Case presentation
A 71-year-old woman, 154 cm tall, weighing 46 kg, with a history of
hypertension and chronic kidney disease, developed lower leg edema one
month before hospitalization. She complained of right lower leg pain and
a red flare on the day of hospitalization. She visited our emergency
room due to the development of dysarthria and gait disturbances. When
she arrived at the emergency room, her
Glasgow Coma Scale (GCS) score
was E4V5M6. However, although she was able to communicate, she had
slurred speech and dysarthria. Her pupillary diameter was 3 mm
bilaterally, indicating no anisocoria, and the light reflex was normal.
Physical examination revealed the following: temperature: 36.9°C, blood
pressure: 114/72 mmHg, heart rate: 116 beats/min, respiratory rate: 25
breaths/min, and SpO2: 97% (on room air).
Electrocardiogram revealed atrial fibrillation.
Multiple areas of erythema were
found on both the right and left lumbar and lower abdominal areas, right
proximal femoral areas, and left proximal inner femoral area. There were
blisters, ruptured blisters, swelling, and aching pain on the right
inner femoral area.
Laboratory examination at admission revealed a low white blood cell
(WBC) count of 1,000 cells/mm3, elevated C-reactive
protein (CRP) of 16.7 mg/dL and elevated procalcitonin level of 30.65
mg/dL, indicating leucopenia with evidence of inflammation and bacterial
infection. Her blood urea nitrogen (BUN) level was 68.9 mg/dL and
creatinine was 7.29 mg/dL, indicating impaired renal function, and
prothrombin time (PT) was 19.3
sec, PT-INR was 1.63, activated partial thromboplastin time (APTT) was
39.2 sec, fibrin degradation products (FDP) were 33.9 μg/mL, and D-dimer
level was 10.08 μg/mL, indicating prolonged coagulation and delayed
activation of the fibrinolytic system. Blood gas analysis showed
increased lactate levels of 4.59 mmol/L.
Brain computed tomography (CT)
examination performed to evaluate her neurological status showed an old
brain infarction, with no new brain hemorrhage or space occupying
lesions. Thoraco-abdominal and pelvic CT examination displayed
predominant right lower leg swelling, subcutaneous edema, and increased
adipose tissue signals in the entire right femoral region (Figure 1).
Her blood pressure gradually decreased after hospitalization, requiring
vasopressors, and hence, continuous administration of noradrenaline at
0.05 µg/kg/min was initiated. The patient then developed disturbance of
consciousness (GCS score was E4V3M4). Based on the clinical, laboratory
and imaging findings, we diagnosed necrotizing fasciitis from the right
lumbar to lower abdominal regions along with septic shock.
Clinical course in the intensive care unit (ICU)
At her admission to the ICU, the patient’s
GCS score was E4V2M2, heart rate
was 100 beats/min, blood pressure was 80/63 mmHg, and Sequential Organ
Failure Assessment score was 11 points. Her systolic blood pressure
subsequently decreased to approximately 60 mmHg, GCS score was E3V1M1,
and respiration became unstable. Therefore, we performed endotracheal
intubation and commenced mechanical ventilation. Since her hemodynamic
parameters did not respond to fluid loading and noradrenaline
administration, the noradrenaline dose was increased to 0.65 µg/kg/min.
Figure 2 shows the time course of changes in hemodynamics on ICU
admission day 1. Two hours after ICU admission, we performed right
femoral and lower abdominal fasciotomy and purulent drainage. During the
procedure, we found right femoral and lower abdominal fascial necrosis.
Since the patient also showed deterioration of renal function, we
initiated renal replacement therapy. Since endotoxin activity (EA) assay
at ICU admission showed increased activity levels to 0.7, we performed
CHDF using an AN69ST membrane, and PMX-DHP was added. We subsequently
started treatment with two antibiotics: tazobactam/piperacillin and
clindamycin (CLDM), and whenStreptococcus dysgalactiaesubsp. equisimilis (SDSE) was detected from culture of blood and
genital wound samples, we de-escalated the antibiotics to penicillin-G
on ICU day 3. Since the patient had wound infection withPseudomonas aeruginosa , ciprofloxacin was additionally
administered. Thrombomodulin-α was administered for treatment of
disseminated intravascular
coagulation (DIC) from ICU day 1 to day 15. Further, since her urine
output was limited to 100 mL/day due to renal failure, high flow CHDF
was performed with a dialysate fluid rate of 2000 mL/h for 5 days, which
was gradually tapered. Due to the substantial drainage from the wound,
crystalloid fluid, fresh frozen plasma and albumin preparations were
administered.
Wound lavage was performed daily, along with blunt scraping of
subcutaneous and inter-fascial tissue and debridement (Figure 3).
Thereafter, the patient’s hemodynamic condition gradually stabilized and
noradrenaline was tapered and stopped on ICU day 6. The patient was
weaned from mechanical ventilation on ICU day 27. Her subsequent
clinical course was favorable and she was transferred from the ICU to
the regular ward on ICU day 43.