Patient Care

Rare Skin Infection Afflicts Hurricane Harvey Rescuer

Issue 3 and Volume 43.

Rare skin infection afflicts Hurricane Harvey floodwater rescuer

J.R. is a young man who worked for a 9-1-1 service immediately after graduation from high school. He loved his job, and was a dedicated and arduous worker.

Although J.R. needed to depart from the EMS world for personal reasons, he maintained his medical acumen via his current position within the medical area of a national organization. He resides in Missouri City, Texas, with his wife and children.

On August 25th, 2017, a few hours away from Missouri City, Hurricane Harvey made landfall along the Texas coast with anticipated catastrophic damage. Not only was this hurricane the third Category 4 to ever make landfall in Texas, but it was also the first since 1961, and the first in 13 years to hit the U.S.1

In anticipation of Hurricane Harvey, J.R.’s neighborhood was to be evacuated. However, there were some neighbors who elected to stay or weren’t able to leave. The flooding that ensued as a result of the storm was unprecedented and profound, trapping and isolating Texas residents.

As a part of a neighborhood care team, J.R. was contacted by a local pharmacy to check on persons in the neighborhood who were likely in need of medications. J.R., in collaboration with his neighbors, used borrowed boats to search his subdivision for neighbors in need of assistance.

Upon returning home that night, J.R. noticed what he thought was a red mosquito bite on his wrist. He described the bite as, “feeling more painful than usual, maybe like a spider bite.”

The next morning, J.R. noticed that the bite and redness had increased in size to that of a half dollar. He described the pain as a burning sensation that radiated through his hand. Concerned, J.R. called a physician friend who recommended that he be evaluated and advised that he obtain a prescription for antibiotics.

Hospital Course

Over the course of the morning, J.R. noticed the swelling had rapidly increased past his wrist. Following his friend’s advice, J.R. presented to an urgent care center later that morning.

Redness at the site of the bite quickly increased in size and resulting in significant swelling. Photos courtesy Renee Johnson

When assessed in urgent care, J.R. had a temperature of 103 degrees F, and was sent to the ED. In the ED, J.R. noticed that he’d lost sensation in his pinky finger of the same hand. Although only in the ED for 45 minutes, his diagnosis was determined, the surgical team was consulted, antibiotics were started, and J.R. was swiftly admitted to the inpatient unit.

Shortly after arriving in the inpatient unit, J.R. reported “feeling weird.” His blood pressure was found to be “80s/40,” so IV fluid resuscitation was started without improvement, eventually requiring the use of vasopressors. J.R. was subsequently moved to the ICU with concern for septic shock.

In addition to medical resuscitation, J.R. underwent a total of three surgeries for debridement and wound closure. His hospital course was complicated by development of compartment syndrome, for which he required an additional incision from his elbow to his wrist to treat with drains initially placed, and eventual closure days later. J.R. also battled with pneumonia while in the hospital, from which he recovered.

After a 14-day hospital stay, nine of which were in the ICU, J.R. was able to return home with a three-week course of oral antibiotics to be taken daily. J.R. was required to have multiple follow-up visits with infectious disease doctors including numerous blood draws. However, J.R. was most anxious to begin rehabilitation to return to his functional baseline.

Although the duration of occupational and physical therapy was estimated to take 90 days, with anticipated cessation of work activities for 3–6 months, J.R. recovered in 2.5 months. J.R. notes that the most difficult part of the recovery for him is the pain from his scars, but he’s utilizing specific therapies to assist with this.

The patient underwent a total of three surgeries for debridement and wound closure.

Discussion

Skin and soft tissue infections (SSTIs) are classified as simple or complicated, and can involve the epidermis, dermis, subcutaneous fat, fascia or muscle. Cellulitis, erysipelas, impetigo, folliculitis, and an abscess are examples of simple SSTIs. Necrotizing fasciitis is an example of a complicated SSTI, one that reaches the level of the fascia and continues to spread.2

Since 2010, necrotizing fasciitis has an incidence of 600–1,200 cases per year in the United States, and the incidence appears to be increasing.3,4 Although rare, it’s associated with high mortality, bearing mortality rates that exceed 30%.5

The incidence of necrotizing fasciitis inpatient admissions in Texas varied between 59 cases per 1,000,000 person between 2001 and 2002, and 76 cases per 1,000,000 person between 2009–2010, with a reported overall in-hospital mortality rate of 9.4%.6 Thus, early diagnosis is imperative with necrotizing fasciitis as appropriate intervention can reduce mortality rates.7 However, this is often difficult to accomplish without a high index of suspicion by medical providers given the rarity of the disease.

Necrotizing fasciitis can occur in any area of the body, but is most commonly seen in the extremities, perineum and genitalia; the extremities are the most common site. The pathogen is often introduced into the subcutaneous tissue. Instances of trauma, injections, bites and surgical complications are a few examples of mediums through which the pathogens may enter the skin.

Various pathogens may cause necrotizing fasciitis, and the specific etiologic agent forms the basis for classification of necrotizing fasciitis. Type 1 infections are classically polymicrobial, including clostridium infections; these infections typically have foul-smelling, serosanguinous fluid with associated crepitus gas. Type 2 infections characteristically involve group A beta hemolytic streptococci (GAS) and/or staphylococcal species. Type 3 infections are usually caused by gram-negative marine organisms, most commonly Vibrio vulnificus.3

The release of bacterial toxins causes the infection to rapidly spread along fascial planes, while the overlying skin doesn’t often reflect the degree of destruction in the deeper tissue layers.6 Thus, being able to recognize necrotizing fasciitis, let alone differentiate the type can be an arduous task.

Early signs and symptoms of necrotizing fasciitis can be similar to those seen with simple SSTIs. Erythema, pain and swelling are the most common physical exam findings. One of the most consistent features of necrotizing fasciitis is pain that’s out of proportion to the swelling or erythema. Blisters and skin necrosis are later findings with necrotizing fasciitis. Fever may or may not be present, and the absence of a fever should not rule out necrotizing fasciitis.7,8

Additional “red flags” for necrotizing fasciitis include surgery at the site of infection in preceding 90 days, altered mental status, skin fluctuance, hemorrhagic bullae or hypotension.5

Laboratory markers are often utilized to aid in the diagnosis of necrotizing fasciitis, however blood cultures are positive in only 60% of cases with GAS. Imaging studies such as XR, MRI, CT and Doppler studies are often utilized to define infection progression.9 Necrotizing fasciitis is a rapidly progressive disease, and patients quickly develop sepsis. Necrotizing fasciitis is life and/or limb threatening, and a surgical emergency.

The Infectious Diseases Society of America (IDSA) guidelines indicate early and aggressive surgical excision of the infected tissue in addition to adequate antibiotic therapy.10 Surgical intervention often consists of radical, widespread debridement to remove infected and necrotic tissue, sometimes requiring amputation.3 Multiple surgeries (3–4 on average) are often required, and in some instances reconstructive surgery is necessary to cover the soft tissue defects. Aggressive care has been successful in lowering case fatality over the last two decades by 16–34%.11 Early recognition, and thus early intervention, will decrease mortality and amputation rates.

Not only does necrotizing fasciitis require early recognition, initial resuscitation and debridement, but it also necessitates extensive wound management and rehabilitation. Thirty percent of necrotizing soft tissue infection survivors have been found to have mild to severe functional limitation at the time of discharge.3

A survivor of necrotizing fasciitis has to endure months of continued physical therapy to regain functional independence. Rehabilitation is aimed at improving functional outcomes, developing psychological well-being and fostering reintegration into society.6 A survivor’s quality of life is significantly impacted by their physical function and ongoing pain, and many often also focus on the effect their experience has had on their family and other relationships.10 Early diagnosis and early, complete surgical intervention have continually shown to improve outcomes in the multi-dimensional nature of this disease and its recovery process.

An incision from the patient’s elbow to his wrist was required in order to place drains after the patient developed compartment syndrome.

Teaching Points

>>Maintain a high index of suspicion for necrotizing fasciitis in patients with cellulitis in setting of trauma;

>>Remember the “red flag” triad of pain, swelling and erythema—and the classical finding of pain out of proportion, rapid worsening of lesion and spread of swelling and/or erythema;

>>Keep draining or open wounds covered with clean and dry bandages;

>>Wash hands often with soap and water or use an alcohol-based hand rub if washing is not possible;

>>Wear gloves if working in environment with potential for contamination; and

>>Generally, a person with necrotizing fasciitis does not spread the infection to other people.

References

1. Historic Hurricane Harvey’s recap. (Sept. 2, 2017.) The Weather Channel. Retrieved Jan. 31, 2018, from www.weather.com/storms/hurricane/news/tropical-storm-harvey-forecast-texas-louisiana-arkansas.

2. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474–483.

3. Hakkarainen TW, Kopari NM, Pham TN, et al. Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014;51(8):344–362.

4. Necrotizing fasciitis. (July 3, 2017.) Centers for Disease Control and Infection. Retrieved Jan. 31, 2018, from www.cdc.gov/features/necrotizingfasciitis.

5. Alayed KA, Tan C, Daneman N. Red flags for necrotizing fasciitis: A case control study. Int J Infect Dis. 2015;36:15–20.

6. Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003–2013. Epidemiol Infect. 2016;144(6):1338–1344.

7. Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–125.

8. Wang JM, Lim HK. Necrotizing fasciitis: Eight-year experience and literature review. Braz J Infect Dis. 2014;18(2):137–143.

9. Sabre A, Robles CG, Krisar-White P, et al. Soft tissue injury of the lower extremity complicated by type II necrotising fasciitis highlighting the need for astute clinical practices and proper treatment. BMJ Case Rep. 2014:bcr2014204720.

10. Faraklas I, Yang D, Eggerstedt M, et al. A multi-center review of care patterns and outcomes in necrotizing soft tissue infections. Surg Infect (Larchmt). 2016;17(6):773–778.

11. Hakkarainen TW, Burkette Ikebata N2 Bulger E, et al. Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft-tissue infections. J Surg Res. 2014;192(1):143–149.