UMEM Educational Pearls

Title: What's the Diagnosis? Case by Dr. Eric Friedman

Posted: 11/26/2019 by Tu Carol Nguyen, DO
Click here to contact Tu Carol Nguyen, DO

Question

A ~55 year-old female with a history of ESRD and diabetes who presented to the ED with progressively worsening foot odor. An x-ray was performed. The picture below shows the right foot.

What is the diagnosis?

Answer

Necrotizing infection of the foot

Labs will show increased lactate, increased CK, increased WBC, and decreased sodium
- Admission serum lactate (>6mmol/L) and sodium levels (<135mEq/L) are predictors of mortality
On x-ray, the characteristic finding of gas in the soft tissues is seen in only a minority of cases.
The presence of gas in the facial planes is highly specific, but not very sensitive.
Diagnosis of necrotizing fasciitis or myonecrosis can only be established by surgical exploration.
Treatment includes a Carbapenem or Zosyn plus Clindamycin and Vancomycin.

References

https://radiopaedia.org/articles/necrotising-fasciitis

Yaghoubian et al. Use of admission serum lactate and sodium levels to predict mortality in necrotizing soft-tissue infections. Archives of surgery. 2007.

Anaya DA and Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clinical infectious diseases. 2007.