A 63-year-old man with recent elective right inguinal hernia repair comes to the emergency department with pain and swelling of the right thigh. The pain began the night before and he could not sleep well despite taking oxycodone and acetaminophen. The patient has mild hypertension and type 2 diabetes requiring daily long-acting insulin. He also suffers from resistant fungal infection of the toenails.
His temperature is 38.4° C (101° F), blood pressure is 110/72 mm Hg, and pulse is 124/min and regular. His lungs are clear to auscultation. A faint systolic murmur is heard at the base. His abdomen is soft and nontender. The surgical incision looks clean with minimal amount of gray discharge. The right inner thigh has a large area of erythema and swelling that is very tender on superficial palpation. Several small vesicles containing pink fluid with surrounding purpura are also present.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Question

A 63-year-old man with recent elective right inguinal hernia repair comes to the emergency department with pain and swelling of the right thigh.  The pain began the night before and he could not sleep well despite taking oxycodone and acetaminophen.  The patient has mild hypertension and type 2 diabetes requiring daily long-acting insulin.  He also suffers from resistant fungal infection of the toenails.
His temperature is 38.4° C (101° F), blood pressure is 110/72 mm Hg, and pulse is 124/min and regular.  His lungs are clear to auscultation.  A faint systolic murmur is heard at the base.  His abdomen is soft and nontender.  The surgical incision looks clean with minimal amount of gray discharge.  The right inner thigh has a large area of erythema and swelling that is very tender on superficial palpation.  Several small vesicles containing pink fluid with surrounding purpura are also present.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's abrupt onset of thigh/groin pain with erythema and bullae after recent abdominal or pelvic surgery suggests necrotizing fasciitis (NF). NF is seen predominantly in patients with diabetes, immunosuppression, or recent surgery/trauma. Necrotizing fasciitis involves destruction of the muscle fascia and overlying subcutaneous fat. Infection initially spreads along the fascia due to the poor blood supply of muscle fascia before it involves subcutaneous fat. As a result, early identification is difficult. Early findings include erythema spreading across muscle fascia, swelling, and exquisite tenderness out of proportion to its appearance. Infection spreads rapidly and the patient appears ill; tender areas become anesthetic due to impairment of the blood supply. At this stage, examination shows skin discoloration, crepitus, and hemorrhagic blisters. The swelling and edema can lead to compartment syndrome. Most infections are polymicrobial, with cultures typically yielding a mix of aerobic and anaerobic pathogens. Initial antibiotic therapy should cover Streptococcus species, Gram-negative aerobes, and anaerobes. NF is a surgical emergency that requires immediate consultation. Despite broad-spectrum antibiotics, aggressive debridement of necrotic tissue is required to prevent local necrosis and systemic toxicity. Delaying surgical intervention can increase morbidity and mortality. (Choice A) Lower-extremity duplex ultrasound can diagnose deep venous thrombosis, which can present with leg swelling and pain. However, this patient's exquisite tenderness and vesicles suggest myonecrosis. (Choice B) Penicillin G does not effectively treat most Gram-positive, Gram-negative, or anaerobic organisms. Metronidazole can treat anaerobic infection but does not cover other organisms well. A preferred therapy is carbapenem or beta-lactam/beta-lactamase inhibitor plus coverage for methicillin-resistant Staphylococcus aureus (eg, vancomycin). (Choice D) Although this patient has a murmur on examination, he does not have other findings (eg, Osler nodes, Roth spots, splinter hemorrhages) to suggest endocarditis. (Choice E) Valacyclovir treats herpes zoster, which can present with vesicular lesions. However, the systemic findings (eg, fever, tachycardia, and leukocytosis) and erythema after recent surgery make necrotizing fasciitis more likely. Educational objective: Early findings of necrotizing fasciitis include erythema spreading across muscle fascia, swelling, and exquisite tenderness out of proportion to its appearance. Infection spreads rapidly and the patient appears ill. Tender areas become anesthetic, and examination shows skin discoloration, crepitus, and hemorrhagic blisters. Early aggressive surgical debridement of necrotic tissue is of utmost importance to prevent local necrosis and systemic toxicity. __________ References: Necrotizing soft tissue infections. (http://www.ncbi.nlm.nih.gov/pubmed/17599015) The diagnosis of necrotizing fasciitis. (http://www.ncbi.nlm.nih.gov/pubmed/15735411)

A 63-Year-Old Man with Recent Elective Right Inguinal Hernia Repair