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An 82-year-old male was admitted to the accident and emergency department complaining of severe pain in his upper right thigh and sudden onset abdominal pain. On examination his temperature was 38.2°C, pulse rate 130 beats/minute and blood pressure 98/65 mm Hg. His right thigh was noted to be extremely tender, swollen and erythematous. In addition, crepitus was notable on palpation. His abdomen was diffusely tender, but was soft with no evidence of peritonism. With regard to his past medical history the patient was known to have insulin dependent diabetes. There was no known history of trauma, insect bites or abrasions. Routine blood investigations revealed a haemoglobin of 15.1 g/dl, white cell count of 7×109/l, C-reactive protein (CRP) of <5, urea of 10.5 mmol/l and creatinine of 173 μmol/l. Serum creatine kinase was extremely elevated at 6058 IU/l and albumin reduced at 30 g/l. An arterial blood gas investigation was carried out and revealed no evidence of metabolic acidosis.
A computerised tomography (CT) scan of the chest, abdomen and lower limbs was performed (figs 1–5).
The patient was rapidly resuscitated and broad spectrum antibiotics were administered intravenously as a penicillin, gentamicin and metronidazole regimen. Unfortunately, the patient died due to overwhelming sepsis and multi-organ failure before surgical debridement could be performed.
Necrotising fasciitis is a rare but life threatening condition with a high mortality and morbidity. Reported mortality varies from 6% to 76%.1 Characteristics that help distinguish patients with idiopathic necrotising fasciitis from secondary necrotising fasciitis include an age greater than 55 years, the presence of co-morbidities such as diabetes mellitus or chronic renal failure, and perineal localisation.2 Various mechanisms have been suggested to account for diabetes associated necrotising fasciitis and include the fact that the peripheral sensory polyneuropathy experienced by diabetics may increase susceptibility to minor trauma or tissue hypoxia caused by diabetic vascular disease.3 The diagnosis of the condition is primarily based on clinical findings with laboratory investigations acting only as an aid to support the clinical picture. A prompt diagnosis is often difficult but is essential with immediate surgical intervention to help ensure a potentially positive patient outcome.
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Competing interests: none.