THE CURATIVE PRICK AND THE COVETOUS MONSTER: POTENTIAL PARTNER

Abstract

Introduction: Necrotizing fasciitis (NF) is a severe form of infection involving the skin, soft tissue, fascia, and muscle. It is a life-threatening and rapidly progressive infection that needs prompt medical attention. Thus, early diagnosis and treatment are vital in determining patient outcomes. We reported a case of NF due to post-intramuscular injection and the role of point-of-care ultrasound (POCUS) in managing her condition. 

Case: A 45-year-old lady with no past medical history, presented with a three-day history of fever, right thigh pain, and swelling. One day prior, she had received a right gluteus intramuscular injection of analgesia at a local private clinic for back pain. Her physical examination showed swelling over the right thigh extending to the calf with erythema, tenderness, and pitting edema. There were multiple round to oval brownish hyperpigmented lesions on the anterior aspect of the right lower extremities. Distal pulses were palpable. Bedside capillary glucose was high and other septic parameters were raised. The right lower limb radiograph was normal. No sonographic evidence of deep vein thrombosis from ultrasound Doppler assessment. A few hours later, she progressively developed multiple bullae containing serous fluid, ecchymosis, and crepitus at the posterior aspect of the right lower limb. POCUS of soft tissue showed subcutaneous thickening and fascial fluid giving a “cobblestone” appearance over the right gluteus, thigh, and calf.

Results: Subsequently, her clinical condition worsened, and she required airway protection. She was started on appropriate antibiotics and vasopressors. Unfortunately, she succumbed to her illness despite aggressive resuscitation. Her blood culture test showed positive for Staphylococcus Aureus.

Discussion: This case illustrates how a simple invasive procedure (intramuscular injection) dramatically causes fatality in an underdiagnosed diabetic patient. Even with appropriate techniques, injection creates a local portal of infection.

Conclusion: We suggest a random glucose test before any invasive procedure for diabetic or non-diabetic patients especially in 40 years and above. In addition, POCUS assessment of soft tissue is relevant when other imaging modalities are limited to determine the source of infection.