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Necrotizing Fasciitis

Necrotizing Fasciitis. History. 66 y female PMH : DM , HTN , IHD , Hypothyroidism Pernicious anemia , ETOH Med: Atenolol , ASA , Nitrospray , Thyroxin , B12 & Atrovastatin. History. Presented to Seven Oaks Hospital 1/12 SOBE , Anasarca & decreased UOP

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Necrotizing Fasciitis

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  1. Necrotizing Fasciitis

  2. History • 66 y female • PMH : DM , HTN , IHD , Hypothyroidism Pernicious anemia , ETOH • Med: Atenolol , ASA , Nitrospray , Thyroxin , B12 & Atrovastatin

  3. History • Presented to Seven Oaks Hospital 1/12 SOBE , Anasarca & decreased UOP 1/7 angina & melena ( 2 minimal ) • No orthopnea , PND , wheeze , cough No palpitation , LOC No heartburn , vomiting or hematemisis No blood in urine

  4. History • In ER : hemodynamicaly stable Sat 94% RA A & O Generalized edema No chronic liver disease signs ? Hypovolemic Chest : clear DRE +ve blood

  5. History • WBC 2.1 poly 1.3 Hb 65 MCV20 INR 1.7 PTT 54 • Creat , BUN & lytes N • AST 110 ALT 70 Albumen 20 Billirubin total 70 direct 40 • UA 0.3- 1 protein NO active sediment

  6. History • Admission Dx  pancytopenia ? Malignancy • Rx PRBC , FFP & HAS • Within hours of admission  Fever , SOB & Hypotension • No response to IVF , Bronchodilator

  7. History • Transferred to ICU Worsening work of breathing On 15 l O2 NRBM PH 7.3 PCO2 33 PO2 76 HCO3 16 • Intubated , Neosenphrine Swan Ganz  septic CXR  Lt effusion

  8. History • Pleural tapping LDH 2995 Glucose 0.3 Protein 38 • Transferred to ICM St.B Shock , Acute renal failure Craet 200 Lactaic acidosis 13 Melena Rhabdomyolysis Myogolbin 5000 ACS TnT 0.05 t wave inversion

  9. Hospital Course • In ICM Seen by 3 services on the same time (reading the chart together) ID  meropenem & Vanco Renal  CRRT GI were scoping the pateint next door they didn’t mind scoping this patient !

  10. Hospital Course • Pleural fluid & Blood C/S  Group C Beta strept • Abx switch to Penicillin G continuous infusion • Cortisol 1750 • Not candidate for activated protein C

  11. Hospital Course • Upper GI scope  diffuse gastritis started on pantprazole • Not candidate for activated protein C • Recovered from shock • Transferred to medicine

  12. Group C Strept. • G +ve cocci , facultative anaerobes • Vast majority are pathogenic • Uncommon cause of bacteremia • Predisposition  old age , animal exposure , immunosupression

  13. Group C Strept. • Dx  hemolytic pattern on blood agar medium • In case in the absence of overt focal disease& +ve Blood C/S search for an abscess, endocarditis or a suppurative process in an obscure area • Usually it is part polymicrobial infection  it is important for the microbiology lab to identify all species in a specimen from a closed space or bacteremic process.

  14. Group C Strept. • 5 y retrospective study • GCBHS caused 0.05 / 1000 admissions • Data from 10/13 patients primary bacteremia (4 cases), pneumonia (2cases), endocarditis (2 cases) meningitis, intraabdominal infection & pericarditis 6 Streptococcus equisimilis; 3 S. equi; 2 S. dysgalactiae; and 1 S. zooepidemicus Diagn Microbiol Infect Dis. 1992 Feb

  15. Group C Strept. • 8 y retrospective study in 5 hospitals • 78 cases  16 bacteremia sources primary bacteremia, cutaneous , meningitis and pneumonia • Higher rates of underlying diseases, ETOH abuse, liver diseases, and cutaneous infections, and lower rates of exposure to animals or raw products • Morbidity and mortality were 20% to 30% Arch Intern Med. 1995 Jun

  16. Group C Strept. • Exquisitely susceptible to penicillin • MIC should be performed in life-threatening infections  meningitis, brain abscess, endocarditis • An aminoglycoside, for synergy

  17. Group C Strept. • In penicillin allergic patients  clindamycin & macrolide • In high resistance or immunocompromised patients  vancomycin • Drainage of abscesses is essential

  18. IVIG & GCBHS • Multicenter randomized Plc control • Jan 1999  May 2001 • streptococcal toxic shock syndrome STSS pateints • Patients could be included before lab confirmation  site of infection or family history strept infection • Rapid antigen test from throat or skin CID 2003

  19. IVIG & GCBHS • IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3 or Albumen 1% • All patients received clindamycin 600mg TID & Penicillin 12 gm / day • Primary outcome 28 days mortality • Secondary outcomes time to shock resolution 180 days survival & organ dysfunction

  20. IVIG & GCBHS • Small number of patients ?may be the reason for non significance results  low incidence of STSS • 53% +ve BC & 41% tissue culture • NO side effects

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