A case of factitious subfascial emphysema

A 44-year-old woman with a history of borderline personality disorder, Hepatitis C, and multiple hospital admissions for cellulitis and cutaneous abscesses presented with pain of several days duration in her left upper extremity following getting her left arm "stuck" in a subway turnstile. The pain and swelling had progressively worsened following the injury. At the time of presentation the patient's temperature was 98.6 degrees F, heart rate was 82 beats/minute, blood pressure of 116/60, and an oxygen saturation of 98% on room air. The left upper extremity was diffusely swollen but minimally tender throughout. Crepitus was noted along the left arm, elbow and forearm areas. No open wounds were visualized during the examination. Radiographs and computed tomography revealed diffuse subcutaneous emphysema extending from the left axillary region to the wrist, as well as gas beneath the fascia extending between multiple muscles in both the upper and lower areas of her left upper extremity. The possibility of necrotizing fasciitis or gas gangrene prompted immediate operative exploration. No evidence of infection was found during the exploration. Stat gram stains sent during the procedure revealed no organisms. Aerobic, anaerobic, fungal, and acid-fast bacteria cultures taken during the operation revealed no final growth. The patient was stable throughout the hospitalization, remaining afebrile with a normal white blood cell count. The gas in the subcutaneous and subfascial layers was not caused by infection but presumably was due to factitious self-injection of air.