JAMA Clinical Challenge March 21, 2022
Fever, Hypotension, and a Worsening Necrotic Wound
Danielle M. Peterson, William E. Damsky, Matthew D. Vesely
JAMA. Published online March 21, 2022. doi:10.1001/jama.2022.2806
On the day of giving birth via a normal vaginal delivery, a healthy woman in her 20s developed painful swelling on her right thigh, at the site of a methergine injection administered 1 day prior. Despite 3 days of treatment with an oral antibiotic (cefalexin), her thigh pain and swelling did not improve, and she was readmitted to the hospital and intravenous clindamycin was started. Wound cultures and blood cultures obtained during incision and drainage performed on hospital day 1 were negative for bacterial, mycobacterial, and fungal organisms. The following day, her temperature was 39.4 °C (102.9 °F), blood pressure was 86/42 mm Hg, and heart rate was 131/min. She was transferred to the intensive care unit for presumed septic shock, and her antibiotics were changed to vancomycin and meropenem. Surgical debridement of the right thigh was performed on hospital day 3.
On hospital day 4, a new purple dusky border developed along the wound edge, and the patent underwent a second surgical debridement. After debridement on hospital day 5, her temperature was 39.8 °C (103.6 °F), and she required vasopressor infusion with norepinephrine for shock. Her right thigh had a deep 9 × 8–cm ulcer with a dusky violaceous border extending 2 to 5 cm from the wound edge (Figure, left), with many 1- to 2-mm pustules (not visible in Figure). Laboratory testing showed a white blood cell count of 30 000/μL (88% neutrophils); lactate level, 77.5 mg/dL (8.6 mmol/L); and procalcitonin level, 16.1 ng/mL (reference, <0.1 ng/mL). Histologic examination of the tissue obtained during the second surgical debridement revealed ulceration with extensive neutrophilic inflammation (Figure, right). Stains for microorganisms, and tissue and blood cultures, remained negative.
What Would You Do Next?
- Add intravenous amphotericin B
- Further surgical debridement
- Start hyperbaric oxygen therapy
- Start intravenous glucocorticoids
