A 70-Year-Old Man With Severe Hand Pain, Part 1

Correct answer: A. Early and aggressive surgical debridement of the affected area.

Discussion. Although the presented case initially seemed like a trivial soft-tissue infection, it quickly devolved into a very serious life- and limb-threatening situation. There are some clues that point to a specific treatment option. First, the severe pain was very out of proportion to the physical findings. Next, there was the concomitant systemic toxicity, as well as an interesting history of exposure.

Looking at the infection, the deterioration of the apparent small, innocuous wound is a very strong clue to the presence of a necrotizing soft-tissue infection. This is a surgical diagnosis characterized by friability of the superficial fascia, gray necrotic exudate, and the absence of pus.¹ A wide variety of wounds can degenerate into a necrotizing infection, including major penetrating trauma, saltwater laceration, mucosal breach as with rectal, vaginal, gastrointestinal or genitourinary surgeries, infected pustules/vesicles, insect bites, and diabetic/peripheral vascular disease ulceration.¹

There is also a microbial schema of classification. Necrotizing fasciitis Type I is polymicrobial (Fornier's gangrene of the perineum with mixed aerobic and anaerobic, for example) while necrotizing fasciitis Type II is mono-bacterial (Group A streptococcal USA 300). Beside the microbial differentiation, as a rule, Type I involves older patients with some form of significant underlying situation-post-surgery, diabetes, or impaired circulation. Type II, however, occurs in any age group and without apparent underlying disease.¹

The key to timely and accurate diagnosis is an informed suspicion based upon several clinical findings. First, is the underlying post-surgical demographic, presence of a penetrating wound, and exposure to brackish water. Next, and importantly, is the presence of a sick patient with signs and symptoms out of proportion to the physical and radiologic findings.¹ These patients have seemingly innocuous wounds, yet are in severe pain, requiring narcotics. They will be ill and toxic with significant tachycardia and hypotension. But the most common signs are redness and swelling. Ultimately, the tell-tale findings of necrotic area (bullae and gas) will manifest but this is often late in the illness.² Radiologic findings (Answer D) including CT and MRI, are also late in manifesting gas in the tissues and/or hyperintensity of intramuscular fascia, which mandates immediate surgical evaluation when present.^1,2

Once any constellation of findings discussed above are encountered, the next steps are prompt surgical exploration and aggressive debridement of the affected area. The key words here are “prompt” and “aggressive.” There is no role for needle aspirations. Rather, serial surgeries with daily debridement are usually required. As to how we define "prompt," there is good data showing that delays cost limbs and lives. Odds of survival increases when surgery occurs within 24 hours of admission compared to delay of more than 24 hours, with even better outcomes with surgery within 6-8 hours.³ In short, when necrotizing fasciitis is suspected, do not wait for blood or tissue cultures, do not wait for findings of bullae or gas on exam or radiology, and do not wait for antibiotics to have effect of hyperbaric oxygen therapy. Early and aggressive surgical exploration and debridement is indicated. This syndrome kills and causes amputation (29% in Group A streptococci infections⁴ and up to 40% in vibriosis cases).⁵

Most patients presenting with wounds and toxicity, whatever the demographic background and findings, will be placed on a broad spectrum of antibiotics, and this is proper. However, antibiotics are not sufficient therapy for necrotizing infections. There must be surgical debridement for survival, amputation prevention, and cure. Risk factors and specific exposures will dictate which antibiotics should be put in place (penicillin and clindamycin for suspected Group A strep, doxycycline and cephalosporins for vibriosis).^1,6 However, they will not cure the infection and clinicians should not delay surgery waiting for a response, so Answer C is incorrect. Similarly, although hyperbaric therapy seems a good idea, arrangements for this are cumbersome and will take time and most studies have not shown significant efficacy in any event¹ making answer B also incorrect. It should be noted that surgical debridement also will yield good material for gram stain and culture/sensitivity, so the precise proper antibiotics can be put in place.

Patient follow-up. The local urgent care physicians were aware of the vibriosis risk in their region. They fluid-resuscitated the patient, initiated IV cephalosporin and doxycycline antibiotics, a suggested regimen, and arranged for transfer to a regional center. Once there, he was immediately taken to the operating room for exploration and debridement, which revealed local findings of necrotizing fasciitis with necrosis. Material also yielded culture positivity for vibrio vulnificus infection. He required several subsequent surgical procedures but improved both systemically and locally. He was discharged on Day 9 afebrile and well with a slowly healing wound with minimal tissue loss. He was cautioned to avoid eating raw oysters and exposure to brackish warm water environments in the future.

What’s the Take Home? Necrotizing fasciitis soft tissue infections are a serious limb and life-threatening infection. A variety of organisms are potentially causative including Group A Streptococci, mixed aerobic and anaerobic infection, and vibriosis, each with their unique demographics and risk factors. There are several key findings that are clues to the presence of necrotizing fasciitis, the best of which are the presence of severe, unrelenting narcotic requiring pain in the affected area and systemic toxicity both out of proportion to local findings in the involved area. Eventually, fever, more specific skin lesions (bullae, necrotic areas), and hypotension manifest. Imaging, especially MRI, may occur but only late in the process and should not be regarded as required before starting therapy. Of course, antibiotics are indicated, but the life and limb saving maneuver is early (less than 24 hours), aggressive, and extensive surgical exploration and debridement.

AFFILIATIONS
¹Lewis Katz School of Medicine at Temple University, Philadelphia, PA
²Department of Medicine, Temple University Hospital, Philadelphia, PA

CITATION
Rubin RN. A 70-year-old man with severe hand pain . Consultant. 2024;64(6):e5. doi:10.25270/con.2024.06.000003

DISCLOSURES
The author reports no relevant financial relationships.

CORRESPONDENCE:
Ronald N. Rubin, MD, Temple University Hospital, 3401 N. Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

References

1. Stevens DL and Bryant AE. Necrotiing soft tissue infections. N Eng J Med. 2017; 377: 2253-2265
2. Alayed KA, Tan C, Daneman N. Red flags for necrotizing fasciitis: a case controlled study. Int J Infect Dis. 2015;36:15-20.
3. McHenty CR, Piotrowski JJ, Petrinic D, Melangone MA. Determinants of mortality for necrotizing soft tissue infections. Ann Surg. 1995:221:558-563.
4. Stevens DL,Tanner MH, Winship J, et al. Severe Group A streptococcal infection associated with a toxic shock-like syndrome and scarlet fever toxin A. N Eng J Med. 1989:321:1-7.
5. Chai WN, Tsai CF, Chang HR, et al. Impact of timing of surgery on outcome of vibrio vulnificus related necrotizing fasciitis. Am J Surg. 2013; 206:32-39
6. Liu JW, Lee IK, Tang HJ, et al. Prognostic factors and antibiotics in vibrio vulnificus septicemia. Arch Int Med. 2006;166: 2117-21

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