When the Skin Lies: Occult Scalp Necrotizing Fasciitis After Blunt Head Trauma

Scalp necrotizing fasciitis (NF) is an exceptionally rare and potentially fatal soft-tissue infection. Early recognition of the condition is challenging in cases where classical skin changes are absent.

A 59-year-old male patient suffering from diabetes mellitus presented with a foul-smelling purulent discharge from a scalp wound that had been sutured ten days prior following a fall from a height of three meters. Notwithstanding the absence of necrosis, bullae, or crepitus, laboratory tests demonstrated leukocytosis (white blood cells [WBC] 16,120/µL) and elevated C-reactive protein (337 mg/L). Cranial Computed Tomography (CT) revealed diffuse subcutaneous emphysema and fascial thickening extending from the frontal to occipital region. The surgical exploration was performed in an urgent manner, which resulted in the exposure of necrotic fascia with purulent exudate. Subsequent histopathological analysis provided definitive confirmation of NF. The presence of polymicrobial infection involving Acinetobacter spp. and Staphylococcus aureus was identified. Following comprehensive debridement and the administration of broad-spectrum antibiotics, the patient exhibited a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: NF of the scalp can present deceptively, with normal-appearing skin despite deep fascial necrosis. The presence of subcutaneous gas on imaging in patients with diabetes who have sustained trauma should prompt immediate surgical consultation. It is imperative to recognize that early suspicion and multidisciplinary action can be life-saving.