Today Dr. Sulpizio presented a thrilling case of a young poorly-controlled diabetic male who presented with acute onset of rapidly progressive facial swelling refractory to steroids, found ultimately to have the dreaded necrotizing fasciitis! Though a surgical diagnosis, it is crucial that we as internists not miss this! The table below is from an excellent summary from NEJM – Necrotizing Soft-Tissue Infections from Dec 2017. It details common pitfalls in diagnosis, such as being falsely reassured by imaging that shows edema only without frank gas or abscess (our major pitfall today!).
Take Home Points:
- Early recognition is VITAL.
- There are two types of necrotizing soft tissue infections.
- Type I (polymicrobial) – Enterobacteriaceae, bacteroides, clostridium, GAS
- Type II (monomicrobial) – GAS, Staph aureus
- Do NOT rely on the LRINEC score (performs poorly in external validation studies).
- Surgical intervention is the only definitive diagnostic and therapeutic approach.
- Include IV clindamycin with empiric antibiotic coverage to counter toxin production.