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Soft Tissue Infections English 3-Rd 2016
Soft Tissue Infections English 3-Rd 2016
History
A 48-year-old man with a history of alcoholism and
cirrhosis presents to the emergency department for
evaluation for severe left leg pain and fever. The
patient says that his symptoms began after he
scraped the lateral aspect of his knee at home 3 days
ago. During the past 2 days, he has had subjective
fever and noticed decreased urinary frequency. The
patient has self-medicated with aspirin for these
symptoms. He consumes approximately 16 oz (473
mL) of whiskey per day and smokes one pack of
cigarettes per day. On physical examination, his
temperature is 39.2 C (102.6 F), pulse rate is 110
beats/ minute, blood pressure is 115/ 78 mm Hg, and
respiratory rate is 28 breaths/ minute. His skin is
mildly icteric.
History
The findings from his cardiopulmonary examination
are unremarkable. The abdomen is soft and without
hepatosplenomegaly or ascites. The left leg is
edematous from the ankle to the upper thigh. The
skin is tense and exquisitely tender; however, it is
without erythema, fluctuance, necrosis, or vesicular
changes. Examination of the right leg reveals
normal findings. Laboratory studies demonstrate a
WBC count of 26,000/ mm3 and normal hemoglobin
and hematocrit values. Other laboratory studies
reveal sodium 128 mEq/ L, glucose 180 mg/ dL, total
bilirubin 3.8 mg/ dL, and direct bilirubin 1.5 mg/ dL.
Radiographs of the left leg reveal no bony injuries
and no evidence of air in the soft tissue space.
Questions
Summary
Considerations
This patient with alcoholic cirrhosis presents with
severe soft tissue infection of the left lower
extremity following a trivial soft tissue injury 3
days ago. His vital signs and laboratory studies
(fever, tachycardia, tachypnea, high WBC count,
and low sodium) indicate that he is already
septic. An individual with alcohol-induced
cirrhosis is considered immune compromised,
and has increased susceptibility to multiple types
of infections and septicemia. Blood cultures
should be obtained promptly, followed by the
initiation of intravenous fluids and empiric
antibiotic therapy to cover potential polymicrobial
infections.
Considerations
In this patients case, vancomycin and
piperacillin/ tazobactam are an appropriate initial
treatment regimen. Next, a CT scan of the
affected lower extremity should be obtained to
evaluate the possibility of deep tissue space
infections and to assess the extent of the soft
tissue infection. Although his history is
suggestive of a skin-based soft tissue infection,
the findings on his affected extremity are not
specific for a necrotizing soft tissue infection
(NSTI) and may be compatible with a deepseated abscess with extensive adjacent soft
tissue infection.
Considerations
A CT scan is valuable to guide the extent of the
wound exploration/ debridement and help identify
potential hidden abscesses. Surgical debridement
and/ or wide drainage are very important adjuncts in
this patients treatment, and delays in surgical
treatment have been demonstrated to negatively
affect the outcomes of patients with NSTIs. It is
important to collect tissue and fluid specimens for
culture and Gram Stain to optimize the antibiotic
treatment. Distant end-organ dysfunction including
acute respiratory insufficiency, acute liver
dysfunction, and acute kidney injuries can occur in
individuals with NSTI, and close monitoring is needed
for prompt implementation of supportive care..
Considerations
The surgical approach should begin with incision and
inspection of the soft tissue space and fascia. Easy
separation of the subcutaneous tissue from the
underlying fascia indicates microvascular thrombosis
and necrosis and should be treated with soft tissue
debridement. The deep fascia overlying the muscle
should be inspected for viability, and if discoloration
and necrosis is encountered, debridement of the
fascia should be carried out. Muscle fascia is a
natural protective layer for the muscles, and
infections deep to the fascia occur uncommonly
unless a deep puncture wound with bacterial
inoculation into the muscle has occurred.
Considerations
Because of the rich blood supple to the skin, patients with
NSTI generally do not develop skin necrosis and bullous
changes until late in the disease process. The absence of skin
abnormalities is one of the leading factors contributing to
delays in recognition of NSTI. When the process is recognized,
all necrotic tissue should be excised. Infectious involvement
of the muscles is uncommon except with deep puncture
wounds into the muscles and in cases of infections involving
Clostridium species. When patients with NSTI fail to improve
with supportive care, antibiotic therapy, and surgical
debridement, consideration should be given that not all
affected soft tissue has been identified and debrided. The
lack of improvement in patients is often due to inadequate
debridement and/ or inappropriate antibiotic selection
(source control).
DEFINITIONS
SIMPLE CELLUTITIS: Milder form of soft tissue infection
without microvascular thrombosis and necrosis. Clinically,
patients do not exhibit systemic signs and symptoms.
Antibiotics therapy are sufficient treatment.
NECROTIZING CELLULITIS: This term refers to skin and
superficial subcutaneous fat infection associated with
microvascular thrombosis and necrosis. The patient often
exhibits systemic signs and symptoms. This process is
generally related to infection with group B streptococcus or
community-acquired MRSA. Treatment consists of
antibiotics, local debridement, and supportive care.
NECROTIZING FASCIITIS: This term refers to infection of the
skin, subcutaneous fat, and fascia. This process is
frequently associated with microvascular thrombosis and
tissue necrosis. Soft tissue debridement is an essential
component of treatment.
DEFINITIONS
FINGER TEST FOR NSTI DIAGNOSIS: This is an adjunct method of
diagnosing NSTI. A 2- to 3-cm skin incision is made under local
anesthesia and carried down to the fascia. This is then followed by
insertion of gloved finger to digitally evaluate the fascia. With NSTI, the
subcutaneous fat will separate easily without bleeding, and there will
often be a presence of murky dishwater fluid in the subcutaneous
tissue.
IMMUNE-DEFICIENT HOSTS WITH NSTI: Immune-deficient hosts include
individuals with who use corticosteroids, with active malignancy,
receiving chemotherapy or radiation therapy, with positive HIV status,
receiving immunosuppressive medications for bone marrow or solid
organ transplantation, with cirrhosis, and with alcoholism. Studies have
shown that immunocompromised hosts do not exhibit the usual
responses to NSTI, and therefore, are susceptible to delayed treatments
and misdiagnoses. Increasing vigilance for this condition in susceptible
individuals is important.
NSTI ASSOCIATED WITH SURGICAL SITES: Occasionally, this can occur
and can be difficult to diagnose and differentiate from simple wound
infections. The systemic signs associated with this process are often
easily attributed to other conditions, such as pneumonia or atelectasis.
DEFINITIONS
COMMUNITY ACQUIRED-MRSA INFECTION (CA-MRSA): These
infections are becoming increasingly more common. CAMRSAs are genetically and phenotypically different from
hospital-acquired MRSA. CA-MRSA may produce the
pathogenic Panton-Valentine leucocidin (PVL) toxin, which
destroys white blood cells. Oral antibiotic options for CAMRSA include clindamycin, trimethoprim-sulfamethoxazole,
tigecycline, doxycycline, minocycline, linezolid, or
daptomycin.
TETANUS IMMUNIZATION: Tetanus is the clinical sequelae
associated with Clostridium tetani infections. Individuals
residing in the United States are given a set of initial
immunization shots during infancy, childhood, and
adolescence. Booster shots are recommended every ten
years for adults. Clostridium tetani is an organism that can be
found in soil, dust, and animal feces, and in high-risk wounds
include animal bites, human bites, and dirty wounds
DEFINITIONS
TETANUS IMMUNE GLOBULIN: This is an IgG
antibody that neutralizes the toxins that would
cause tetanus. Administration provides
transient passive immunity for individuals who
are not properly immunized (or have unknown
tetanus immunization history) and have been
exposed to or suspected of having been
exposed to the tetanus toxin.
CLINICAL APPROACH
Soft tissue infections should be suspected in individuals with
pain and edema involving the skin, an extremity, or a body
region, which may or may not be associated with
inflammatory changes in the skin. It is important to elicit a
detailed history from the patient regarding recent trauma to
the affected area, including trivial trauma such as skin
abrasions and minor lacerations. Severe soft tissue
infections should be suspected when individuals described
above exhibit systemic signs such as tachycardia, fever,
tachypnea, hypotension, or oliguria.
Physical examination of the affected soft tissue area can be
extremely helpful. Pain out of proportion to skin changes is a
highly suspicious finding, and is often thought to be related
to microvascular thrombosis and tissue ischemia associated
with NSTI. It is extremely important to pay attention to the
patients descriptions of symptoms and not disregard their
complaints due to absence of specific skin changes.
CLINICAL APPROACH
Laboratory studies are helpful in identifying patients with
NSTI and may be helpful for disease severity stratification.
WBC count over 20,000 mm3 and hyponatremia (serum
sodium < 130 mEq/ L) have been reported to prognosticate
poor outcomes.
For patients with possible NSTI, deep abscesses, and
unclear extent of their infectious processes, a CT scan can
be very helpful to identify fat stranding, fluid and/ or gas
collections tracking along fascial planes, which are early
signs of NSTI. In addition, CT scans can identify deep soft
tissue abscess that clinically may present as a simple soft
tissue infection. CT imaging have been reported to be
associated with 100% sensitivity and 81% specificity for
NSTI diagnosis. Visualization of the subcutaneous tissue
and fascia are important during surgical exploration for
NSTI.
T
CLINICAL APPROACH
The finger test helps to identify tissue necrosis
along the fascia. In addition, the findings of
marked subcutaneous tissue edema and dishwater-appearing fluid in the subcutaneous
space are highly suggestive of NSTI.
Close monitoring of patients following the initial
wound exploration and/ or soft tissue
debridement is vital, because if the patients do
not show improvements, re-exploration and/ or
modification of antibiotic treatments should be
implemented.
Fourniers Gangrene
This is a rapidly progressive soft tissue infection of
the perineal, scrotal, and penis area in males, but
the process can occur less commonly in the perineal
region in females. The infection can lead to skin
necrosis, sepsis, and death within hours to days if
unrecognized and untreated. Fourniers gangrene
was originally described in 1883 as scrotal soft
tissue infections in a group of healthy young men.
The infection is commonly a polymicrobial
synergistic type of infection leading to sepsis and
MODS. Treatment consists of broad-spectrum
antibiotics directed at aerobic and anaerobic
organisms and radical debridement of the affected
soft tissue.
Review questions
E.
individuals
The outcome of NSTI treatments in immune-compromised
hosts is the same as in healthy normal hosts
NSTI in immune-compromised hosts usually is caused by
different bacterial organisms from the usual population
Clinical presentations of NSTI is the same for immune
compromised individuals and immune competent
individuals
Treatment is often delayed in immune compromised hosts
because of variability in clinical presentation.
Review questions
2. Which of the following is most accurate for
Review questions
3. Which of the following soft tissue infection
prosthesis implantation
D. Necrotizing myositis
E. Impetigo
Review questions
4. A 38-year-old man with a history of injection heroin abuse
Review questions
5. A 33-year-old house painter sustained an abrasion and
Review questions
6. A 62-year-old man with diabetes returns to the emergency
Review questions
debridement
C. Supportive care, penicillin G, tetracycline, ceftazidime, surgical
debridement, and hyperbaric treatment
D. Supportive care, penicillin G, clindamycin, and Intravenous Ig
E. Supportive care and penicillin G
CLINICAL PEARLS
The most common findings in a patient with NSTI are
local edema and pain in the presence of systemic
signs such as high fever (hypothermia in some
patients), tachycardia, and often mental confusion.
NSTI should be suspected when pain and tenderness
extend beyond the area of skin erythema.
When NSTI is strongly suspected, exploration of the
wound through a limited incision may help to
establish the diagnosis. Drainage of dish water
fluid and easy separation of the subcutaneous tissue
from the affected fascia is seen during digital
exploration.
CLINICAL PEARLS