Download CBL infection

Case-based learning
內科部 感染醫學科
鄭鈞文
案例簡介-Necrotizing fascitis

Mr. Huang, a 34 year-old man, was a case of alcoholic liver
cirrhosis. He visited our emergency department due to left
lower leg pain and swollen 2 days ago. Initially he visited local
clinic and received oral antibiotics. But his left foot swollen,
pain, and tense sensation, rapidly extended to left thigh on
the next day. Fever with hypotension was found at ER, and
emergent medical and surgical management was arranged…
學習目標-Necrotizing fascitis






To identify the symptoms and signs of skin and soft tissue
infection
To identify the early symptoms and signs of necrotizing
fascitis
To understand the common pathogens of skin and soft tissue
infection
To understand the common pathogens of necrotizing fascitis
To understand the appropriate empiric antibiotics for skin and
soft tissue infection
To understand the indications of surgical management for
skin and soft tissue infection
感染科案例-Necrotizing fascitis
場景(1): 病史



Mr. Huang, a 34 year-old man, was a case of alcoholic liver
cirrhosis for 8 years. He didn’t receive regular GI OPD followup and kept drinking in recent years.
Three days ago, he got his left toe injured by an oyster shell
during fishing at the beach. Initially it was a 0.5x0.5 cm wound.
However, his left foot got pain, swollen and tense sensation
on the next day. He visited local clinic and took some oral
medications. But left leg pain and swelling rapidly progressed
to thigh. Several big blisters was found on his left calf.
He visited our emergency department on third day. Fever and
hypotension were found.
感染科案例-Necrotizing fascitis
討論(1)
 Identify Mr. Huang’s problems.
 Discuss possible hypotheses that account for one or
more of Mr. Huang’s problems.
 Prioritize your list of hypotheses.
 What further information is needed to prove or
disprove the hypotheses?
感染科案例-Necrotizing fascitis
場景(2):檢驗檢查
•
•
•
•
•
•
•
•
Vital sign: BT 38.6℃, PR 110/min, RR 22/min, BP 85/56 mmHg,
BW 68 kg
Conscious: clear, E4V5M6
Eye: pale conjunctiva, no icteric sclera
Neck: supple, no JVE, no palpable lymph node
Chest: bilateral clear breath sound
Heart: regular heart beat, tachycardia, no murmur
Abdomen: soft and mild obese, no abdominal tenderness
Extremities: Erythematous change, swelling and severe
tenderness over left foot, lower leg and thigh. Several
hemorrhagic blisters over left calf area were noted.
感染科案例-Necrotizing fascitis
場景(2):檢驗檢查
WBC
1400 /uL
Sugar
85 mg/dL
Hb
15.2 g/dL
Cre
6.64 mg/dL
PLT
91000 /uL
AST
66 U/L
A-Lym
5%
ALT
41 U/L
Meta
2%
Na
130 mEq/L
Seg
64%
K
3.4 mEq/L
Band
11%
CRP
186.2
Lym
4%
Myoglobin
4902.2 ng/mL
Mono
15%
Eos
2%
感染科案例-Necrotizing fascitis
討論(2)
 How dose the above information change your
hypothesis ?
 What further examinations do you need to confirm
your diagnostic hypothesis ?
感染科案例-Necrotizing fascitis
場景(3)確認診斷與後續治療計畫

Plain film and CT scan for Mr. Huang’s lower extremities. Main radiological
findings were: gas in the subcutaneous tissues, thickening of the affected
fascia, fluid collections along the deep fascial sheaths, and extension of
edema into the inter-muscular septa and the muscles
感染科案例-Necrotizing fascitis
場景(3)確認診斷與後續治療計畫

His blood culture grew gram negative bacilli (2/2) 16
hours after admission.

Blood culture result turned out to be Vibrio vulnificus
感染科案例-Necrotizing fascitis
討論(3)
 What is your main diagnosis for this patient ?
 How would you treat this patient ?
NF-Pathogens
 A substantial proportion of community-acquired NFs are
monomicrobial (type II)
Pathogens and clinical condition
Predisposing factors
Group A Streptococcus (S pyogens)
Erysipelas, Cellulitis, Necrotizing fascitis
Trauma or minor skin breaks, lymphedema,
relatively healthy host
Group B Streptococcus (S agalactiae)
DM, premature neonate
Clsotridium spp.
Clostridial myonecrosis
Grossly contaminated wound (C perfringens)
associated with colon neoplasms (C septicum)
intravenous drug use (C sordellii, C noyvi)
NF-Pathogens
Pathogens and clinical condition
Predisposing factors
Aeromonas spp (A hydrophilia)
Freshwater exposure, medicinal leeches
Vibrio spp (V vulnificus)
Chronic liver disease, Saltwater exposure,
improperly cooked crustaceans
Pasteurella spp
Dog bites (P canis), cat bites (P multocida)
Less common but emerging
organisms:
Commnity-acquired MRSA
Enterobacteriaceae (E coli, K
pneumoniae, Serratia marcescens)
Pseudomonas aeruginosa (Ecthyma
gangrenosum)
Erysipelothrix rhusiopathiae
Empirical antimicrobial agents
 Group A Streptococcus –
First choice: Penicillin G + Clindamycin
Alternative: 1st-3rd generation cephalosporin, glycopeptide, new
fluoroquinolone
 Virbio vulnificus –
First choice: minocycline or doxycyline + 3rd generation
cephalosporin
Alternative: fluoroquinolone
Management of NF
 Early diagnosis
 Appropriate antimicrobial agents directed at the
most likely pathogens
 Prompt consideration of surgical intervention
(fasciotomy and debridement)
感染科案例-Necrotizing fascitis
參考資料及文獻



Rapidly progressive soft tissue infections. Donald C Vinh, John
M Embil. Lancet Infect Dis 2005; 5: 501–13
Skin and Soft Tissue Infections: The New Surgical Infection
Society Guidelines. Addison K. May. Surgical infections. 2011;
12(3): 179-84
Emergent Management of Necrotizing Fasciitis. Medscape
reference. http://emedicine.medscape.com/article/784690overview