What is the diagnosis?

Concern for necrotizing fasciitis, which was later confirmed during surgery. Note the story of rapid spread of rash and pain, hemorrhagic bullae on exam, and subcutaneous gas on x-ray, as this is the classic presentation of necrotizing fasciitis. 

• Pearl: Necrotizing fasciitis is a life-threatening, rapidly progressive skin and soft tissue infection that is characterized by extensive tissue necrosis. Risk factors include trauma, immunocompromised state, IV drug use, diabetes and recent surgery [1].

What physical exam findings are expected?

Exam findings include pain out of proportion to exam, skin necrosis, hemorrhagic bullae, crepitus and woody edema [1,2].

Which imaging modalities can be used?

CT with contrast is the study of choice for the work-up of necrotizing fasciitis. CT can show fascial gas, fascial edema and fascial enhancement, and these findings have a sensitivity of 94% and a specificity of 77% for necrotizing fasciitis [2].

• Pearl: Other options include plain radiographs which can show gas in soft tissues but have poor sensitivity [2]. Ultrasound can be used as an adjunct, however it is less sensitive than CT and is limited due to inadequate resolution of deep structures [3,4].

• Pearl: Remember that although imaging can be helpful, necrotizing fasciitis is primarily a clinical diagnosis that requires rapid surgical consultation if concern exists 

What is the management in the ED?

Broad spectrum antibiotics, appropriate resuscitation and surgical consult

• Pearl: Antibiotics should be targeting gram-positives, gram-negative and anaerobes. A common regimen includes Vancomycin, Zosyn and Clindamycin. However, studies have shown Linezolid to be superior to Vancomycin in the treatment of skin and soft tissue infections [5,6].

When do you consult surgery?

Any clinical suspicion for necrotizing fasciitis

• Pearl: Necrotizing fasciitis is a surgical emergency and patients can deteriorate rapidly even if treated appropriately, as happened with this patient. Early surgical exploration and debridement is associated with significantly decreased mortality [7].

• Pearl: Depending on location and institution, this may be managed by general surgery vs orthopedic surgery.