Extensive subcutaneous emphysema resembling necrotizing fasciitis

Area of Science:

• Infectious Diseases
• Surgical Critical Care
• Diagnostic Imaging

Background:

• Necrotizing fasciitis is a severe soft tissue infection requiring prompt diagnosis and surgical debridement to reduce mortality.
• Clinical diagnosis of necrotizing fasciitis relies on nonspecific signs like pain, swelling, and crepitus, with limited evidence on diagnostic tool efficacy.
• Early identification is crucial, yet diagnostic challenges persist due to the condition's aggressive nature and often subtle initial presentations.

Observation:

• A patient presented with left upper extremity swelling and crepitus, initially treated for cellulitis.
• Despite normal vital signs and a clear chest radiograph, emergent fasciotomy was performed for suspected necrotizing fasciitis.
• Intraoperative findings did not confirm necrotizing fasciitis; subsequent imaging revealed a left apical pneumothorax.

Findings:

• The patient's presentation of upper extremity crepitus, despite a normal chest radiograph, was a key indicator.
• Absence of intraoperative signs of infection despite aggressive surgical intervention highlighted diagnostic uncertainty.
• Postoperative chest imaging identified a left apical pneumothorax, suggesting an alternative or contributing intrathoracic source.

Implications:

• In specific clinical scenarios, such as a stable patient with upper extremity crepitus and a normal chest X-ray, a chest computed tomography (CT) scan should be considered.
• This imaging approach may aid in ruling out occult intrathoracic pathology that could mimic or contribute to soft tissue findings suggestive of necrotizing fasciitis.
• Further research into diagnostic criteria and imaging modalities for necrotizing fasciitis is warranted to improve diagnostic accuracy and patient outcomes.