A 10-year-old boy was brought to the rural ER by his parents, who were alarmed by the sudden onset of severe pain, swelling, and redness in his left lower thigh area. The symptoms had started during the night after he had waded through flood water near their home the previous day. Initially, the area appeared as a minor abrasion, but it quickly progressed to severe pain disproportionate to the visible injury.

Upon examination, his vital signs indicated a fever of 101 degrees fahrenheit, heart rate of 120, respiratory rate of 20, and blood pressure of 90/62. The affected area on the left thigh was dusky (purplish) red, tender, and warm to palpation. Crepatus was also noted indicating subcutaneous emphysema (gas). There was a small abrasion centrally. 

The pain was excruciating and out of proportion to the physical findings, a hallmark of necrotizing fasciitis (also referred to as flesh-eating bacteria). The area of erythema measured about 12 cm.  I marked the leading edge of the erythema with a marking pen. This can be useful for reassessment. In fact, within the short time the patient was in the ED, the area of erythema increased 1.5 cm beyond the initial outline – this is a very ominous and terrifying thing to see.

Blood tests were immediately ordered, including a complete blood count (CBC), blood cultures, and inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). 

Broad-spectrum IV antibiotics were initiated and continued on transport to a tertiary care center. The patient was also started on supportive measures, including IV fluid and pain management. 

On arrival at the Pediatric Trauma Center, he had an immediate surgical consult and was taken to the operating room for debridement of infected necrotic tissue. He required daily wound packing and dressing changes to ensure the complete removal of necrotic tissue and to prevent the spread of the infection. The wound was managed with negative pressure wound therapy (NPWT), also known as a wound VAC, to promote healing and reduce the risk of further infection.

Gradually, the boy’s clinical condition stabilized. His fever subsided, and his inflammatory markers began to decrease, indicating a positive response to the treatment. After several days in the PICU, he was transferred to the pediatric ward for continued care, including physical therapy to aid in the recovery of his affected leg.

This case underscores the importance of early recognition and prompt intervention in cases of necrotizing fasciitis. Group A Streptococcus, the most common cause of this condition and the most aggressive, can enter the body through minor cuts or abrasions, especially in environments like floodwater where the risk of contamination is high. The mortality rate is 20-80% and is influenced by time to treatment, the underlying health of the patient, the age of the patient ( older people at higher risk), and the extent of the infection.

The histopathology of necrotizing fasciitis reveals a rapidly progressing and devastating infection characterized by widespread tissue necrosis, minimal inflammatory response in necrotic areas, and vascular thrombosis. 

Common signs and symptoms include severe pain out of proportion to the appearance of the injury, rapid progression, tenderness, paresthesia or loss of sensation to the affected area (due to local nerve damage), dusky red or blistered appearance, crepitus of the affected area indicating subcutaneous emphysema, and the presence of systemic signs such as fever or vital sign changes. 

As this case highlights, a high index of suspicion and rapid aggressive treatment are essential for patient outcomes.