5°C), chills, malaise, and a rash on the medial surface of the right thigh, vulva, and lower abdominal wall (Panel A). The symptoms had progressed during the previous 48 hours. Three days earlier, she had visited a general practitioner for recurrent vulvar pruritus accompanied by excoriation due to scratching. A yeast infection was diagnosed, and she was treated with a topical antifungal agent. On admission, the physical examination revealed crepitus of the abdominal wall, with no vaginal discharge or evidence of a perianal abscess. Laboratory results included a white-cell count of 13,900 per cubic millimeter and a fasting serum glucose level of 390 mg per deciliter (22 mmol per liter). Computed tomography of the abdomen showed gas dissecting along the perineum into the right thigh and bilateral flank regions (Panel B, arrows). The diagnosis of a necrotizing soft-tissue infection was made. Aggressive fluid resuscitation, broad-spectrum antibiotics, and insulin were administered. The patient underwent extensive surgical débridement and reconstructive surgery. Enterococcus species, streptococci of the viridans group, bacteroides species, and Escherichia coli were isolated from cultures. The patient had a response to aggressive therapy and was discharged 3 weeks later. She returned for outpatient consultation at the plastic-surgery and diabetes clinics. At her last visit, she had completely recovered and was continuing to receive oral antidiabetic agents.
Fone-Ching Hsiao, M.D.
Chang-Hsun Hsieh, M.D.
Tri-Service General Hospital, Taipei 114, Taiwan
m10959@ms94.url. com. tw
