Staged Comprehensive Management for Necrotizing Fasciitis of the Lower Extremity with Sepsis: A Case Report

Summary

A previously healthy man with acute necrotizing fasciitis and sepsis underwent bedside incision, staged debridement, antibiotics, insulin, VSD, and skin grafting. Limb salvage and return to normal life at 1-year follow-up illustrate the value of timely diagnosis and a multidisciplinary staged approach.

Abstract

Necrotizing fasciitis is a severe soft tissue infection characterized by rapid necrosis of the skin, subcutaneous tissue, and fascia. Its onset is sudden, and progress is rapid. Complications such as sepsis, septic shock, and multiple organ dysfunction syndrome (MODS) can appear early, leading to high mortality and disability. The early symptoms lack specificity, posing diagnostic challenges and a high risk of misdiagnosis. This case report describes a 37-year-old male patient who presented with progressive redness, swelling, and pain of the left lower limb. Bedside incision and exploration under local anesthesia confirmed acute necrotizing fasciitis. Staged comprehensive management included early surgical debridement, empirical antibiotics, anti‑shock therapy, vacuum sealing drainage, and eventual skin grafting. The patient’s limb was salvaged, and at 1-year follow-up, he had returned to normal daily activities. This case may provide limited insights for the clinical management of similar patients, particularly regarding the importance of timely bedside exploration and a multidisciplinary, staged approach.

Introduction

Necrotizing fasciitis is a rare, serious, and potentially life-threatening infectious disease. This disease is caused by the invasion of pathogenic bacteria into the body, and is characterized by progressive infection and necrosis of deep fascia, superficial fascia, skin, and subcutaneous tissue. The onset of the disease is acute, and the condition is rapid. Severe cases can cause systemic inflammatory response syndrome (SIRS), septic shock, multiple organ dysfunction syndrome (MODS), and even death^1,2. Because early clinical manifestations lack specificity, diagnosis is often delayed or missed. Even after diagnosis, the depth of tissue infection and progressive wound expansion often lead to inadequate debridement and drainage. Consequently, infection control remains unsatisfactory, often requiring multiple operations. These factors contribute to high rates of disability, amputation, and mortality³. The prognosis of patients often falls short of expectations.

This case report describes a 37-year-old man with acute necrotizing fasciitis complicated by sepsis, who was successfully managed with a staged comprehensive approach. The aim is to illustrate the value of timely incision and exploration, multidisciplinary decision-making, and stepwise surgical and medical management. This case may offer limited insights for improving the treatment of similar patients.

CASE PRESENTATION:

The case involves a 37-year-old man, otherwise healthy, who presented on November 1, 2023, with "redness, swelling, heat, and pain in the left lower limb for 4 days, aggravated for half a day" as the main complaint. Four days before the visit, the patient suddenly developed redness, swelling, and pain in the left knee joint. The predisposing factors are unknown, and the history of minor trauma, neglected by the patient, cannot be ruled out. The patient then went to the local hospital for treatment and was given a wet compress with Glauber's salt and anti-inflammatory treatment with penicillin. After treatment, the above symptoms did not improve significantly, and the condition even showed a progressive aggravation trend. The range of redness and swelling in the patient's left lower limb gradually expanded, extending from the knee joint to the proximal end of the hip joint, and extending to the distal end of the ankle joint. Half a day before the visit, the patient's symptoms worsened. The pain level of the affected limb was unbearable, the movement was limited, and walking was impossible. Simultaneously with fever, the body temperature rose to 39.4 °C. The patient's family immediately sent the patient to the hospital. The patient had no prior diabetes, hypertension, immunosuppression, or chronic organ disease. No drug/food allergies were reported. The patient had a 20-year smoking history and occasional alcohol use.

On physical examination, the patient had a temperature of 39.4 ˚ C, a heart rate of 156 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure of 135/90 mmHg (1 mmHg = 0.133 kPa). The patient was conscious and able to answer questions but appeared lethargic. The left lower limb was diffusely swollen and erythematous. The skin temperature was significantly higher than that of the contralateral side, and the affected limb was markedly tender. There was a sense of fluctuation when touched at the left knee, and the pulsation of the dorsal pedal artery was weak (Figure 1). Motor function, sensation, and capillary refill were normal in the affected limb. No signs of compartment syndrome were observed.

Laboratory investigations revealed the following findings. The white blood cell count (WBC) was 9.55 × 10⁹/L with a neutrophil percentage (NEUT%) of 84.8%. The C-reactive protein (CRP) level was 163 mg/L, and the procalcitonin (PCT) level was 3.62 ng/mL. Random blood glucose was 19.9 mmol/L. Coagulation studies showed a platelet count (PLT) of 117 × 10⁹/L, an activated partial thromboplastin time (APTT) of 24.7 s, a fibrinogen level of 9.18 g/L, and a D-dimer level of 1.96 mg/L. Renal function tests demonstrated a serum creatinine of 64 µmol/L and a blood urea nitrogen of 7 mmol/L. Hepatic function tests revealed an alanine aminotransferase (ALT) of 32 U/L, an aspartate aminotransferase (AST) of 17 U/L, and a total bilirubin of 13.6 µmol/L. Baseline scores were a Glasgow Coma Scale (GCS) score of 15 and a Sequential Organ Failure Assessment (SOFA) score of 1.

The left knee joint was punctured with a fine needle at the place where the fluctuation sensation was obvious, and pus could be seen. A surgical incision about 5 cm long was made in the abscess, and a large amount of milky white material was seen, with a foul odor. The volume of pus was about 300 mL (Figure 2 and Supplementary Video 1, which demonstrates the incision and drainage procedure). Further exploration of the pus cavity revealed that it was large, extending to both ends, and the fascia of the lower extremities was necrotic in a large area.

DIAGNOSIS, ASSESSMENT, AND PLAN:

According to the patient's clinical manifestations and exploration results: (1) Extensive necrosis of the subcutaneous fascia of the left lower limb, accompanied by extensive subcutaneous foci, spreading to the surrounding area; (2) No muscular layer was involved; (3) Symptoms of systemic poisoning were obviously accompanied by mental changes, so the initial diagnosis considered acute necrotizing fasciitis. The differential diagnosis included acute cellulitis and acute inflammation. Acute cellulitis can manifest as local soft-tissue redness, swelling, and pain, but its scope is relatively limited. The infection location is deep, and the edges of redness and swelling are not clear. There may be a sense of fluctuation after the local abscess is formed. In this patient, however, bedside incision and exploration revealed extensive fascial necrosis, foul-smelling pus, and easy separation of the skin and fascia – findings not seen in cellulitis. Acute inflammation can manifest in skin redness, swelling, and pain, but the edges are not very clear. It is often seen that a red line spreads upward along the lower limbs, tenderness. There is swelling and tenderness in the abdominal area. Based on the combination of deep fascial necrosis, purulent discharge with foul odor, and rapid progression, acute necrotizing fasciitis was the most likely diagnosis. The green channel for emergency surgery was immediately opened, and at the same time, the departments of general surgery, hand surgery, anesthesiology, and the intensive care unit (ICU) were invited for joint consultation. The patient's condition deteriorated rapidly, with a GCS score of 9. Vital signs worsened: heart and respiratory rates increased significantly from admission, and pulse oxygen saturation decreased to 92–93%. Dynamic monitoring of organ function showed a SOFA score of 10 (an increase of >2 points from baseline), meeting the criteria for sepsis. Despite initial fluid resuscitation, the patient remained hypotensive and required continuous norepinephrine infusion to maintain mean arterial pressure ≥ 65 mmHg, with persistent hyperlactatemia (>2 mmol/L). Therefore, a diagnosis of septic shock was established. After a multidisciplinary team (MDT) evaluation, anti-shock therapy was administered.

Once the patient's vital signs stabilized, the patient was immediately treated surgically. During the operation, a full-length incision was made on the medial and lateral sides of the left lower limb, and a large amount of deep fascia necrosis and a large amount of milky white purulent material were seen (Figure 3). The wound surface was thoroughly debrided, infected and necrotic fascia were removed, and drainage tubes were placed to ensure adequate drainage. The wound was covered with wet gauze soaked in ornidazole, and the wound dressing was strengthened after the operation. The patient's vital signs were unstable again during the operation. After cardiopulmonary resuscitation, life support treatment, blood transfusion treatment, and so on, the rescue was successful.

After the operation, the patient was transferred to the ICU for further monitoring and treatment. The patient had recurrent high fever, and blood tests showed elevated infection markers (WBC 25.03 × 10⁹/L, CRP 197.9 mg/L, PCT 6.69 ng/mL). Multiple blood cultures and material cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). Susceptibility testing revealed sensitivity to meropenem, vancomycin, and levofloxacin. The patient had no history of β-lactam or fluoroquinolone allergy. In the ICU, patients were treated with meropenem (0.5 g via microinfusion pump every 8 h) combined with vancomycin (1 g intravenous drip every 12 h) for anti-infection, ulinastatin for anti-inflammatory response, volume resuscitation, and nutritional support. The duration of intravenous therapy was 8 days, after which de-escalation would be considered based on clinical response. It was worth noting that the patient had no history of diabetes in the past, but the blood glucose fluctuated greatly after the illness. Fasting blood glucose was measured at 19.3 mmol/L. Glycosylated hemoglobin was 6.9%, slightly elevated. After consultation with a physician specializing in internal medicine, it was considered that the cause of the patient's current hyperglycemic state might be related to insulin resistance, possibly induced by the septic stress response. Hypoglycemic treatment was performed with an intravenous insulin infusion. Two more debridement and drainage operations were performed subsequently.

Following a 10-day ICU admission, the patient’s vital signs became stable, and the patient was transferred to the hand surgery general ward. The re-examination of infection indicators showed a trend of improvement (WBC decreased to 9.63 × 10⁹/L, CRP to 61.3 mg/L, PCT to 0.27 ng/mL). Therefore, the anti-infection regimen was de-escalated to levofloxacin (0.5 g intravenously once daily) for a total of 16 days. The reasons for choosing levofloxacin were: (1) Susceptibility testing confirmed sensitivity. (2) Levofloxacin has high bioavailability and convenient once-daily dosing. (3) Local surveillance data indicate a low resistance rate of MSSA to levofloxacin (<5%). There was a significant reduction in wound exudate. After surgical contraindications were excluded, the modified "sandwich" vacuum-sealing drainage was performed (Figure 4). After the wound base was cleaned, the VSD device was replaced. The subcutaneous tissue and muscular layer were completely attached, and VSD covered the wound surface to promote wound healing. In the later stage, the remaining granulation wounds were covered by autologous skin grafting (Figure 5). Because of the large area of skin grafting in the left lower limb, stamp skin grafting is used. About 7 days after skin grafting, the VSD device was removed. The patient did well in the stamped skin-grafted area of the left lower limb (estimated take rate >95%). Because the patient has left knee flexion activity disorder, guide the patient to perform functional exercises of the affected limb in a stepwise manner.

Protocol

1. Early diagnosis

NOTE: Early clinical symptoms are not typical and are easily confused with other soft tissue infections. Although auxiliary examination methods such as color Doppler ultrasound and computed tomography are available in clinical practice, timely incision and exploration remain the standard for a clear diagnosis.

1. Local anesthesia was administered at the site where palpation fluctuation was most obvious. A small incision (≤ 5 cm) was made through the skin and subcutaneous tissue.
2. The incision was explored with blunt dissection to assess the underlying fascia.
3. The presence of pus accompanied by a foul odor, as well as easy separation of the skin and fascia, was observed. Based on these findings, necrotizing fasciitis was highly suspected.
4. Emergency surgical treatment was arranged immediately.

2. Systematic treatment

1. Staged operation
   1. Debridement and drainage
      ​NOTE: Active debridement and adequate drainage are the most important treatment measures for this disease. The depth and breadth of debridement should be carefully monitored.
      1. In the extent of debridement, the longitudinal surgical incision was made to expand to normal tissue to fully expose the lesion area. The depth of debridement reached the deep fascia layer, and the subcutaneous tissue and fascia were fully free.
      2. All infected and necrotic tissues were removed and repeatedly rinsed with benzalkonium bromide solution, hydrogen peroxide solution, normal saline, etc.
      3. Selective resection of the skin of submerged necrotic tissue was done to avoid resection of possible viable tissue, resulting in large skin defects.
      4. Special attention was paid to retaining soft tissue coverage at the joints as much as possible to avoid risks such as infection breaking through the joints and later dysfunction.
         ​NOTE: Wounds are open, covered with gauze of ornidazole solution, dressing changed once a day, and adequate drainage. If abnormalities are still found in the wound a few days after surgery, debridement should be performed again.
   2. Vacuum sealing drainage
      ​NOTE: VSD is not recommended until the infection is effectively controlled. The method should be applied only after the lacuna has been thoroughly debrided and the wound bed is clean. Negative pressure must be properly controlled to avoid dead space formation.
      1. VSD material was implanted into the fascial space, and an irrigation tube and a drainage tube were indwelled. A bio-semipermeable membrane was used to cover and seal the wound, forming a “sandwich”-like structure.
      2. The drainage tube was connected to the hospital’s central negative pressure system, and continuous negative pressure suction was maintained 24 h a day at −200 to −300 mmHg.
      3. Normal saline (500 mL every 8 h) was regularly infused through the irrigation tube for flushing.
      4. Repeated debridement and VSD changes were performed according to the healing and cleanliness of the wound.
   3. Skin grafting
      NOTE: After the assessment that the base of the wound is clean and the granulation grows well, skin grafting is performed to cover the wound. The soft tissue coverage of the joint is retained, and the rest of the wound is skin grafted.
2. Anti-infection treatment
   ​NOTE: Early, sequential, and combined antibiotic use is essential for the treatment of necrotizing fasciitis. High-dose antibiotic therapy requires monitoring to avoid flora imbalance and secondary fungal infection. Treatment can be discontinued after systemic and local infection symptoms have resolved.
   1. Empirical antibiotic therapy was initiated immediately after blood and tissue specimens were collected. The empirical regimen was designed to cover Gram-positive, Gram-negative, and anaerobic bacteria.
   2. Multiple blood cultures and secretion cultures were performed. Once the culture and susceptibility results were available, the antibiotic regimen was adjusted to targeted therapy.
   3. After infection indicators improved and wound exudate significantly decreased, the anti-infection regimen was de-escalated.
   4. Anti-infection treatment was continued until the patient remained afebrile for 48 consecutive hours and local signs of inflammation (redness, swelling, heat, pain) had significantly subsided.
3. Anti-shock treatment
   ​NOTE: For patients with severe septic shock in the early stage of onset, active anti-shock treatment is essential. Adequate fluid resuscitation and effective life support are key to saving the patient‘s life and improving prognosis.
   1. Vital signs (heart rate, blood pressure, respiratory rate, and oxygen saturation) were continuously monitored.
   2. Intravenous fluid resuscitation was initiated using crystalloids as the first-line choice to restore circulating volume.
   3. Vasopressors were titrated to maintain mean arterial pressure ≥65 mmHg.
   4. Blood gas analysis and serum lactate levels were measured every 2–4 h to guide resuscitation.
   5. When cardiac arrest occurred, cardiopulmonary resuscitation was performed immediately, followed by life support treatment and blood transfusion.
4. Blood glucose management
   ​NOTE: In addition to patients with a history of diabetes, patients without diabetes also require attention to blood glucose management during necrotizing fasciitis treatment. Blood glucose monitoring and control should be carried out throughout the treatment course, and an individualized management plan should be formulated based on the patient‘s blood glucose levels and overall condition.
   1. Fasting blood glucose was measured, and glycosylated hemoglobin was tested.
   2. An endocrinology specialist was consulted to evaluate the cause of hyperglycemia. Hypoglycemic treatment was initiated with a continuous intravenous insulin infusion, and the infusion rate was adjusted based on hourly blood glucose measurements.
   3. Throughout the intensive care period, blood glucose levels were monitored at least every 2–4 h, and the insulin regimen was titrated to maintain blood glucose within the target range (6–10 mmol/L).
      The specific drugs and medical devices used in this study are detailed in the Table of Materials.

3. Perioperative nursing

NOTE: It is necessary not only to perform well in surgical nursing, such as wound care and vital signs monitoring, but also to provide psychological care to patients and families. Only by making patients and families feel warm can patients cooperate more actively with treatment, and the families better understand and support medical work.

4. Rehabilitation

NOTE: Exercise rehabilitation begins early after surgery. For patients who are bedridden after surgery, guiding bed rehabilitation training can effectively avoid complications such as deep vein thrombosis and pulmonary embolism of the lower extremities. For patients with stable conditions and good wound healing, guide lower-limb weight-bearing functional exercise and joint activities stepwise, and add physical therapy as an aid. Active rehabilitation treatment can prevent sequelae such as joint stiffness, joint contracture, and atrophy to a large extent.

Results

The patient was discharged from the hospital on December 14, 2023. Before discharge, the patient’s infection markers had returned to normal levels. The stamp skin graft on the left lower limb survived well, with no signs of necrosis or infection. Sensation and blood perfusion of the distal left lower limb were intact. However, the patient exhibited limited flexion of the left knee joint.

After discharge, the patient underwent a gradual, stepwise rehabilitation program. At the 1-year follow-up,...

Discussion

In this single case of acute necrotizing fasciitis with sepsis, a staged comprehensive management approach was applied. The patient achieved a favorable outcome. Based on this experience and a review of the literature, the following three key points are discussed below. It should be noted that, because this is a single case, the contribution of each individual component of the staged approach cannot be separated, and the broader applicability of the approach remains to be determined.

The first...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
DISPOSABLE PULSED FLUSHING SYSTEM	SAC (XIAMEN) MEDICAL TECHNOLOGY CO., LTD.	6305005000	Specification:SAC-WPWS-1000
Vacuum Sealing Drainage Dressing	Wuhan VSD Medical Science & Technology Co., Ltd.	UDI-DI:06943246600075	Specification:VSD-D-2-15*10*1
Vacuum Sealing Drainage Dressing	Wuhan VSD Medical Science & Technology Co., Ltd.	UDI-DI:06943246600099	Specification:VSD-D-2-15*28*1
Insulin Injection	Fosun Wanbang (Jiangsu) Pharmaceutical Group Co., Ltd.	NDC:86901729000251	10 mL:400 units
Levofloxacin and Sodium Chloride Injection	Shandong Qidu Pharmaceutical Co., Ltd.	NDC:86904145002243	100 mL:levofloxacin (calculated as C18H20FN3O4) 0.5 g and sodium chloride 0.9 g
Meropenem for Injection	SCPC PHARMACEUTICAL GROUP LIMITED	NDC:86902777002372	0.5 g (calculated as C17H25N3O5S)
Ornidazole Injection	Hebei Kaiwei Pharmaceutical Co. Ltd.	ATC:J01XD03, P01AB03	3 mL:0.5 g
Ulinastatin for Injection	Techpool Bio-Pharma Co., Ltd.	NDC:86900344000189	100,000 units
Vancomycin Hydrochloride for Injection	Eli Lilly Japan KK Seishin Laboratories	NDC:86978400000084	0.5 g (500,000 units) (calculated as C66H75Cl2N9O24)