Mrs.Sujathamma F /55 , from Nellore

Referred with Fever Abdominal wound in the right flank and gluteal regionHistory of I &D for injection Abscess – 2 weeks ago Multiple debridement's Known Diabetic and hypertensive ( on regular medications)

Patient details

Febrile( 101˚F), BP- 220/120 mm of Hg ,Pulse- 110/mt , Spo2 – 97% ( Room air)Wound present in the right flank and right gluteal region Extension: superiorly from lower rib cage on right side to the right iliac crest medially from the mid clavicular line to the lateral border of sacrospinalis. Measuring 35 cm x 16 x 6 cm Exposing Internal oblique and Transversalis Fascia.

Examination Findings

Margins : Raised and inflamedFloor : covered with necrotic tissues and sloughBase: Transversalis fascia and internal oblique were exposed , minimal bleeding +.Right groin and right axillary lymph nodes were enlarged.

Examination findings

CLINICAL DIAGNOSIS

Necrotizing Fasciitis

Tissues for culture and sensitivityCT scan of the AbdomenCBC ,RBS , Serum creatinine , LFT , ElectrolytesGrouping and typing, PT, INR,PTT.Screening for Anti HIV, Hbs Ag , HBc.

Investigations

Total WBC COUNT : 22400ESR : 126Hb% : 11.4 gm%PCV : 33 %INR : 1.31 ( 16/12.2)PTT : 34 ( Control: 30.0)Grams staining : Many pus cells , plenty of gram negative bacilli & many gram positive cocci in pairs and short chains.CT abdomen : Necrotizing Fasciitis No definite focal fliud collections , intra abdominal extension , free fliud or plueral effusion.

Investigation reports

Debridement under GAI.V Antibiotics Imepenem Linezolid LevofloxacinMetrinadazole

Treatment

Aerobic cultutures: Gram negative bacilli in pairs , chains & Gram positive cocci to be identified. Sensitivity repotrs – will follow• Anerobic cultures : no anerobes grown after overnight incubation

Culture reports on 18/12/2009

Anaerobic cultures:Grams staining : Many pus cells , plenty of Gram negative bacilli & many Gram positive cocci in pairs and short chains seen.Culture report : heavy growth of Gram positive bacilli & small gram negative bacilli resembling anaerobes grown in culture.

Culture reports on 18/12/2009

No growth after 48 hours of incubation

Urine cultures

Abdominal wall tissue was consistant with necrotising fasciitis.

Histo pathological examination

Grams stain : Many pus cells, plenty of gram negative bacilli & many gram positive cocci in pairs & short chains seen.Cluture report: Klebsiella species & enterococci species grown in culture.Klebsiella sensitive to Imepemen , meropenem, ofloxacin.Enterococci sensitive to gentamycin, Imepenem, Teicoplanin ,Tigecycline , vancomycin.

Culture report on 21/12/2009

Blood cultures:No growth after 5 days of incubation.

Culture reports on 22/12/2009

Anaerobic cultures:Grams staining : many pus cells , plenty gram negative bacilli& many gram positive cocci in pairs and short chains seen.Culture report: heavy groth fo bacteroids grown after 4 days of incubation.

Culture reports on 22/12/2009

Aerobic cultures:Grams stain: moderate number of pus cells , few gram negative bacilli & occasional gram positive cocci seen.Culture report: heavy growth fo Acinetobacter. species. Sensitive to Colistin, Minocycline, Polymixin-B and Tigecycline.Anaerobic cultures: no anaerobes grown so far.

Culture reports on 24/12/2009

Heavy growth fo Klebsiella sensitive to Amikacin, Imepenem, Meropenem, Polymixin- B and Tigecycline.

Culture reports on 28/12/2009

Heavy growth of gram negative bacilli to be identified.

Culture reports on 30/12/2009

Heavy growth fo KlebsiellaSensitive to Amikacin, Imipenem, Meropenem,ofloxacin and Tigecycline.

Culture reports on 31/12/2009

Candida glabrataSensitive to Nystatin, Amphotericin –B , Voriconozole.

Culture reports on 04/12/2009

0N 17 /12/2009 - 22400ON 19/12/2009 - 27100ON 20/12/2009 - 36900ON 21/12/2009 - 43000ON 22/12/2009 - 40600ON 23/12/2009 - 38400ON 24/12/2009 - 36100ON 25/12/2009 - 32500

TLC COUNTS

ON 26/12/2009 - 32700ON 27/12/2009 - 24700ON 28/12/2009 - 27600ON 29/12/2009 - 32800ON 30/12/2009 - 33300ON 31/12/2009 - 35000ON 01/01/2010 - 39300

TLC COUNTS

ON 02/01/2010 - 39000ON 03/01/2010 - 45200ON 04/01/2010 - 50100

TLC COUNTS

1st Debridement was done on 17th Dec2nd Debridement was done on 22nd Dec3rd Debridement was done on 23rd Dec4th Debridement was done on 26th Dec5th Debridement was done on 29th Dec

Surgical procedures

On 28th myonecrosis was noticed involving Internal oblique. External oblique looks viable.Right kidney got exposed with necrosis of Gerot’s fascia.CT abdomen done on 30th revealed functioning right kidney.

Wound findings