Abstract
Introduction:
Necrotising fasciitis is an infection of the deep soft tissues characterised by fulminant tissue destruction, systemic toxicity and high mortality. We report a case where accurate diagnosis, timely surgical intervention and antibiotic therapy along with strict glycemic control resulted in a favourable outcome.
Case:
A 74 year old woman with a history of type 2 diabetes mellitus, hypertension and end stage renal disease(ESRD) on peritoneal dialysis(PD) presented to the emergency department with the complaint of pain in the right lower quadrant of abdomen, right pelvis and right groin since 4 days which acutely worsened overnight. Of note the patient has Peritoneal catheter for dialysis and was last dialysed last night without any difficulty. Other associated symptoms were chills, nausea. The patient denied fever, skin changes in the affected area.
On physical examination, the patient was awake, alert and oriented, in moderate distress. Abdomen was soft, non distended, PD catheter was in place with no surrounding skin erythema or tenderness. Genitourinary examination showed swelling of Mons Pubis with overlying erythema on the right side with extension to the right labia majora, exquisitely tender to palpation, no crepitus, no pustules, no palpable abscesses or visible wounds.
Initial labs showed elevated WBC count(36.4K/UL; n<10.5K/UL) and Blood glucose of 361mg/dl(n 70-100mg/dl). CT scan of the abdomen and pelvis showed right anterior pelvic wall subcutaneous infiltration extending inferiorly into the mons pubis and right labial regions suspicious for cellulitis with no abscess. Broad spectrum intravenous antibiotics Meropenem, Vancomycin and Fluconazole were started and patient was taken to the operative room for debridement and approximately 25 cm long and 15 cm wide and 8 cm large abscess originating in the right labia extending up into her right groin was found along with necrotic skin, subcutaneous tissue and fat which was sharply excised. Peritoneal dialysis catheter site looked non infected and was left in place and fluid cultures were sent. Patient was switched to Hemodialysis while awaiting PD catheter fluid cultures. Hospital course was complicated by multiple debridements, severe septic shock requiring upto 4 pressors and intubation. She was started on insulin drip for glycemic control as the blood sugars were constantly ranging 300mg/dl(n 70-100mg/dl). HbA1C was 10.9% (n 5.7-6.4%). After 10days she was extubated and off pressors and was stable to be transferred to subacute rehab facility for diligent wound care for the next few weeks before she could go home.
Conclusion:
In patients with uncontrolled diabetes mellitus who present with critical illness like necrotising fasciitis, strict glycemic control with insulin drip yield favourable outcomes.
Strict glycemic control is needed in times of COVID19 epidemic in India: A Call for action for all physicians