8/5/25:
Necrotizing Fasciitis
Dr. Stephanie De Mel
Case:
A 55-year-old female with PMH of DM2 and peripheral neuropathy presents to the ED with 3 days of Right foot pain with active COVID infection. Her vitals in triage were normal. Exam finding below (photos taken with patient permission)
What do you see? There is no crepitus on exam. Patient has TTP.
Should we order labs? Imaging? Discharge on PO antibiotics?
Labs were ordered and shown below:
WBC: 15
Na: 117
BUN/Cr: 65/2.4
Glucose: 327
Lactate: 2.6
These labs triggered the ED providers to look for another insidious cause. Antibiotics were given for cellulitis and CT was ordered.
What do you see?
The patient was treated with Vancomycin, Cefepime, Flagyl + clindamycin (after CT)
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This is a case of necrotizing fasciitis. Before you open the attached PDF, ask yourself a few questions:
Why did the ED team order a CT scan if the X-ray looked somewhat normal?
Why were 4 different antibiotics given, and is there one specific antibiotic that should always be given? (Hint: the answer is yes)
Have you ever heard of the LRINEC score? How useful is it to us in the ED?
For continuity: the patient was admitted and emergently taken to the OR with podiatry, where she underwent debridement and amputation of her 3rd toe. At the time of writing this, she has returned to the OR twice for repeat washout and further debridement but remains on a general medical floor.