Severe Functional Loss of the Hand due to Necrotizing Fasciitis with Underlying Vasculitis Neuropathy

Abstract

A 72-year-old man presented with an erythematous, painful, swollen, and blistering left hand associated with a systemic fever. The patient was diagnosed with microscopic polyangiitis and was receiving steroid therapy from a year before the incident. Based on a clinical diagnosis of necrotizing fasciitis, emergency surgery was performed within 2 days after the onset. β-Hemolytic Streptococcus group A was isolated from a culture of the blood and wound. Radical debridement and high-dose penicillin and clindamycin therapy successfully saved the patient's life and affected limb except for the second finger on his left hand, which was completely necrotic. However, the function of the left hand was seriously decreased and did not recover. The important point to note in this case was the preexisting vasculitis neuropathy due to microscopic polyangiitis. The severe postoperative dysfunction of the hand was considered to be due to ischemic neuropathy that was aggravated by compartmental syndrome and microvascular thrombosis. In conclusion, necrotizing fasciitis of an extremity with underlying vasculitis neuropathy can lead to a poor functional prognosis of the limb.

Keywords

upper extremity - group A Streptococcus - antineutrophil cytoplasmic antibody–associated vasculitis - microscopic polyangiitis - mononeuropathy multiplex

• References

• 1 Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 1996; 224 (05) 672-683
• 2 Chauhan A, Wigton MD, Palmer BA. Necrotizing fasciitis. J Hand Surg Am 2014; 39 (08) 1598-1601
• 3 Lille ST, Sato TT, Engrav LH, Foy H, Jurkovich GJ. Necrotizing soft tissue infections: obstacles in diagnosis. J Am Coll Surg 1996; 182 (01) 7-11
• 4 Kuncir EJ, Tillou A, St Hill CR, Petrone P, Kimbrell B, Asensio JA. Necrotizing soft-tissue infections. Emerg Med Clin North Am 2003; 21 (04) 1075-1087
• 5 Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg 2005; 140 (02) 151-157
• 6 Hsiao GH, Chang CH, Hsiao CW, Fanchiang JH, Jee SH. Necrotizing soft tissue infections. Surgical or conservative treatment?. Dermatol Surg 1998; 24 (02) 243-247
• 7 Jennette JC, Falk RJ, Andrassy K. et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 1994; 37 (02) 187-192
• 8 Ozaki S. ANCA-associated vasculitis: diagnostic and therapeutic strategy. Allergol Int 2007; 56 (02) 87-96
• 9 Sugiyama K, Sada KE, Kurosawa M, Wada J, Makino H. Current status of the treatment of microscopic polyangiitis and granulomatosis with polyangiitis in Japan. Clin Exp Nephrol 2013; 17 (01) 51-58
• 10 Giuliano A, Lewis Jr F, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977; 134 (01) 52-57
• 11 Morgan MS. Diagnosis and management of necrotising fasciitis: a multiparametric approach. J Hosp Infect 2010; 75 (04) 249-257
• 12 Ryssel H, Germann G, Kloeters O, Radu CA, Reichenberger M, Gazyakan E. Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years. Arch Orthop Trauma Surg 2010; 130 (12) 1515-1522
• 13 Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotizing fasciitis of the upper extremity. J Hand Surg Am 1982; 7 (01) 15-20
• 14 Yuen JC, Feng Z. Salvage of limb and function in necrotizing fasciitis of the hand: role of hyperbaric oxygen treatment and free muscle flap coverage. South Med J 2002; 95 (02) 255-257
• 15 Hankins CL, Southern S. Factors that affect the clinical course of group A beta-haemolytic streptococcal infections of the hand and upper extremity: a retrospective study. Scand J Plast Reconstr Surg Hand Surg 2008; 42 (03) 153-157