Necrotizing fasciitis
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Necrotizing fasciitis

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internal medicine board review question about necrotizing fasciitis

internal medicine board review question about necrotizing fasciitis

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Necrotizing fasciitis Necrotizing fasciitis Presentation Transcript

    • 68 years old male
    • Pain in leg for 1 day
    • Alter mental status and fever this morning.
    • V/S BP 88/40 HR 126/min RR 28/min Temp 39.3 C O2Sat 92 %
    • Left leg: Diffuse swelling with brawny edema, pain on light palpation, several bullaes with dark purple fluid.
    • ABG pH 7.22 PaCO2 28 Pa02 93
    • Cr 3.2
    • WBC 22660 N 70% Band 28% L 2%
    • CPK 553
    • Gram stain of fluid aspirated from bulla.
  •  
  •  
    • What is the most appropriate therapy for this patient?
    • A. Ampicillin, Clindamycin and Gentamycin
    • B. Clindamycin and Penicillin
    • C. Clindamycin, penicillin, and debridement
    • D. Penicillin and debridement
    • E. Vancomycin, penicillin, and debridement
    • Answer:
    • Penicillin ,Clindamycin and debridement
    • Diagnosis:
    • Septic shock secondary to NF with GAS.
  • NF
    • Caused
    • GAS
    • Mixed aerobic anaerobic organism
    • C. Perfringens
    • Some strains of MRSA
  • Symptoms and Signs
    • Starts with pain and fever
    • Swelling then edema and tenderness
    • Dark red induration of epidermis with bullae
    • In later stage, the skin will be friable and turn brownish grey accompanying with shock
  • GAS
    • Absent of Hx of streptococcal infection is common.
    • Myositis occurs in 20-40% of cases which might cause elevation of CPK level.
  • Mixed aerobic-anaerobic
    • Site of breach in the integrity of mucosa of GI or GU tract may be presented in question e.g. malignancy, diverticulum or hemorrhoid
    • Other possible comorbidities : DM, Peripheral vascular disease, Surgery or penetrating abdominal trauma
  • Clostridium
    • Hx of severe penetrating trauma with contamination by soil.
    • Spontaneous case can happen in patient with neutropenia, GI cancer or recent RT to abdomen.
  • Treatment
    • IVIG is not recommended.
  • Explanation
    • Clinda is more effective than penicillin in terminating toxin production by bacteria (Inh. of protein synthesis VS Inh. of cell wall synthesis.)
    • Because clinda resistance in GAS, although rare, has been reported. Penicillin should be administered concomitantly until C/S result is available.
    • Same manifestation but different gram stain. Which antibiotic?
    • Same question but with history of penicillin allergy, which antibiotic?
      • Depend on type of reaction
      • immediate reaction or life threatening manifestation : Vancomycin
      • minor reaction : 1 st gen cephalosporin
    • 2. NF with history of colon cancer and uncontrolled DM with following gram stain?
  •