Case summary: Thanks to Manoj, Lily and Matt Schwede in abstention for presenting the case of a 60M with schizoaffective disorder who was admitted to the Psychiatric ICU (PICU) for psychosis and transferred to Medicine after he developed LLE pain/erythema and sepsis physiology, with concern for necrotizing fasciitis.
1. In the setting of SSTI and sepsis physiology, consider: necrotizing fasciitis, toxin-producing beta-hemolytic Strep (e.g. toxic shock syndrome), abscess (lack of source control) and bacteremia.
2. Goop reminded us that the world of bullae is wide, and venous stasis ulcers + overlying cellulitis is a common diagnosis! Life threatening diagnoses include: toxic epidermal necrolysis, staph scalded skin syndrome, necrotizing fasciitis, disseminated HSV or VZV and purpura fulminans. See below for a comprehensive DDx.
3. See Grant Smith’s awesome post on necrotizing fasciitis (with his Evernote integrating all the Chiefs’ blog posts on nec fasc ever!), with a major takeaway a (small, single-center) study from the Archives of Surgery showing that CT is extremely sensitive for necrotizing soft tissue infection (Sensitivity was 100%, Specificity 81%, PPV 76%, NPV 100%).
The wide world of bullae
Grant’s blog post (with Evernote summarizing all the prior Chiefs’ blog posts on nec fasc): https://ucsfmed.wordpress.com/2018/01/26/zsfg-am-report-pearls-1-17-2018-almost-doesnt-count-or-does-it-sensitivity-of-ct-for-necrotizing-fasciitis/
Fantastic NEJM review on necrotizing SSTIs: Stevens DL , Bryant AE. Necrotizing soft-tissue infections. N Engl J Med 2017;377:2253–65.