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Question
A ~55 year-old female with a history of ESRD and diabetes who presented to the ED with progressively worsening foot odor. An x-ray was performed. The picture below shows the right foot.
What is the diagnosis?
Answer
Necrotizing infection of the foot
- Labs will show increased lactate, increased CK, increased WBC, and decreased sodium
- Admission serum lactate (>6mmol/L) and sodium levels (<135mEq/L) are predictors of mortality
- On x-ray, the characteristic finding of gas in the soft tissues is seen in only a minority of cases.
- The presence of gas in the facial planes is highly specific, but not very sensitive.
- Diagnosis of necrotizing fasciitis or myonecrosis can only be established by surgical exploration.
- Treatment includes a Carbapenem or Zosyn plus Clindamycin and Vancomycin.
References
https://radiopaedia.org/articles/necrotising-fasciitis
Yaghoubian et al. Use of admission serum lactate and sodium levels to predict mortality in necrotizing soft-tissue infections. Archives of surgery. 2007.
Anaya DA and Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clinical infectious diseases. 2007.