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).