A Case Report of Synchronous Multifocal Necrotizing Fasciitis Due to Clostridium Septicum in an Immunocompromised Host

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INTRODUCTION: Necrotizing fasciitis is a rare and aggressive bacterial infection with a high mortality and morbidity rate. An accurate and timely diagnosis can prompt emergent surgical intervention with the intent to cure. Synchronous multifocal necrotizing fasciitis (SMNF) is an exceedingly rare presentation, with less than forty reported cases in the literature. CASE PRESENTATION: This case involved an 84-year-old male with a past medical history of metastatic prostate cancer, chronic steroids use, and diabetes. The patient presented with worsening fatigue and falls. While being triaged in the emergency department, his initial vitals and examination were benign. Lab evaluation revealed a high anion gap metabolic acidosis, AKI, and Neutropenia. The patient was treated with IV fluid resuscitation, broad-spectrum antibiotics, and eventual IV vasopressor support due to refractory hypotension. Due to the inability to localize the source of infection, additional images were performed before his transfer to the ICU. The CT imaging revealed multiple areas of dense gas, raising concern for infection in the bilateral upper arms and left gluteal region. Repeat examinations of these areas revealed no pain or overlying skin changes. The patient was given a single dose of Clindamycin, and evaluation by surgery was requested. Due to the lack of physical exam findings and patient apprehension, he was not initially taken to the OR. However, within 1 hour, the patient decompensated, requiring increasing vasopressor support, and developed skin changes consistent with crepitus and necrosis. The patient was taken emergently to the OR and underwent three site surgical debridement. Surgical site cultures revealed clostridium septicum. DISCUSSION: Necrotizing soft tissues infections are rapidly progressing, life-threatening infections that carry high mortality and morbidity. Dermatological and physical exam findings vary between erythema, pain out of proportion, swelling, bullae, crepitus, and skin necrosis. Synchronous Multifocal Necrotizing Fasciitis (SNMF) is an exceedingly rare presentation of necrotizing fasciitis due to a lack of contiguous spread. It is thought that immunocompromised patients are at high risk for spontaneous bacterial translocation of gut flora leading to monomicrobial or polymicrobial infections. Clostridium species is a rare cause of necrotizing fasciitis, with a short incubation period resulting in very high mortality within 12-48 hours of presentation. In our case, the patient did not report any of the aforementioned signs early in his presentation. Emergent surgical intervention was pursued after delayed physical exam manifestations. CONCLUSIONS: This case highlights the importance of prompt recognition of synchronous multifocal necrotizing fasciitis, even in the absence of dermatological manifestations, and that delay in surgical intervention could worsen patient outcomes.




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Chest 2022 Annual Meeting, October 16-19, 2022, Nashville, TN.