Necrotising fasciitis with Escherichia coli

Abstract

A 29-year-old man living in Beijing presented with a 2-day history of constant excruciating leg pain and a fever of 40°C. The pain was fi rst noted on the lower abdominal wall, and spread rapidly to the bilateral lower extremities, with diff use swelling and violaceous bullae. 2 hours after presentation in the emergency room, with increasingly severe pain, he became unconscious. Before admission the patient had a 1-year history of nephritic syndrome. Examination showed a temperature of 38·4°C, a pulse of 140 beats per min, respiration 28 breaths per min, and a blood pressure of 100/51 mmHg. Rhonchi were found in the lungs. There was obvious peripheral oedema with purple streaks all over the body. Flaring red indurate swelling with severe tender spread out from abdominal wall to the bilateral low extremities scattered with reddish-purple discoloration. There were bullae on the calf and dorsal regions. Blisters and erosions developed on the groin and scrotum (fi gure, A). He had a white blood cell count of 10·3×10 cells per L with 81% band cells, an ESR of 66 mm/h, a creatinine level of 171 μmol/L, and a creatine kinase level of 1135 IU/L. Urinanalysis showed proteinuria (14·7 g/day). Bullous needle aspiration detected bacteria, and Escherichia coli was recovered from fascia fl uid on both sides of the legs and feet. The antibiotic sensitivity pattern of all cultures were similar. Skin biopsies showed necrosis from dermis to fascia, and small-vessel thrombi (fi gure, B). The patient was fi rst treated with penicillin and then meropenem (0·5 g every 12 h) according to in-vitro antibiotic susceptibility results. Low molecular weight heparin (0·4–0·8 mL/d for 7 d), dexamethasone (10 mg/d for 3 d), immunoglobulin (5 g/d for 10 d), and diuretics were used for rescue. The wounds were debrided and then covered with self-split thin skin grafts. The patient was transferred to the nephritic department and was given prednisone (40 mg/d) for the treatment of nephritic syndrome. On follow-up, he had normal skin with mild scarring and no disfi guration, and now lives a normal life. Necrotising fasciitis is a life-threatening skin infection. Most cases are caused by virulent forms of group A streptococci, often referred to as “fl esh-eating bacteria”. The case presented here shows that E coli is another fl esh-eating bacterium. Lancet Infect Dis 2006; 6: 456