Case Study: Treating Necrotizing Fasciitis Caused By Serratia Marcescens

Ronald Guberman, DPM, DABPS, CWS, and Lida Faroqi, DPM

These authors detail the case of a 52-year-old man who presented with a fast spreading necrotizing fasciitis and a severe infection.

   Necrotizing fasciits is an infection of the deep layers of the skin and subcutaneous tissues. The disease consists of two variants, classified as Type I and Type II. Type I is a polymicrobial infection whereas Type II is a monomicrobial infection, mainly due to Group A Streptococcus. Since 2001, methicillin-resistant Staphylococcus aureus (MRSA) has been the most commonly reported bacteria causing necrotizing fasciitis. Early signs of the disease, such as an erythematous or edematous extremity, may be subtle. Other signs may consist of blister formation on the affected limb or systemic signs such as nausea and vomiting.

   A 52-year-old male presented to the emergency department after experiencing pain and redness of his right leg/foot. The morning of his admission, the patient noticed bulla formation on the dorsum of his right foot and it became worse in a matter of hours.

   The patient denied any trauma to the right foot but noted a fever and generalized malaise. The past medical history included lower extremity cellulitis, cirrhosis of the liver, hepatitis C, acute renal failure, hyperkalemia, esophageal varices and morbid obesity.

   The patient’s current medications include pontoprazole (Protonix, Wyeth), propranolol, OsCal, multi-vitamins and folic acid. He has no known drug allergies. The patient does have a past social history of IV drug use but this concluded 15 years ago.

   The patient presents with blood pressure of 114/69, heart rate of 81, respiratory rate of 20 and temperature of 97º. The patient has significant lab results with a white blood cell count of 11.5 thousand and an erythrocyte sedimentation rate of 55.

   During the physical examination, we noted palpable dorsalis pedis and posterior tibial pulses in the right lower extremity with extensive erythema extending from the knee to the base of the digits. Bulla formation was present on the central and medial aspects of the foot dorsally. The patient also had pain on palpation to the foot and leg. He was also experiencing calf tenderness.

   We performed an emergency incision and drainage on the foot and extended this to the proximal third of the leg. We started the patient on vanocmycin, clindamycin and maxipime. The venous duplex was negative for deep vein thrombosis. We applied VAC therapy (KCI) to the right leg and foot after we performed the initial fasciotomy. The patient returned to the OR six days postoperatively for further debridement.

   This patient had a case of necrotizing fasciitis caused by Serratia Marcescens. This was a true necrotizing fasciitis as evidenced by the speed in which it progressed and the type of infection it caused. Despite the severity of this infection, the deeper tissues were spared and we were able to discharge the patient to a rehabilitation facility without the loss of his foot or leg. The patient followed up to the wound care clinic and had Dermagraft (Advanced Biohealing) applications to the leg with complete healing to the leg within six months. The foot wound was much more extensive and required more local wound care.

   Dr. Guberman is the Director of Podiatric Medical Education and is the Co-Chief of the Podiatry Division in the Department of Surgery at Wyckoff Heights Medical Center in Brooklyn, N.Y.

   Dr. Faroqi is a Fellow in the Wound Care Fellowship at Wyckoff Heights Medical Center. She completed the PG&Y 36 program at Wyckoff Heights Medical Center as well.


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