Necrotizing Soft Tissue Infection Management: a Clinical Case Study

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Necrotizing infections occupy a special place in the structure of purulent-inflammatory diseases of soft tissues, which are characterized by rapid spread, difficulties in diagnosis on early stages and extreme severity of the clinical course [1]. The morphological basis of these diseases is progressive necrosis of subcutaneous adipose tissue, fascial formations and muscles, due to thrombosis of the vessels of the microcirculatory bed against the background of severe inflammation [2].The most common cause of necrotizing soft tissue infection is group A beta-hemolytic streptococcus. According to the literature, it is sown from the foci of infection in 80% of cases. However, other, primarily anaerobic (clostridial and non-clostridial) microorganisms, which are often identified in association with aerobic microflora, also play an important role [3].Factors predisposing to the occurrence of necrotizing infection include diabetes mellitus, the presence of an immunodeficiency condition, obesity, the use of hormones, elderly and senile age, the presence of vascular diseases. At the same time, cases of the occurrence of the disease against the background of complete health are described [4].Autoimmune aggression, hyperproduction of cytokines and reactive oxygen species aggravating local hypoxia and tissue damage play an important role in the pathogenesis of necrotizing soft tissue infection, in addition to microbial invasion and progressive thrombosis of skin vessels and subcutaneous fat against this background [5]. The entrance gates of infection are most often post-traumatic and postoperative wounds, injections, chronic ulcers, as well as abrasions, scratches and scuffs of the skin. There are reports of the occurrence of this disease with hematogenic dissemination of the pathological process [6].Depending on the depth of the soft tissue lesion, there are three levels of infection. At the first level, there is a lesion of the skin and subcutaneous tissue (necrotic forms of erysipelas). With the development of a second-level infection, the superficial fascia (streptococcal necrotizing fasciitis) is involved in the inflammatory process. Infections of the third level, in addition to skin lesions, subcutaneous fat and fascia, are characterized by the development of necrotic muscle damage (streptococcal myonecrosis) [7].Clinical manifestations of necrotizing soft tissue infection at the initial stage are extremely scarce and differ little from those with superficial phlegmon and abscesses. However, as the disease progresses, local symptoms manifest and are characterized by the development of intense edema, a change in skin color to gray with a bluish tinge, separation of the epidermis and the appearance of bullae with hemorrhagic contents, as well as the formation of ulceration and necrosis of the skin. As a rule, the development of soft tissue infection is accompanied by severe fever, the progression of intoxication with the rapid development of multiple organ failure and septic shock [8].The main principles of treatment of necrotic dermatofasciitis are emergency surgery in combination with immediate antibacterial and detoxification therapy. In the complex of therapeutic measures, surgical intervention is the leading one and includes stage-by-stage surgical rehabilitation with complete excision of necrotically altered skin, subcutaneous fat and superficial fascia. Extensive soft tissue defects formed after radical surgical treatment in most cases require subsequent reconstructive skin plastic surgery using autodermoplasty [9]. It should be noted that the difficulties of diagnosing necrotizing soft tissue infection in the early stages, as well as the lack of alertness of practitioners regarding this disease, are often the cause of diagnostic errors, delayed and inadequate surgical treatment, which significantly worsens the results of treatment of patients in this category [10].Thus, the problem of effective treatment of patients with necrotizing soft tissue infections is far from its final solution, and many aspects of surgical and conservative treatment need further study.Description of the case.Patient G. 44 years old medical history No. 2026 was hospitalized in the department of purulent surgical infection in the OBUZ KGKB SMP of Kursk on 01.06.2022 with complaints of pain and swelling of the right hand, fever up to 380. 36 hours ago at work he was injured by the first finger of the right hand, as a result of a blow by a ruptured cable while towing transport. I did not seek medical help due to the small size of the finger wound. Colleagues at work treated the wound with iodine and applied a bandage. 12 hours after the injury, pain and swelling of the right hand appeared. The condition began to progressively deteriorate: the intensity of the pain increased, the swelling spread to the entire hand, a febrile temperature appeared. He was taken to the hospital by ambulance. Upon admission, the patient is in a moderate condition, excited, insists on providing emergency assistance. Pulse is 84 beats per minute, blood pressure is 130/80 mm Hg, there are no pathological deviations from the internal organs. The right hand is sharply swollen, hyperemic, painful on palpation. On the nail phalanx of the first finger there is a lacerated wound measuring 3 by 1 cm, from which cloudy contents are released. The skin and subcutaneous tissue around the wound are black. There is a band of hyperemia of the skin on the forearm and shoulder along the lymphatic vessels. A conglomerate of lymph nodes is palpated in the right axillary region. No bone changes were detected during radiography of the hand. Blood tests show leukocytosis of 11,000 with a shift of up to 27% of young forms. In biochemical blood tests, liver and kidney function indicators are at the upper limits of the norm, a pronounced increase in C - reactive protein to 332.8 mg / l. Urine tests without pathological changes.Taking into account the presence of endogenous intoxication syndrome, the patient underwent preoperative preparation in the volume of intravenous transfusion of 600 ml of blood substitutes. After 2 hours from the moment of admission, the first operation was performed: opening and drainage of the phlegmon of the right hand. Under intravenous anesthesia, 4 parallel vertical incisions 3 cm long were made on the lateral surfaces of the nail and main phalanges of the first finger. The subcutaneous tissue is gray, the discharge from the wounds is cloudy. The seeding of the separated on the bacterial medium was carried out. End-to-end drainage of finger wounds by rubber graduates was performed. A 5 cm long incision exposes the cellular space of the elevation of the first finger. Fascia and muscles are flabby, soaked with serous fluid, bleed badly. A tubular drainage is inserted into the wound.Photo of the right hand of the patient G. after the first operation is shown in Fig. 1.Fig. 1 Photo of the right hand of the patient G. after the first operation.Fig. 1 Photo of patient G.'s right hand after performing the first operation.After the operation, antibacterial (ceftriaxone, metronidazole), analgesic (ketorol), detoxification (transfusion of 2 liters of blood substitutes), therapy was prescribed, tetanus serum and tetanus toxoid were administered.After the operation, the patient's condition continued to worsen: pain and edematous syndromes spread to the right forearm and shoulder. The patient began to notice weakness, dizziness. Tachycardia increased to 110 beats per minute, blood pressure decreased to 110/70 mmHg. In blood tests, a pronounced leukocyte reaction with a shift to the left remained. Taking into account the increase in the syndrome of endogenous intoxication, the spread of the inflammatory process on the forearm and shoulder, it was decided to perform a second surgical intervention.02.06. 2022, 12 hours after the first operation, repeated surgical intervention was performed. Two parallel incisions were made on the back of the right hand, fascial spaces were opened. Necrotic areas of the skin and subcutaneous fat, superficial fascia are excised. In the wounds of the hand performed during the first operation, necrotic tissue was excised. In the distal part of the right forearm, two incisions up to 6 cm long were made along the ulnar and radial edges, and the Pirogov space was opened. Up to 20 ml of liquid pus was released, necrotic areas of soft tissues were excised. Two similar incisions were made in the proximal part of the right forearm. The discharge from the wounds is cloudy, the superficial fascia with areas of necrosis is excised. On the lateral and medial surfaces in the middle third of the right shoulder, 2 incisions were made with a length of 6 cm, the fascia was opened and the intermuscular spaces were revised. Soft tissues are edematous, the discharge is serous, the muscle tissue is viable. All postoperative wounds on the cyst, forearm and shoulder are drained.A photograph of the right hand of patient G. after the second operation is shown in Figure 2. Figure 2 is a photograph of the right hand of patient G. after the second operation.Fig. 2 Photo of patient G.'s right hand after performing the second operation.The patient was transferred to the intensive care unit. The results of microbiological examination of the discharge from the surgical wounds were obtained.

About the authors

Boris Semyonovich Sukovatykh

Kursk state medical University

Email: SukovatykhBS@kursksmu.net
ORCID iD: 0000-0003-2197-8756

MD, Professor, head of chair of General surgery 

Russian Federation, K. Marx str., 3 Kursk, 305041, Russian Federation

Yuri Yurievich Blinkov

Kursk state medical University

Email: BlinkovUU@kursksmu.net
ORCID iD: 0000-0002-0819-0692

MD, Professor of the Department of General Surgery 

Russian Federation, K. Marx str., 3 Kursk, 305041, Russian Federation

Ilya Alexandrovich Zaitsev

Kursk City Clinical Hospital of Emergency Medical Care

Email: sukovatykhbs@kursksmu.net
ORCID iD: 0009-0004-5889-2002

Head of the department of purulent surgical infection

Russian Federation, Pirogova str., 14, Kursk, 305035, Russian Federation

Yuri Sergeevich Zuev

Kursk City Clinical Hospital of Emergency Medical Care

Email: sukovatykhbs@kursksmu.net
ORCID iD: 0009-0009-6563-6433

doctor of the department of purulent surgical infection

Pirogova str., 14, Kursk, 305035, Russian Federation.

Vyacheslav Mikhailovich Pashkov

Kursk state medical University

Author for correspondence.
Email: pashkovvm@kursksmu.net
ORCID iD: 0009-0004-8401-4991

PhD, Associate Professor Department of General Surgery

Russian Federation, K. Marx str., 3 Kursk, 305041, Russian Federation

References

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