Severe Necrotizing Fasciitis in a Human Immunodeficiency Virus-Positive Patient Caused by Methicillin-Resistant Staphylococcus aureus

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) is a rarely reported cause of necrotizing fasciitis. We report an unusually severe case of MRSA necrotizing fasciitis in a previously undiagnosed AIDS patient. Molecular analysis revealed that the strain had the USA300/spa1 genotype, now an abundant cause of community-acquired MRSA infection. CASE REPORTA 36-year-old Hispanic male with no previously recognized significant medical conditions presented to the emergency department (ED) of an outlying community hospital with a chief complaint of exquisite right arm pain, lethargy, fever, and shortness of breath. He had been treated 2 weeks previously with clindamycin for right axillary hidradenitis following a selfreported spider bite. The patient had no recent traumatic injury or known contact with methicillin-resistant Staphylococcus aureus (MRSA). Although the skin infection failed to resolve, he had been otherwise asymptomatic and did not seek further medical attention until awakening that morning with acute distress. Physical examination in the ED revealed a tensely edematous and markedly erythematous right upper arm and shoulder. The right hand and fingers were cool, but they retained complete range of motion. The results shown by a chest X ray were unremarkable despite coarse breath sounds and the deep soft tissue infection. All analytes measured in the initial chemistry and coagulation panels were within normal limits. He was diagnosed with severe cellulitis, septic shock (blood pressure, 58/32; pulse, 130; temperature, 99.4°F; white blood cell count, 1,600/l), and possible necrotizing fasciitis. Empirical antimicrobial treatment was initiated immediately with vancomycin, piperacillin-tazobactam, and clindamycin. However, his condition deteriorated quickly, and he required ventilator assistance with fluid and vasopressor support. Emergency surgical exploration was undertaken within 24 h of admission, and extensive soft tissue necrosis was observed intraoperatively. The right arm was amputated, and the chest wall was extensively debrided. Sputum and blood cultures collected in the ED prior to administration of empirical therapy, as well as intraoperative wound cultures, grew MRSA that was resistant to erythromycin, clindamycin, and levofloxacin (Table 1). The antimicrobial regimen was then switched to vancomycin, imipenem/cilastatin, rifampin, and voriconazole. Histologic analysis of the surgically excised tissue revealed features typical of necrotizing fasciitis (Fig. 1). Despite initial improvement following surgical intervention and antimicrobial therapy, the septic shock persisted (maximum temperature, 103.4°F; average blood pressure, 100/60) and the necrotizing fasciitis continued to spread to the bilateral chest walls, right abdomen, and right back. He was transferred to a tertiary-care hospital for continued evaluation and management of the severe MRSA infection. Nine additional debridement procedures were performed. Tissues collected during these surgical interventions grew rare MRSA strains with ide...

Human Immunodeficiency Virus Infection Associated with Necrotizing Fasciitis: A Cohort Study of Texas Population, 2001-2010

“…We found that 57% of HIV-associated NF hospitalizations required ICU care. Use of ICU was mentioned in 4 patients described in prior case reports of HIVassociated NF [7,8,11,13]. Our findings are similar to those reported by Widjaja et al [27] and Das et al [24], showing need for ICU care in 63% and 56% of their patients, respectively.…”

“…The site of infection was described inconsistently in case reports of NF in HIV-infected patients. Two case reports indicated NF involving limbs [5,13], while cervical infection was described in 3 patients [7,10,11], and breast involvement in one [14]. While the small number of patients precludes meaningful analysis, the available data from these cases suggest involvement of uncommon body sites in patients with HIV-associated NF.…”

“…Our findings may have been affected by underreporting of microbiology, analysis restricted to HIV-associated NF hospitalizations without other reported sites of infection, and administrative data precluding information on specimen sources. Microbiology findings were often not described in case reports [1,5,8,9,12], though tended to be monobacterial isolates when reported [6,10,13].…”

“…However, diabetes was reported only in about 1 in 7 HIV-associated NF hospitalizations, as compared to about 1 in 2 in the general population with NF [2]. Chronic comorbidities were inconsistently described in reported cases HIV-associated NF though, when described, most affected patients had no non-HIV chronic illness [10,[12][13][14] or only a single one [7,11]. The reported chronic comorbidities included hypertension [7] and non-Hodgkin's lymphoma [11], with the later possibly a sequela of AIDS in the affected patient.…”

“…However, occurrence of HIV as an underlying illness among NF patients has not been examined at a population level, with only few case reports of HIV-associated NF described to date [5][6][7][8][9][10][11][12][13][14]. While the risk of HIV-associated NF may exceed that of the general population, there are sparse data on the epidemiology of NF in these patients.…”