ABSTRACT. Extremity pain is a common complaint in adolescents. Pain out of proportion to examination findings should raise suspicion of deep tissue infection. Clostridial myonecrosis is a rapidly progressive disease consisting of muscle necrosis and systemic toxicity. It is usually seen in elderly and immunocompromised patients. Here we report a case of clostridial myonecrosis in an adolescent male. C lostridial myonecrosis is a rare disease in the United States, with an estimated incidence of 900 to 1000 cases per year. 1 However, its virulent course and high mortality rate necessitate a high degree of suspicion among treating physicians. Here we present a case in an otherwise healthy teenager and a review of the recent literature.
CASE REPORTA previously healthy 17-year-old male presented to the emergency department with a 2-day history of bilateral leg pain. The day before admission he was seen by his pediatrician and found to have fever, facial swelling, and oral ulcers. He was diagnosed with a presumptive viral illness and treated with supportive measures. He returned the next day with increasingly severe leg pain, and additional evaluation was undertaken.His past medical history consisted of a diagnosis of EpsteinBarr virus 1 month before presentation from which he still complained of fatigue. He had done some light weight-lifting several days before the onset of pain but had no recent participation in organized sports activities. There was no history of trauma, and he denied drug or steroid use.His initial vital signs were notable for a temperature of 39.1°C, respiratory rate of 32 breaths per minute, heart rate of 132 beats per minute, and a blood pressure of 141/62 mm Hg. He was pale, diaphoretic, and unable to stand secondary to his pain. Mild orbital edema was present as well as gingival swelling and a single oral ulceration. There was severe tenderness involving both of his thighs and his right calf muscles.Urinalysis revealed hematuria and proteinuria and the absence of red blood cells. Blood counts showed a white blood cell count of 2700/L (57% bands, 5% segmented neutrophils, 13% lymphocytes, 19% monocytes), and his creatine phosphokinase was elevated at 3594 IU/L. His electrolytes and coagulation profile were within normal limits. The erythrocyte sedimentation rate was 42 mm/hour.Despite intravenous hydration and multiple doses of morphine and ketorolac, there was no improvement in the patient's pain, and he was admitted to the hospital with a presumptive diagnosis of viral myositis for pain control, continued hydration, and monitoring of renal function. Within 2 hours of admission, he developed a violaceous rash over his legs and became hypotensive. On examination, he was noted to have subcutaneous emphysema in both lower extremities. His legs were noted to be markedly enlarged, and distally they were cool and pale. The symptoms soon spread to involve his right arm. Surgery was consulted and an emergent computed tomography scan was obtained, which showed gas extending from his calves to his psoa...