807 - An Unlikely Outcome: A Minor Hand Laceration Turns Into A Shoulder Disarticulation

We present the case of a 33-year-old male with a minor right-hand laceration ultimately diagnosed as necrotizing fasciitis.

Case Description:

Ten days post-injury, he began experiencing disorientation, increasing pain and edema from the hand extending proximally, and eventually skin sloughing. He was initially diagnosed with septic shock and a soft tissue infection. Zosyn and Linezolid were started, and he was transferred for escalation of care. I&D for a right dorsal hand was performed, and post-surgery, the patient required mechanical ventilation and pressor support. Admission labs were notable for WBC = 25.5, hemoglobin = 8.4, and glucose = 187 for a LRINEC score = 5. Cultures resulted in S. pyogenes bacteremia. Ultimately, the patient required amputation at the glenohumeral joint. He then presented to pain management one month later, experiencing right phantom limb pain, and started on Nortriptyline and Skelaxin. A follow-up 1.5 months later demonstrated improved pain control, an upcoming prosthesis fitting, and another soft tissue infection requiring antibiotics.

Discussions:

This case highlights the importance of early diagnosis and intervention for those with suspected necrotizing fasciitis, which, if left untreated, can result in limb amputation. Necrotizing fasciitis can frequently be diagnosed by clinical presentation; however, with mild to moderate suspicion, the Laboratory Risk Indicator for Necrotizing Infection (LRINEC) Score can help distinguish necrotizing from other severe soft tissue infections with a score of 6 having a 92% PPV and a 96% NPV. The incidence of upper extremity amputation associated with the condition is relatively low. A study of 122 patients resulted in only 17 (14%) requiring amputation, and only 8 were at or above the transhumeral level, making it a relatively novel outcome. 

Conclusions:

Necrotizing fasciitis is a rapidly progressive and potentially fatal condition, and early diagnosis and aggressive treatment should not be delayed in order to prevent potential amputation.