A Case of Necrotizing Soft Tissue Infection Presenting as a Sore Throat
AAPA ePoster library. Forest C. 05/17/17; 180561; 243
Christopher Forest
Christopher Forest
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Abstract
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History A 53-year-old male presents to the emergency department (ED) with a sore throat, dysphagia, and subjective fevers intermittently for two weeks. Within the previous two days, he developed a 'raspy' voice, productive cough, right upper trapezius discomfort and bilateral lower extremity swelling. He rates the throat pain as 6/10 that is relieved with acetaminophen. He stated that he was treated elsewhere for strep throat a week prior with unknown intravenous antibiotics. While being treated, he accidentally removed an internal jugular (IJ) central line, which they replaced. The reason for the central line was unclear. He has a history of a benign heart murmur, prior alcohol abuse, and smoked one-pack-per-day of cigarettes for 35 years. Physical Exam Vital signs were within normal limits with a temperature of 97.9°F; pulse, 79 beats/minute; respirations, 22; blood pressure, 116/58 mmHg, and oxygen saturation 97% on room air. The patient was alert, orientated, and in no acute distress. Examination of the throat revealed white patches on the right tonsillar base. His airway had no obvious swelling. Examination of the neck revealed a mildly tender, dusky, erythematous indurated area in the right supraclavicular region, measuring 10cm x 20cm with ill-defined margins. The was no fluctuance or crepitus. Purulent fluid was expressed from the site of the right IJ wound. The cardiovascular exam revealed a 3/6 systolic apical murmur and 2+ bilateral lower extremity pitting edema. His lungs were clear to auscultation bilaterally. Diagnostic Studies Chemistry panel, CBC, wound culture, and chest x-ray were ordered. (Figure 1) Differential Diagnosis Erysipelas Abscess Cellulitis Necrotizing soft tissue infection (NSTI) Outcome The chest x-ray showed no evidence of pneumonia but revealed small pockets of gas within right-sided soft tissues of the neck. The patient was started on an antibiotic regimen of levofloxacin, cefepime, clindamycin, and vancomycin. Neck computerized tomography with contrast confirmed presence of subcutaneous air compatible with an abscess, raising concern for gas-forming organisms and necrotic lymph nodes. Acute care surgery was immediately consulted and the patient was taken to the operating room. A large amount of purulent fluid surrounding the sternocleidomastoid was expressed and areas of necrotic muscle were debrided. The post-operative diagnosis was positive for NSTI. The patient underwent further irrig...
History A 53-year-old male presents to the emergency department (ED) with a sore throat, dysphagia, and subjective fevers intermittently for two weeks. Within the previous two days, he developed a 'raspy' voice, productive cough, right upper trapezius discomfort and bilateral lower extremity swelling. He rates the throat pain as 6/10 that is relieved with acetaminophen. He stated that he was treated elsewhere for strep throat a week prior with unknown intravenous antibiotics. While being treated, he accidentally removed an internal jugular (IJ) central line, which they replaced. The reason for the central line was unclear. He has a history of a benign heart murmur, prior alcohol abuse, and smoked one-pack-per-day of cigarettes for 35 years. Physical Exam Vital signs were within normal limits with a temperature of 97.9°F; pulse, 79 beats/minute; respirations, 22; blood pressure, 116/58 mmHg, and oxygen saturation 97% on room air. The patient was alert, orientated, and in no acute distress. Examination of the throat revealed white patches on the right tonsillar base. His airway had no obvious swelling. Examination of the neck revealed a mildly tender, dusky, erythematous indurated area in the right supraclavicular region, measuring 10cm x 20cm with ill-defined margins. The was no fluctuance or crepitus. Purulent fluid was expressed from the site of the right IJ wound. The cardiovascular exam revealed a 3/6 systolic apical murmur and 2+ bilateral lower extremity pitting edema. His lungs were clear to auscultation bilaterally. Diagnostic Studies Chemistry panel, CBC, wound culture, and chest x-ray were ordered. (Figure 1) Differential Diagnosis Erysipelas Abscess Cellulitis Necrotizing soft tissue infection (NSTI) Outcome The chest x-ray showed no evidence of pneumonia but revealed small pockets of gas within right-sided soft tissues of the neck. The patient was started on an antibiotic regimen of levofloxacin, cefepime, clindamycin, and vancomycin. Neck computerized tomography with contrast confirmed presence of subcutaneous air compatible with an abscess, raising concern for gas-forming organisms and necrotic lymph nodes. Acute care surgery was immediately consulted and the patient was taken to the operating room. A large amount of purulent fluid surrounding the sternocleidomastoid was expressed and areas of necrotic muscle were debrided. The post-operative diagnosis was positive for NSTI. The patient underwent further irrig...
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