The Boil Bites Back

Scene

A fire department BLS ambulance and engine company respond to a call for a man with a burning sensation in his lower extremities. Upon arrival, a 38-year-old male—ambulatory and slightly agitated—meets the crews outside his residence.

He complains of a bilateral burning sensation in his lower extremities, and a quick exam finds cyanosis in his lips and nail beds. He denies any trauma. He is hyperventilating at a rate of 32. His blood pressure is normal, 120/80, and he has a pulse rate of 80. He reports being an athletic and otherwise-healthy individual. He then mentions that he has recently self-lanced a boil on his posterior upper right leg. An exam of the area shows a slight rash at the site.

A family friend arrives and is somewhat uncooperative when questioned about any medical history and her relationship with the patient. She does mention that she believes he was seeing a psychiatrist at one time and was on psych drugs.

Impressions

The agitation, limited history and otherwise-benign symptoms initially lead crews to believe this is a relatively insignificant call with possible psychiatric overtones. It appears this is a simple hyperventilation call, possibly brought on by an emotional crisis. This conclusion, however, proves incorrect.

Hospital

The patient is placed on oxygen via a non-rebreather mask and transported, nonemergency, to the closest hospital. Transport takes less than five minutes. Upon arrival at the ED, a more detailed physical exam under better lighting conditions shows the patient to be ashen gray, with pronounced cyanosis. His vitals drop during transport, and he loses a measurable blood pressure in the ED. He is intubated and placed on life support. Within two hours, his right leg turns black from gangrene.

A blood draw in the ED finds an extremely dark color, poor pH levels and poor blood gases. The patient is septic, suffering from necrotizing fasciitis, also known as flesh-eating bacteria. The disease received this nickname because it can spread through and destroy human tissue at a rate of as much as an inch per hour. The ED physician gives the patient only a 40% chance of survival.

Summary/Discussion

Symptoms of necrotizing fasciitis (NF) may develop rapidly, often within 24 hours after a minor skin injury. NF means decaying infection of the fascia (the layers of tissue that surround muscle). When the disease spreads into the muscle tissue, it is called necrotizing myositis.

A major characteristic of NF is that the pain may be greater than one would expect from the insignificant appearance of the wound. Signs of inflammation may not develop quickly if the infection is deep in the tissue.

Unfortunately, because common early indicators (usually within 24 hours) include flulike symptoms of fever, nausea, fatigue, weakness and general malaise, the vast majority of NF cases are misdiagnosed—the natural assumption is the patient is suffering from the flu. Usually, minor trauma or some other skin opening has occurred. The wound may not necessarily appear infected. It can be as minor as a paper cut, staple puncture, pinprick, insect bite or, as in this case, a lanced boil. It can also follow major trauma or surgery. Sometimes there is no obvious point of entry.

The victim may feel an annoying discomfort in the general region of the trauma. The pain worsens as the infection spreads through the extremity. The pain is often disproportionate to the injury and is sometimes described as a muscle pull that becomes unbearable. The patient may feel worse than they’ve ever felt before, with no plausible explanation.

Necrotizing fasciitis most commonly affects the legs, but it may also affect the groin, abdomen or any other part of the body. Within a few days of infection, gangrene develops, and the bacteria continue to spread into other tissue. Certain strains of the bacteria, such as streptococci, are extremely aggressive, shortening the entire process to a few days.

Advanced symptoms, usually seen within 3–4 days, include edema in the extremity and development of bronzed/purplish marks and blisters filled with blackish fluid. The wound may actually look necrotic (dead), with a bluish, white or dark mottled appearance.

Critical symptoms include severe septic shock. The patient’s blood pressure drops, and decreased mental status may progress to unconsciousness from poor brain perfusion and toxicity that occurs as the body becomes too weak to fight off the disease. Multisystem organ failure may occur. This usually happens within 4–5 days.

NF is a bacterial infection caused by the common Streptococcus bacteria, the same one that causes Strep throat. While Strep is normally easily killed by antibiotics, sometimes a strong mutant variety occurs. It is commonly transferred by coughing, sneezing or direct contact with secretions of someone carrying it. Fifteen to 30% of the population carries Strep at any given time, usually with no symptoms. The source spreads the bacteria directly or indirectly to the wound, and the infection occurs. The source individual is rarely identified.

Overall, if treatment is delayed more than 24 hours, the mortality rate is 70%–80%. If treatment is obtained in less than 24 hours, mortality is around 40%. Diabetics, alcoholics and those with other chronic diseases are at much higher risk for NF, as are those with weakened immune systems due to diseases such as HIV, AIDS and cancer. Treatment may include antibiotics, debridement, amputation and hyperbaric oxygen therapy. Aggressive supportive therapy, including IV fluids, vasopressors such as dopamine and ventilatory support, is usually necessary. Though this disease is rarely seen in children, a recent chickenpox infection can increase a child’s risk of developing NF by 10 times.

NF was first documented in 1783 by French doctors. It initially tended to be restricted to military hospitals during times of war, though that is no longer the case. During the U.S. Civil War, 2,600 cases of NF were reported. It has also been known as hospital gangrene, streptococcal gangrene, supportive fasciitis, necrotizing erysipelas, soft tissue gangrene, group A streptococcal disease (GAS) and streptococcal toxic shock. The Centers for Disease Control and Prevention estimates that there are 500–1,500 cases of necrotizing fasciitis each year. The National Necrotizing Fasciitis Foundation believes this number to be higher.

The NF patient presenting to the EMS provider may show a wide variety of symptoms, ranging from flulike to severe septic shock. The most important factors for a successful outcome are early recognition and aggressive treatment. The patient should be placed on high-flow oxygen with appropriate airway management, which may include endotracheal intubation. Establish an IV of normal saline or lactated Ringer’s in an unaffected limb. This patient needs to be in the hospital, where the appropriate diagnostic and surgical procedures can be performed.

Universal precautions should be utilized when dealing with any patient in the prehospital setting. No additional precautions are necessary with the NF patient. Practically speaking, the likelihood that you will recognize necrotizing fasciitis in this setting is remote unless you remember the possibility of the disease.

Should a significant exposure to NF occur, follow your department’s significant-exposure policy, which should include blood draws and follow-up on the source patient. Your physician will become part of the process and decide if any course of action, possibly an antibiotic regimen is required.

Update

The patient in this incident survived. At the time of this writing, he was undergoing rehab and in the sixth week of his hospital stay. He had extensive debridement surgery and skin grafting, with additional grafting planned. He lost feeling in his feet and hence the ability to ambulate. He will require long- term physical and occupational therapy to regain his mobility. He is also undergoing extensive pain management.

Battalion Chief Succumbs to NF

On March 17, 2000, the Fairborn (OH) Fire Department lost a 22-year veteran of the fire service to this tragic disease. Battalion Chief David Lykins, 42, died after a courageous two-week battle with NF.

Lykins sought medical attention at an urgent care center for severe pain to his left shoulder, fever and nausea early on the morning of March 2, 2000. The physician there sent him immediately to Miami Valley Hospital’s ED to rule out a “septic joint,” as the clinic did not have the equipment to perform the necessary laboratory work or CT scan. The ED physician misdiagnosed Lykins’ condition, contrary to the notes from the clinic, and treated him for a shoulder strain or possibly the flu.

Early on March 3, Lykins’ wife, Tina, noticed a discoloration similar to a bruise on his shoulder. He was diagnosed with necrotizing fasciitis later that day at the same hospital.

Lykins was the father of four children, including a daughter born five months after his death. The source of his infection was not discovered. There was no evidence linking it to any on-the-job exposure.

Bibliography

• BC Health Files. Necrotizing Fasciitis. www.bchealthguide.org/healthfiles/hfile60.stm.
• Callender TA. Necrotizing Fasciitis of the Head and Neck. www.bcm.edu/oto/grand/123192.html.
• Lamb K. Flesh-Eating Disease Bacteria Claims Fairborn Man. Dayton Daily News, March 18, 2000.
• Maynor M. Necrotizing Fasciitis. www.emedi cine.com/emerg/topics332.htm.
• Modic R. Disease Victim’s Widow Suing. Dayton Daily News, March 5, 2002.
• National Necrotizing Fasciitis Foundation Quick Print Fact Sheet. Recognizing Symptoms. www.nnff.org.
• University of Maryland. Necrotizing Soft Tissue Infection. www.umm.edu/ency/article/001443.htm.