Progress Report

PROGRESS REPORT ON Wesbild #20041406
This patient’s deep-seated infection of subcutaneous tissue progressively destroyed fascia and fat, but the skin and muscle was spared. We’ve identified the cause as mixed organisms (aerobic gram-negative bacteria, anaerobes, microaerophiic streptococci) in an open wound contaminated with bowel contents. Within 24 hrs. of the initial lesion tenderness rapidly developed, the erythema changed from red to purple and then to blue. Blisters and bullae containing clear yellow fluid then appeared. On day 7 the line of demarcation became sharply defined, the dead skin began to separate at the margins, revealing an extensive necrosis of the subcutaneous tissue. The patient became dull, unresponsive, and delirious at times. Current Hypostheses Regarding Mechanisms of Shock and Tissue Destruction Caused by Virulent Group A Streptococci. Though the antibiotic selection was critically important, other measures, like prompt, aggressive exploration and debridement of suspected deep-seated S. pyogenes infection was mandatory. The patient had fever and was in excruciating pain. Systemic toxicity would have developed. There was definite evidence of necrotizing fasciitis. If we had waited any longer, surgical debridement would have been too late. Prompt surgical exploration through a small incision, and timely Gram stain of surgically obtained material provided an early and definitive etologic diagnosis. Surgical colleagues were involved early in this case because the infection may have extended to vital areas impossible to debride.