Dave is a 33-year-old carpenter who presents to you with a painful red leg. It started about 48 hours previously as a red area and since then has spread and is now very painful. He feels unwell and says he has had a fever. Dave is generally well with no past medical history and is on no regular medications. He wonders whether something has bitten him.
One examination, Dave has a temperature of 38.6 and his leg appears as below. The area is hot and very tender to palpation.
Necrotising fasciitis is the diagnosis that must be considered and excluded in a presentation like Dave.
Necrotising fasciitis is a bacterial infection of the soft tissue and fascia and is a surgical emergency requiring urgent and aggressive management. While often spontaneous, it may follow penetrating or crush injury, or surgical procedures. In children, necrotising fasciitis S. pyogenes can follow varicella infection. Risk factors include age, diabetes, obesity, immune suppression and malignancy.
The cardinal clinical feature of necrotising fasciitis is pain disproportionate to the degree of redness. More advanced cases include bullae, obvious skin necrosis and crepitus. Patients need urgent admission for IV antibiotics and debridement.
- Therapeutic Guidelines https://tgldcdp.tg.org.au/etgAccess
- DermNET NZ https://dermnetnz.org/topics/necrotising-fasciitis/
- Necrotising fasciitis BMJ2020; 369 doi: https://doi.org/10.1136/bmj.m1428
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