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Necrotizing myofascitis (NM) is a limb and life-threatening condition which is a surgical emergency. Early disease recognition with appropriate diagnosis and quick decision making are vital to minimize morbidity and mortality.
10 years old boy presented to Emergency Department (ED) with complaint of left forearm pain and swelling following fall from stairs 2 days prior to symptoms. He also developed fever and had history of massage prior to ED visit. The boy was brought to ED few days after incident as the father initially seek traditional treatment. Examination revealed septic looking boy with swollen left forearm from above elbow until dorsum and volar aspect of hand with multiple blisters. He had loss of sensation over all nerves distribution. Compartment was tense over distal forearm with weak radial pulse. Radius/ulna radiograph showed gas shadow up to elbow joint meanwhile urgent ultrasonography of left upper limb revealed features of intramuscular collection with soft tissue gas. Resuscitation with fluid and intravenous antibiotic were done and he was sent to operation theater for emergency fasciotomy and wound debridement which later on end up with left transhumeral amputation. Operative findings demonstrated necrotic muscle with pus in the compartment which fit the diagnosis of necrotizing myofascitis. The culture and sensitivity came out as Enterobacter.
NM is a severe but extremely rare form of soft tissue infection with often nonspecific presentation. It is associated with high rates of morbidity and 100% mortality without surgical intervention. Predisposing factor in this case is trauma which allow the organism to enter the tissue. Bacterial myositis is usually associated with gram-positive organisms and aerobic gram-negative bacteria being very rare which made our case unique as Enterobacter was found in the culture taken. The role of ultrasonography in emergency setting should be highlighted as it facilitates immediate intervention.
Although NM is very rare, a high index of suspicion for the diagnosis is important when encountering patient with extreme muscle pain and swelling as early diagnosis and prompt surgical and pharmacological intervention is vital in determining patient’s outcome.
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