An 81-year-old Caucasian Italian American man was admitted for acute, severe left hand pain and swelling for 24 h. The previous day he had incurred a puncture injury to the dorsum of the left hand while cleaning crabs. Over the last 24 h he had been febrile with a temperature of 38.8°C (101°F), with subjective chills, and worsening pain to the point that he was unable to move the left hand and decided to come to the emergency department.
The patient’s past medical history was significant for end stage renal disease (on haemodialysis three times per week), hypertension, seizure disorder, coronary artery disease with stents, deep vein thrombosis (DVT) with inferior vena cave (IVC) filter placement, and gout. He reported a penicillin allergy of itching. Social and travel history were unremarkable.
Vital signs were significant for temperature (39.6°C, 103.3°F), blood pressure (98/46 mm Hg), pulse (103/min), and respiration (18/min). The patient was in moderate distress due to pain. Physical examination was notable for significant left hand swelling and erythema with severe pain elicited upon passive movement. There was a bluish discoloration of the dorsum of the left hand with minimal drainage. Distal pulses and neurological examination of the left hand were normal.
Initial laboratory results revealed a white blood cell (WBC) count of 14.3×103 cells/mm3 with 91% polymorphonuclear leucocytes. The patient’s blood urea nitrogen (BUN)/creatinine values were 26 mg/dl (9.3 mmol/l) and 3.8 mg/dl (336.3 mmol/l), respectively, with a glomerular filtration rate (GFR) of 15 ml/min (baseline creatinine, 4.2 mg/dl (371.7 mmol/l) 1 month earlier). Chest x-ray and ECG were normal. Radiograph of the left hand revealed extensive soft tissue swelling with no fracture. Fluid resuscitation was started, blood cultures were drawn, and the patient was started on intravenous clindamycin.
Subsequently, the patient was taken to the operating room for emergent surgical debridement and fasciiotomy for suspected necrotising fasciitis complicated by compartment syndrome. The procedure was significant for extensive necrotic tissue in the dorsum of the hand, while the palmar aspect was essentially unaffected. Pulse irrigation with antibiotics was used to remove the necrotic tissue. Surgical wound cultures were taken. Pathological examination of the surgical specimen showed significant ulcerative necrosis, acute and chronic inflammation, and granulomatous tissue reaction. Antibiotics were empirically changed to intravenous meropenem, doxycycline, and vancomycin.
Interim blood culture was negative for growth. Gram stain of the surgical specimen revealed curved, gram-negative rods. Subsequent wound culture was significant for Vibrio vulnificus with pan-sensitivity. Antibiotics were changed to intravenous ceftriaxone, ciprofloxacin, and doxycycline.
Over the next several days, the patient required numerous incision and drainage procedures, surgical debridements, as well as a full thickness skin graft to the dorsum of the left hand. These all resulted in clinical improvement of the hand, with notably less swelling and pain. After a 14 day hospitalisation, the patient was discharged with an indwelling catheter on intravenous ceftriaxone and oral doxycycline, with outpatient follow-up for further debridements.