Surgical Decision-Making in the Setting of Diagnostic Uncertainty in Upper Extremity Subcutaneous Emphysema

Necrotizing soft tissue infections (NSTIs) are life-threatening and require emergent surgical debridement. Benign subcutaneous emphysema is a rare, noninfectious condition characterized by subcutaneous gas on imaging without systemic symptoms or abnormal laboratory values typical of NSTIs. Patients with subcutaneous emphysema and risk factors for NSTI can pose a diagnostic challenge.

We report an 18-year-old female with Ehlers-Danlos syndrome who developed left elbow pain and crepitus following multiple insect bites, freshwater pond exposure, and contact with farm animals. She was afebrile with a benign exam and normal labs, yet imaging demonstrated extensive upper extremity subcutaneous emphysema. Given the concern for NSTI, she was admitted on broad-spectrum antibiotics and underwent surgical exploration. Normal intraoperative findings, along with negative cultures and pathology, confirmed the diagnosis of benign subcutaneous emphysema. She was discharged postoperatively with oral antibiotics and made a full recovery.

This case highlights the importance of multidisciplinary evaluation in differentiating benign from life-threatening subcutaneous emphysema to guide appropriate management and avoid unnecessary surgery.