If you can't read please download the document
Upload
dwight-chase
View
222
Download
0
Embed Size (px)
DESCRIPTION
HPI 43 yo female presented to ED with abdominal pain and nausea for 4-5 days, subjective fever and chills x 2 days, and vomiting for 1 day Takes 50 U of Lantus every morning but missed morning dose due to nausea
Citation preview
Case Follow Up Vicky Stahl PGY 1 HPI 43 yo female presented to
ED withabdominal pain and nausea for 4-5 days, subjective fever and
chills x 2 days, and vomiting for 1 day Takes 50 U of Lantusevery
morning but missed morning dose due to nausea Past medical history
PMH: DM, HTN, glaucoma
PSH: Left TMA 1/2015, Left BKA4/2015; osteomyelitis 2/2 to diabetic
ulcer Social Hx: Denies smoking, alcohol or illicit drug use Family
Hx: DM, colon cancer Review of Systems Constitutional: Fevers and
chills
HEENT: negative for rhinorrhea, sore throat, ear pain Respiratory:
negative for cough, SOB, DIB Cardiovascular: Negative for chest
pain, palpitations GI: Nausea and vomiting, negative for diarrhea
GU: Negative for dysuria, increased frequency or urgency MSK: Right
foot pain Skin: Discoloration of right great and second toe
Physical Exam Vitals: Temp: 37.2 BP 130/90 HR: 126 RR: 21 SpO2: 99
RA
Constitutional: No acute distress HEENT: dry mucus membranes
Cardiac: Regular rhythm, tachycardic, 1+ DP pulse of right foot
Resp: CTA, breath sounds equal bilaterally, no wheezes or crackles
GI: Soft, non distended, no pain to palpation MSK: Left BKA, pain
to palpation of right foot, no crepitus palpated on right foot
Skin: Black discoloration of great and second toe of right foot,
erythema and edema from toes to midtarsal of right foot Pain in 2nd
toe for four days. Discoloration started 3 days before
Pain in 2nd toe for four days.Discoloration started 3 days before.
Denied trauma, cuts, previous infections Labs BMP: CBC: Lactate:
2.5 Na: 126 WBC: 25.6 CRP: 33.6 K: 4.8 HgB: 9.4 Cl: 86 HCT: 30.1
Urinalysis: HCO3: 17 Plt: 458 >500 glucose, AG: ketones BUN: 17
Negative LE and Nitrate Cr: 1.56 Glucose: 616 ED course ED:
Attributed air on xray to open wound on plantar surface of second
toe.Beside debridement to allow drainage. Started on Vancomycin and
Zosyn, scheduled for TMA the following morning Admitted to MICU for
DKA and sepsis 2/2 to wet gangrene Inpatient Course Admission Day
1: CT showed soft tissue emphysema to lateral malleolus. Taken
emergently to OR for right Guillotine amputation above the ankle
Admission Day 3: Transferred to GPU Admission Day 7: BKA with
closure Importance of diagnosis
Mortality rate around 34% Major reason due to delayed recognition
15-34% of discharge diagnosis of necrotizing fasciitis had the same
admitting diagnosis Diabetic patients, especially those presenting
with diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic
acidosis have higher rates of death and longer lengths of hospital
stay. A delay in surgery of more than 24 hours was an independent
risk factor for mortality. Laboratory Risk Indicator for
Necrotizing Fasciitis (LRINEC score)
However, the LRINEC score was based on retrospective studies of
patients with diagnosed or highly suspected NF. It has not been
validated in patients for whom the diagnosis of NF is not apparent
in the initial assessment. positive predictive value of 92% and a
negative predictive value of 96%. Etiology Type 1 (Polymicrobial):
gram positive cocci, gram negative rods, and anaerobes
Immunocompromised hosts; Diabetes and CKD Typically occur in
perineum and trunk Normal flora adjacent to site of infection Type
2 (Monomicrobial): beta hemolytic strep or staph Less common form
Previously healthy hosts with hx of trauma (usually trivial)
Typically found in extremities Clinical features Stage 1 Stage 2:
Stage 3: (Day 3-5)
Hard to distinguish from other soft tissue infections Erythema,
warmth and tenderness Poorly defined margins and pain extending
beyond erythema Stage 2: Ischemia->bullae formation Stage 3:
(Day 3-5) Tissue necrosis causing hemorrhagic bullae and gangrene
Ischemia of superficial nerves causing anesthesia Blisters and
gangrene are most specific clinical sign but not commonly seen
Imaging Xray: CT: 80% sensitive for NF MRI Ultrasound
Gas only present on 25% of cases Present with polymicrobial or
clostridium infections CT: 80% sensitive for NF Asymmetrical
fascial thickening Fat stranding Gas tracking along fascial plane
MRI Found to overestimate amount of deep tissue involvement
Ultrasound Not well studied in necrotizing fasiciitis Diagnosis
Definitive diagnosis made during surgery
Gray necrotic fascia Lack of resistance of normally adherent
muscular fascia Lack of bleeding Foul smelling dishwater pus
Pathognomonic for necrotizing fasciitis is positive finger test 2
cm incision down to fascia Lack of bleeding, dishwater pus and no
resistance diagnostic of necrotizing fasciitis Diagnosis Blood cx:
Histopathology: Positive in 60% of type 1
May not reflect all organisms involved Positive in 20% of Type 2
Histopathology: Extensive tissue destruction, thrombosis of blood
vessels, bacterial spreading along fascial plans, inflammatory
cells Concentration of bacterial and neutrophils may have
prognostic importance Treatment Treatment: Penicillin, high dose
clindamycin, and fluroquinolone or aminogycoside for gram negative
organisms Vancomycin, daptomycin, or linezolid for possible MRSA
Clindamycin for toxin production QuestionS A 52-year-old diabetic
male sustained minor blunt trauma to his left thigh 10 hours prior
to presentation. He initially complained of extreme thigh pain with
erythema and swelling but rapidly developed bullae and worsening
erythema over the affected area along with fever and tachycardia.
What clinical factor has been shown to reduce mortality when
treating this pathology? A) MRI findings B) Decreasing time from
admission to surgery C)Administration of pressors D) Location of
injury Questions A 56-year-old diabetic male presents to the
emergency department with high-grade fevers, malaise, and altered
mental status. He is found to be hypotensive and initial labs show
an elevated WBC with a profound left shift. Skin manifestations
confined to the foot at initial presentation. He is started on
broad spectrum antibiotics. Upon follow-up exam 3 hours later his
clinical condition deteriorates and he is taken to the operating
room for surgical debridement. In a bacterial culture, what would
be the most common single isolate for this condition? A) Staph
aureus B)Group A stept C) Enterobacteriaceae D) Pseudomonas
ncluding gram-positive, gram-negative, aerobic, and anaerobic
bacteria were found most commonly in necrotizing fasciitis, Group A
streptococcus was the most common bacterial isolate. Wong et al
also found the most isolated organism to be group A streptococcus.
References Cunha B Infectious Disease in Critical Care Medicine
Third Edition Pallin D, Nassisi D, Skin and Soft Tissue infection,
Rosens Pasternack M, Swartz N ( ). Cellulitis, Necrotizing
Fasciitis, and Subcutaneous Tissue Infections . Mandell, Douglas,
and Bennett's Principles and Practice of Infectious Diseases
Puvanendran R, Chan Meng Huey J, Pasupathy S. Oct V 55(10)
Necrotizing Fasciitis. Canadian Family Physician Woon, Colin. Feb
Necrotizing Fasciitis.Orthobullets. Wong C, Khin, L, Heng K, etc V
32 (7) The LRINEC (Laboratory Risk Indicator for Necrotizing
Fasciitis)score: A tool for distinguishing necrotizing fasciitis
from other soft tissue infections. Critical Care Medicine
https://books.google.com/books?id=syasCQAAQBAJ&pg=PA304&lpg=PA304&dq=dishwater+pus&source=bl&ots=ATwxqup_eH&sig=vQhJN3TwjgM8cO2u85ZYTq3VpPY&hl=en&sa=X&ved=0ahUKEwifmfXihLDKAhVBHT4KHbh8BIQQ6AEIQTAI#v=onepage&q=dishwater%20pus&f=false