Necrotizing Fasciitis in a Middle-Aged Woman

For 4 days, a 58-year-old woman with type 1 diabetes mellitus had had increasing right vulval pain that spread to the suprapubic area and abdomen. She reported that swelling and a "heavy feeling" in the lower abdomen had developed during the last 24 hours; these symptoms were associated with fever and chills.

The patient was in severe distress and appeared dehydrated. Heart rate was 108 beats per minute; blood pressure, 100/60 mm Hg; and temperature, 38.8°C (102°F). The area from the right vulva to the mons pubis and lower abdominal wall was tender and erythematous (A, the induration is outlined in black). The right vulval skin had a dark-colored patch with minimal foul-smelling drainage. Results of a complete blood cell count showed marked leukocytosis, and the blood glucose level was 340 mg/dL.

Urgent massive debridement revealed widespread foul-smelling necrosis of the subcutaneous tissues and fascia and slough, characteristic of necrotizing fasciitis (B). Intravenous imipenem and metronidazole were started. The wound cultures grew Escherichia coli and Pseudomonas. After 4 weeks of excellent wound care, secondary closure of the granulating open wound was performed (C). The patient recovered well.

Most patients with necrotizing fasciitis are immunocompromised as a result of diabetes mellitus or other medical conditions. Early recognition is essential; however, the skin manifestations may be minimal and deceptive. Untreated infection can spread within minutes to hours and may be fatal; thus, aggressive surgical debridement and intensive broad-spectrum antibiotic therapy are required. Adjuvant hyperbaric oxygen therapy may be considered for patients with infections caused by anaerobic bacteria.