Journal: BMJ Case ReportsPaper: bcr-2012-007025Title: Necrotising soft-tissue infection
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Miguel F Carrascosa,1 Mariano Pérez Santamaría,2 José-Ramón Salcines Caviedes,1
Department of Internal Medicine, Hospital of Laredo, Laredo, Cantabria, Spain
Service of Orthopedic and Traumatologic Surgery, Hospital of Laredo, Laredo, Cantabria, Spain
Service of Radiology, Hospital of Laredo, Laredo, Cantabria, Spain
Correspondence to Dr Miguel F Carrascosa, miguel.carrascosa@scsalud.es
A 55-year-old woman presented with a 3-day history of
progressively worsening pain, swelling and ‘unpleasant
crackling feeling’ on her left upper limb. These complaints
had begun after she noticed a small reddish lesion on her
left elbow. The patient had received a diagnosis of sys-
temic lupus erythematosus 15 years before coming to us
and was taking methylprednisolone and acenocoumarol,
the last for previous deep vein thrombosis associated with
protein S deficiency. There was history of neither acute or
chronic trauma nor diabetes (in the patient or in her
family). She was allergic to penicillin. On admission,
blood pressure and temperature were normal but heart
rate was 99 beats/min. Her left upper extremity showed
erythema, an elbow wound (figure 1), and generalised
tense oedema and crepitus, the last also being evident on
the ipsilateral supraclavicular region. Plain radiographs
of the left upper limb and chest identified abundant sub-
cutaneous gas (figure 2 and 3), a very specific finding
of necrotising soft-tissue infection (NSTI). The patient
was immediately started on intravenous clindamycin
and vancomycin and then urgent, extensive surgical
Plain radiographs revealing the presence of
subcutaneous widespread gas in the left upper extremity (white
arrows). ‘Dissection’ of muscular and other tissular structures by
debridement of the necrotic tissue was performed. She
afterwards received hyperbaric oxygen as an adjunct to
operative procedure and antibiotics. Culture of several
samples obtained from the necrotic tissue grew no micro-
organisms. The postoperative course was uneventful and
she was discharged on hospital day 11.
NSTI is infrequent but still remains a highly lethal dis-
order.1 Some patients seem to be more prone to develop
this condition, as those with diabetes mellitus, immuno-
suppression, obesity and intravenous drug use.1 2 Other
reported risk factors are age greater than 50 years, periph-
eral vascular disease and chronic alcoholism.2 3 Although
NSTIs are more commonly polymicrobial,1–3 the aetiology
may remain unknown in some patients.1 Early and aggres-
sive surgical debridement combined with empiric broad-
spectrum antimicrobial therapy and physiological support
Left elbow appearance on admission showing a
are of paramount importance to increase the survival
non-exudative, ulcerative lesion (arrow) with surrounded oedema
and erythema (suspected portal of entry for the infection). The
visible portion of the left upper extremity is swollen and
BMJ Case Reports 2012; doi:10.1136/bcr-2012-007025
1. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and
management. Clin Infect Dis 2007;44:705–10.
2. Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med
3. Headley AJ. Necrotizing soft tissue infections: a primary care review.
Plain radiographs revealing the presence of
subcutaneous widespread gas in the both ipsilateral hemithorax
(thin black arrows) and supraclavicular area (thick black arrows).
Dissection’ of muscular and other tissular structures by the gas
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Please cite this article as follows (you will need to access the article online to obtain the date of publication).
Carrascosa MF, Santamaría MP, Caviedes J-RS, Gutiérrez P G. Necrotising soft-tissue infection. BMJ Case Reports 2012;
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BMJ Case Reports 2012; doi:10.1136/bcr-2012-007025
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Miguel F Carrascosa,1 Mariano Pérez Santamaría,2 José-Ramón Salcines Caviedes,1
Department of Internal Medicine, Hospital of Laredo, Laredo, Cantabria, Spain
Service of Orthopedic and Traumatologic Surgery, Hospital of Laredo, Laredo, Cantabria, Spain
Service of Radiology, Hospital of Laredo, Laredo, Cantabria, Spain
Correspondence to Dr Miguel F Carrascosa, miguel.carrascosa@scsalud.es
A 55-year-old woman presented with a 3-day history of
progressively worsening pain, swelling and ‘unpleasant
crackling feeling’ on her left upper limb. These complaints
had begun after she noticed a small reddish lesion on her
left elbow. The patient had received a diagnosis of sys-
temic lupus erythematosus 15 years before coming to us
and was taking methylprednisolone and acenocoumarol,
the last for previous deep vein thrombosis associated with
protein S deficiency. There was history of neither acute or
chronic trauma nor diabetes (in the patient or in her
family). She was allergic to penicillin. On admission,
blood pressure and temperature were normal but heart
rate was 99 beats/min. Her left upper extremity showed
erythema, an elbow wound (figure 1), and generalised
tense oedema and crepitus, the last also being evident on
the ipsilateral supraclavicular region. Plain radiographs
of the left upper limb and chest identified abundant sub-
cutaneous gas (figure 2 and 3), a very specific finding
of necrotising soft-tissue infection (NSTI). The patient
was immediately started on intravenous clindamycin
and vancomycin and then urgent, extensive surgical
Plain radiographs revealing the presence of
subcutaneous widespread gas in the left upper extremity (white
arrows). ‘Dissection’ of muscular and other tissular structures by
debridement of the necrotic tissue was performed. She
afterwards received hyperbaric oxygen as an adjunct to
operative procedure and antibiotics. Culture of several
samples obtained from the necrotic tissue grew no micro-
organisms. The postoperative course was uneventful and
she was discharged on hospital day 11.
1. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and
management. Clin Infect Dis 2007;44:705–10.