Necrotizing fasciitis after scalpel injury sustained during postmortem examination

Abstract

A 44-year-old pathologist presented to the emergency department after sustaining a scalpel injury during a postmortem examination 16 hours previously. He had stabbed the dorsum of his left thumb overlying the interphalangeal joint and immediately irrigated the wound with water. At the time of presentation, he felt feverish, and had erythema and severe pain in his thumb. He was previously healthy, and did not smoke or have any known allergies. He was not taking any medications.The patient was given ceftriaxone empirically in the emergency department, and the plastic surgery service was consulted. Upon examination, he was afebrile and had a 0.5-cm laceration oriented obliquely over the dorsum of the interphalangeal joint of his thumb ( Figure 1A). There was a hemorrhagic blister distal to the laceration and minimal purpuric discolouration around the laceration. Erythema tracked proximally to the metacarpophalangeal joint of the thumb, with lymphangitic streaking extending into the axilla. There was no impairment of range of motion of the thumb, no substantial pain and no tenderness on axial loading of the interphalangeal or metacarpophalangeal joints. There was no pain upon palpation over the flexor sheath or the volar deep spaces of the hand. However, there was substantial pain upon palpation over the dorsal thumb. A radiograph of the hand showed no abnormality other than swelling of soft tissue.We suspected a localized subcutaneous infection and undertook a bedside incision and drainage. The hemorrhagic blister contained only blood and no pus. We extended the laceration overlying the interphalangeal joint and expressed a small amount of frank purulence. There was a 3 mm laceration in the extensor pollicis longus tendon overlying the interphalangeal joint, which communicated with the joint, but there was no purulence within the joint itself. The pus tracked proximally to the level of the metacarpophalangeal joint in a plane above the extensor pollicis longus tendon. We expressed all visible pus, irrigated copiously with 1 L of normal saline and packed the area with gauze. We continued to monitor the patient because of the rapid development of this infection and consulted the infectious diseases service.We reassessed the patient two hours later and, although he remained afebrile with normal blood pressure, PRACTICE | CASES

Risk of occupational infection in forensic workers: a review

“…In this review, we found 17 cases of occupational infections with direct contamination by aerosolization, all of them concerning tuberculosis [ 30 , 33–35 ]. For the 10 cases linked to indirect contaminations, eight were caused by scalpel wounds (one case of HIV [ 28 , 29 ], five cases of blastomycosis [ 31 ], and two cases of Streptococcus pyogenes [ 36 , 39 ]), another one was caused by a wound occasioned by a bone fragment (tuberculosis) [ 37 ], and the last one was caused by an unspecified trauma (tuberculosis) [ 32 ]. In two cases, the route of contamination was unknown but the information was sufficient to link them with occupational exposure (one case of toxoplasmosis [ 42 ], one case of tuberculosis [ 38 ]).…”

Necrotizing Fasciitis of the Upper Extremity: A Systematic Review of the Literature

“…Erythema was present in 24 (44%) patients, 11,14,15,[21][22][23][24]27,35,39,51,56,[60][61][62][64][65][66][67][68][69][70][71] and 15 (28%) reported fever. 11,14,19,24,27,31,33,34,[37][38][39]51,55,70,72 Less commonly seen presenting symptoms included blisters/bullae, hypothermia, crepitus, malaise, ecchymosis or discoloration, hyperemia, drainage, numbness, confusion, and/or nausea and vomiting. Each were reported in five or fewer cases.…”

“…10,33,37,38,51,55,57,65,71,72 Overall, the most common infectious agents were gram- positive cocci, identified in 32 (59%) cases, 5,10,11,14,15,21-24, 27-29,31,33,34,38,39,51,52,55,58,59,65,67,69,72 followed by gramnegative bacilli in 21 (39%) cases. 10,12,13,19,30,33,35,37,38,51,54,56,57,61,65,66,70,71 The most common pathogen was Group A streptococcus (GAS), reported in 15 (28%) cases 11,14,21,23,24,27,29,31,39,52,55,67,69,72 followed by Vibrio in 6 (11%) cases. 17,20,25,26,60,64 While bacteria were identified in a majority of cases, 4 (7.4%) cases identified fungi (Cryptococcus spp., Candida albicans, or Scedosporium apiospermum) 38,…”

“…10-13,15,18-21,24,25,28,29,31,37, 39,52,55,58-60,62,63,65-67,70-72 Lincosamides were used in 12 (22%) patients. 11,18,27,31,33,37,52,56,57,65,67,72 Penicillins were used in 11 (20%) cases, 10,19,25,28,52,55-57,60,62,72 as were third-generation cephalosporins. 5,11,15,22,24,26,28,31,37,52,64 Other medications reported include aminoglycosides, second and fourth-generation cephalosporins, monobactams, penems, oxazolidinones, nitroimidazoles, quinolones, and tetracyclines.…”

“…11,18,27,31,33,37,52,56,57,65,67,72 Penicillins were used in 11 (20%) cases, 10,19,25,28,52,55-57,60,62,72 as were third-generation cephalosporins. 5,11,15,22,24,26,28,31,37,52,64 Other medications reported include aminoglycosides, second and fourth-generation cephalosporins, monobactams, penems, oxazolidinones, nitroimidazoles, quinolones, and tetracyclines. After obtaining cultures, 34 (63%) patients remained on three or fewer narrow-spectrum antibiotics.…”