A case of upper limb necrotising fasciitis

Julia Fattore and Shruti Krishnan

Background

Necrotising fasciitis (NF) is a rapidly progressive, life threatening soft tissue skin infection that primarily involves the extremities, abdomen or perineum. NF generally occurs when trauma to an area compromises skin integrity, allowing the entry of harmful microorganisms. The most common site of NF infection is the extremities, affecting 57.8% of patients. This is followed by the abdomen and perineum, each involved in 12.1% of cases. Of the extremities, lower limb disease is significantly more common than upper limb disease, 68% vs 32% respectively. The gold standard of current management is a combination of surgical debridement and antimicrobial therapy, with the addition in certain circumstances of immunoglobulin or hyperbaric oxygen Therapy.

Case presentation

A 48 year-old smoker and insulin dependent diabetic female presented to hospital with a three day history of pain and increased swelling of her right upper limb, as well as a single bulla over its medial aspect. She denied trauma to the site or a history of intravenous drug use and had recently completed a course or oral cephalexin for a suspected infected carbuncle. Suffering from septic shock and associated multiorgan failure, she quickly deteriorated soon after presentation. Broad spectrum intravenous antibiotics were commenced along with renal replacement therapy, and she remained inotrope/vasopressor dependent. Surgical debridement confirmed a suspected NF and fasciotomies were required for limb preservation. Over weeks she progressively improved with weaning of organ support and successful surgical grafting of the site. She subsequently underwent rehabilitation and gained good return of function to her dominant upper limb.