Photo Rounds

Painful area above cesarean scar

A 39-year-old G11P11 woman with type 2 diabetes presented to the emergency department (ED) 10 days after having a cesarean section. A painful purple area above the cesarean section scar had developed a day earlier and was rapidly progressing. Her temperature was 101° F, blood pressure was 88/52 mm Hg, and her pulse was 110 beats per minute. The ED physician noted bullae and erosions over the lower abdomen, as well as white areas that suggested purulence.

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The ED physician suspected necrotizing fasciitis (NF) and immediately called for a surgical consult. This patient had type II NF, which can be caused by common skin organisms, such as Streptococcus pyogenes and Staphylococcus aureus.

Surgical debridement is the primary therapeutic modality. If the first debridement occurs within 24 hours of the onset of symptoms, there is a significantly improved chance of survival. Extensive, definitive debridement should be the goal with the first surgery. This may require amputation of an extremity to control the disease. Surgical debridement is repeated until all infected devitalized tissue is removed.

Antibiotics are the main adjunctive therapy to surgery. Broad-spectrum empiric antibiotics should be started immediately when NF is suspected and should include coverage of Gram-positive, Gram-negative, and anaerobic organisms. Antimicrobial therapy must be directed at the known or suspected pathogens and used in appropriate doses until repeated operative procedures are no longer needed. Empiric vancomycin should be considered while awaiting culture results to cover for the increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA). Aggressive fluid resuscitation is often necessary because of massive capillary leak syndrome.

In this case, the patient was started on empiric broad-spectrum intravenous antibiotics to cover Gram-positive, Gram-negative, and anaerobic organisms. The surgical team then rapidly admitted the patient to the operating room (OR) for debridement. From the OR, she was transferred to the surgical intensive care unit where she received ongoing supportive and postoperative care. The intraoperative tissue cultures grew out MRSA.

The patient in this case was fortunate. She survived because of the speed with which she received a proper diagnosis and treatment.

Photo courtesy of Michael Babcock, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Franklin J. Necrotizing fasciitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:702-706.

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