Microbial Strangulation After a Chinese Dinner?
Vergragt, J., Blokhuis, T.J., Lange, D.W. de
Voorzitter(s): prof.dr. J.W. de Fijter, Leiden & dr. P.J. de Vries, Hilversum
Locatie(s): Zaal 0.5
Categorie(ën):
A 55 year old male presented to the Emergency department with headache, swelling of the upper lip and tachycardia. Initially he was treated for an alleged allergic reaction to the Chinese meal he consumed the evening before.
Absence of improvement led to consultation of the neurologist and ENT specialist. After CT-scanning a cerebral sinus thrombosis could not be ruled out, so he received therapeutic dose of low molecular weight heparin. Despite feeling relatively well, the swelling worsened. With a modest fever as the only sign of infection, antibiotics were added. As any diagnosis was still lacking, he was observed on a medium care unit.
About 15 hours post admission, things started to go downhill. He was feeling dyspnoeic, the swelling prevented normal speech and saturation dropped. He was put on 100% oxygen and taken to the operating theatre to perform urgent fiberoptic nasal intubation. With exceptional skill and a sheer dose of luck the anesthesiologist could secure the airway without adverse events.
Still clueless we “strongly observed” the clinical course on the ICU. Then, at first daylight, we noticed a spreading reddish discoloration of the left thorax. Meanwhile his need for hemodynamic support also increased. The, at that time, spot-diagnosis was necrotizing fasciitis.
Within minutes, he was back in the operating theatre to undergo extensive debridement of the thoracic fasciae. Remarkably, the face and neck remained totally unaffected by the necrotic process. After 41 days in the hospital, our patient recovered quite well.
Necrotizing fasciitis is very well known for its destructive power, although the incidence is very low. The typical presentation is excruciating pain, oedema and rapidly spreading erythema. Later, the affected area becomes anaesthetic, due to thrombosis.
However, less then 50% of cases presents classically, and the average time to reach diagnosis is 24-48 hours. Why then, the impressive airway obstruction without infection of the neck? Older literature describes oedema outside the affected area, but the underlying pathophysiological mechanisms still need to be elucidated.
Although it almost killed him, the airway obstruction served as an early warning something was seriously wrong. Should we have done better and reach the diagnosis at an earlier stage? Most authors agree having a high degree of suspicion or trusting your gut feeling is superior to any scoring system. Our case illustrates that, when in doubt, the best way is to stick with your patient until things have become clear.