Necrotizing Fasciitis With Pelvic Osteomyelitis: A Fulminant Disease

Necrotizing fasciitis (NF) is a rare, rapidly progressive soft-tissue infection associated with high morbidity and mortality. Diabetes, obesity, and immunosuppression are well-known risk factors that predispose to severe disease and atypical presentations. Complications such as pelvic osteomyelitis and fungal coinfection are exceptionally uncommon in NF and are associated with markedly worse outcomes. Early recognition and immediate surgical intervention are critical to improving survival. We report the case of a 64-year-old woman with poorly controlled type 2 diabetes, obesity, and baseline gait limitation due to degenerative disc disease, who presented with severe prostration and inability to walk for one week. On admission, she was hypotensive, tachycardic, and confused. The right lower limb was poorly perfused, externally rotated, and exhibited crepitus. Laboratory studies revealed leukocytosis, elevated C-reactive protein, and acute kidney injury. Computed tomography (CT) demonstrated extensive subcutaneous and intermuscular emphysema of the anterior abdominopelvic wall with caudal extension to both legs, along with pelvic bone changes consistent with osteomyelitis. A diagnosis of septic shock secondary to NF with pelvic osteomyelitis was established. Empiric broad-spectrum antibiotics with piperacillin-tazobactam, clindamycin, and vancomycin were initiated immediately, followed by emergency surgery on the day of admission and subsequent procedures, including amputation and right hip disarticulation. Intraoperative cultures revealed a polymicrobial infection involving bacterial and fungal organisms, including Candida tropicalis. Antibiotic therapy was subsequently adjusted, and fluconazole was added for antifungal coverage. Despite repeated debridement, broad-spectrum antibiotics, antifungal therapy, and vasopressor support, the infection progressed, resulting in the patient's death. NF can progress insidiously in diabetic patients, particularly those with neuropathy, and may present atypically with diminished pain and less pronounced tenderness, delaying diagnosis. Osteomyelitis is a rare but severe complication reflecting contiguous extension. Fungal involvement, though uncommon, may occur and is associated with increased severity and mortality. Prompt recognition, early empiric broad-spectrum antibiotic therapy, and immediate surgical source control, which remains the cornerstone of management, are essential. This case highlights the devastating consequences of delayed recognition of NF in high-risk patients and illustrates its rare association with pelvic osteomyelitis and fungal coinfection.