Case report
A 37 years old man was admitted to our maxillo facial surgery department with a two weeks history of dental pain under treatment with antibiotic therapy at home. During this time, after extraction of the lower right third molar, there was a progressive swelling of the submandibular and laterocervical region showing tense and painful skin and progressive involvement of the right upper thoracic region. The patient did not report any pathologies in his past medical history. On admission he was conscious and cooperating, his body temperature was 37,5°C, blood pressure 110/60 mmHg, heart rate 94 b.p.m., oxygen saturation on room air 98% with no signs of respiratory exertion. Physical examination revealed swelling of the latero-cervical region with involvement of the right pectoral region where the skin appeared tense, burning and painful on palpation (fig 1). Our examination of the oral cavity revealed a poor oral hygiene condition with inflammation of the gingival mucosa and leak of purulent material in the gingival fornix . The computed tomography (CT) scan of the head, neck and thorax with contrast was performed and revealed locules of gas and ill-defined low attenuation in the cervical area and in the thigh chest muscle, highly suspicious for a gas-forming infection (figure 2-3).
Routine laboratory report as follow: white blood cell count 15.230 mm3, Hb 14,5 gr/dl, CPK 414 U/L, CRP 150 mg/L, PCT 0.94. The day after admission the pain and swelling increased and he developed dysaesthesia on the right upper thoracic zone. A compartment syndrome due to infection was diagnosed, thus patient was urgently carried on operating room where underwent to extensive surgical debridement of right pectoral area. The operating field showed interstitial “dishwater-like” fluid and discolored poor contractile muscles, with pockets of necrosis and pus. The tissues were irrigated with 10 L of saline and based on advice with infectious disease empiric antibiotic therapy was started with piperacilline-tazobactam 4,5 gr ev/4 die and daptomycin 8 mg/kg/day ev. Blood cultures were performed pre-operatively with a sterile peripheral vein technique and during surgery cultures were taken from the surgical site. After surgery patient was extubated and the day after he started HBOT as adjunctive therapy in the treatment of NSTIs and myositis. The HBOT treatment consisted in two dives with 100% oxygen in a pressure chamber 2,8 atmospheres absolute within the first two days, and then daily for a total of 16 session. Clinical improvement was observed after third day of HBOT and three weeks after admission patient was discharged at home in good health (figure 4).