Abstract: A healthy, 14-year-old girl presented with what was initially a minor hand abrasion with edema and apparent ecchymosis. Over the next 12 hours, dusky rings developed over the forearm. Key features leading to diagnosis were pain out of proportion to the injury and a CT scan that was positive for gas in the tissues. Optimal limb salvage was obtained with an integrated, multidisciplinary approach that included hyperbaric medicine, surgery, infectious disease, wound care, rehabilitation services, and behavioral health. Multiple surgeries included debridement, layered matrix dressings, and a split-thickness skin graft. The following case report discusses the etiology, diagnosis, mechanism of injury, and treatment of Type II necrotizing fasciitis. Unique problems that are encountered when treating pediatric patients with this problem are discussed and keys to successful outcomes are proposed.

Address correspondence to:
Joan Eggert, MD, MPH
Dept. of Hyperbaric Medicine
Intermountain Dixie Regional Health Center
544 S 400 E
St. George, UT 84790
Phone: 453-669-2148
E-mail: lveggert@msn.com

Case Report

     A healthy, 14-year-old girl presented to the emergency room 10 days after playing the “ABC game.” The game requires the participant to think of words starting with the letter called out by other players while fingernails or other sharp objects are used to scratch the hand. The patient also recalled moving a heavy dresser 2 days earlier, which had fallen on her arm. The morning after moving the dresser she noted a circular bruise on the distal part of her forearm, but had full use of the arm until about 5 pm the night of admission. Her mother brought her to the emergency room just before midnight with an extremely painful and swollen left hand. Examination of the dorsal surface showed a healed 4-cm linear scar, minor erythema, moderate edema, and slight ecchymosis. She was afebrile, plain radiograph did not show any fracture or intraosseous abnormality, and she was admitted to the pediatrics floor. The pediatrician and social worker interviewed the patient and excluded non-accidental trauma. There was no evidence of bruising anywhere else on her body. Initial laboratory findings were: white blood cell count (WBC) of 14.6 K/uL, erythrocyte sedimentation rate (ESR) of 4 mm/h, C-reactive protein (CRP) of .4 mg/dL, partial thromboplastin time (PT) of 13 seconds, D-Dimer 846 ng/mL, and fibrinogen 309 mg/dL. All basic metabolic profile values were normal. Blood pressure was 114/77, respirations were 18 breaths per minute, and pulse was 69. She had developed some nausea and vomiting, but did not appear to be systemically ill or in any pain unless the arm was palpated. Pediatric hematology consultation was obtained. Differential diagnosis included traumatic injury with rapidly spreading hematoma, vasculitis, bleeding disorder, or infection. Vancomycin and ceftriaxone were started and she immediately developed a red-man reaction to the vancomycin with itching and hives. This resolved with Benadryl, and the ceftriaxone was continued. Over the next 12 hours, the patient developed progressive dusky-purple rings over the lower and upper arm (Figure 1). At this time, a CT scan of the arm was taken showing evidence of gas in the tissues. She was emergently taken to the operating room by the orthopedic and plastic surgeons.

     Extensive Type II necrotizing fasciitis involving the entire lower arm and the distal half of the upper arm was found (Figure 2). A small amount of “soupy fluid,” but no frank pus, was found. The subcutaneous tissue and skin on the volar aspect of the forearm was thrombosed and nonviable.