Sun17October0936AM 4

A 27-year-old man presents with cellulitis in his left lower limb. He had been started on oral antibiotics by the GP earlier that day, but has presented to the Emergency department with continued pain despite analgesia, swelling and rapidly spreading erythema.

On examination he is pyrexial at 38.5°C and tachycardic at 110/min. Blood pressure and oxygen saturations are stable.

He sustained a traumatic injury to the leg a week ago following a rugby match and this may well be the portal of entry. The leg is erythematous spreading from the ankle to above the knee; the area has been demarcated. It is tender on palpation and warm to touch. There is no obvious area of collection but there is a pus filled blister.

He is otherwise fit and well with no past medical history. He has been commenced on clindamycin. An x ray of the leg confirms that there is no osteomyelitis.

Blood test results are as follows:

Hb 166 g/L

WCC 23 ×109/L

Plts 569 ×109/L

U&E normal

LFTs normal

Blood glucose 6 mmol/L

Lactate 5 IU/L

HIV negative

Which of the following would be the most appropriate course of action in this case?

(Please select 1 option)

Add antifungal agent

Surgical review Correct

Administer fluid challenge

ITU review

Swab the wound

Explanation

This patient may well be suffering with a necrotising fasciitis. It is important to act quickly and to treat this as a medical emergency in order to reduce morbidity and mortality. The raised lactate in this man is a big clue, indicating tissue necrosis.

Necrotising fasciitis, though uncommon, requires a high degree of clinical suspicion in order to be diagnosed early and to avoid the potential loss of a limb. Severe pain, swelling, fever and tachycardia are all initial presenting clinical features. Blistering and crepitus are common.

Common organisms associated with this condition include:

Staphylococcus aureus

group A Streptococcus (pyogenes)

Clostridium perfringens, and

methicillin-resistant staphylococcus aureus (MRSA).

One should look for underlying immunocompromisation, such as diabetes, HIV or malignancy. Sites of trauma are also usual sites for the infection to present.

A CT scan can help to determine the tissue necrosis, though a plain x ray will usually confirm findings of gas in the soft tissue. Surgical debridement alongside antibiotics is the treatment of choice and involving the surgeons early is essential.

Due to the nature of progression, ITU involvement would also be pertinent.

Answer Statistics

1

1%

2

79%

3

14%

4

1%

5

6%

Times answered: 254