Isolated compartment syndrome: case reportA 72-year-old woman developed isolated compartment syndrome during treatment with doxycycline for gram-positive cocci infection.The woman presented with a 1-week history of weakness, cough and shortness of breath. She was admitted with a diagnosis of COVID-19 pneumonia superimposed with bacterial pneumonia and sepsis. Her medical history was consistent with hypothyroidism, obesity and hypertension. She started receiving nasal cannula oxygen, salbutamol [albuterol] and an off-label treatment with dexamethasone. She also received prophylactic treatment with enoxaparin sodium [enoxaparin]. Blood cultures revealed gram-positive cocci in clusters, and she was commenced on meropenem, vancomycin and IV doxycycline 100mg in normal sodium chloride [saline]. On day 2 of admission, the IV piggyback set to gravity containing doxycycline infiltrated via the peripheral IV catheter inserted in the left dorsal and induced mild pain and swelling. On day 4, she experienced worsening respiratory failure secondary to COVID-19 pneumonia. She was shifted to the ICU and intubated. She also received norepinephrine for hypotension. On day 18, her left hand showed worsened swelling along with a large dorsal purplish bulla. She also reported pain in her distal forearm and hand, and was unable to flex her fingers. A CT scan revealed haematoma of the dorsal wrist. Hand surgery was taken into consideration on day 21 for haematoma evacuation following deterioration of her symptoms. Upon examination, her left hand had faint ulnar and radial Doppler signals, considerable blistering, intrinsic minus posturing, mottling and cool fingers. She had limited active range of motion and worsened pain with the passive extension of her interphalangeal (IP) and metacarpophalangeal (MCP) joints of the digits and thumb. Compartment pressures were 52mm Hg and 54mm Hg in the hypothenar eminence and 40mm Hg and 42mm Hg in the thenar eminence. Delta pressures were within a range of -2 and 30mm Hg, confirming a diagnosis of isolated compartment syndrome secondary to doxycycline.The woman then underwent an emergent decompressive fasciotomy of the left hand. With volar and radial incisions, all compartments were released and the dorsal fasciotomies were closed loosely. On day 2 post-operation, she was extubated with improved pain. The range of motion of all her digits was limited but improved as compared to her pre-surgery condition. Additionally, the flexion and extension at the IP and MCP joints to <10° of all digits including her thumb and an improvement in the swelling. By day 9 post-operation, an improved flexion and extension of all digits to >10° at the IP and MCP joints and was able to oppose the thumb as far from her middle finger. Her dorsal wound showed a superficial necrosis region and eschar ulnarly. She was discharged on day 31 of admission. She continued to recover her function through physical therapy with progress from a composite fist to fully extended fingers within 3 weeks of surgery. The necrotic eschar ...
