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Received Feb 22, 2018; Accepted Apr 10, 2018
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1. Introduction
Necrotizing soft tissue fasciitis (NSTIs) or necrotizing fasciitis is a rare and severe infection characterized by rapid and extensive necrosis of the dermis, subcutaneous tissue, fat, superficial fascia, deep fascia, or muscle, associated with a high mortality rate.
The infection is caused by mono- or polymicrobial flora of both anaerobic and aerobic germs. The common etiologies of NSTIs are insect bites, chronic wounds, trauma, or idiopathic origin. Otherwise, possible and infrequent sources are iatrogenic, for example, injections or surgical wounds.
Several small studies and cases reports have been published describing fulminant NSTIs after injection. Only a case study of 10 patients with NSTIs after intramuscular injections has been reported in a recent work [1].
2. Case Report
A 60-year-old woman, suffering since 10 years from rheumatoid arthritis and treated since one month with nonsteroidal anti-inflammatory drugs (NSAIDs) (Diclofenac 75 mg, 2 tablets a day) and corticosteroids (methylprednisolone 16 mg, 1 tablet a day), was admitted to our department after the occurrence of a large bulla on her left gluteus.
Her relatives referred an intramuscular injection of ceftriaxone in the same site 8 days before for an upper respiratory tract infection. They also referred severe pain onset at the site of injection 24 hours later, which seemed out of proportion to physical findings and the appearance of a bulla after 3 days which rapidly grown up to the size of 8 × 10 centimeters. They reported that she had been sleepy and confused since 2 days before.
At admission, the patient showed poor physical conditions and pallor; she was in forced supine decubitus, in drowsiness state, and disoriented. Vital signs were as follows: skin temperature 37.2°C, blood pressure 80/60 mmHg, hearth rate 110 bpm, and SpO2 between 86% and 96% (at a flow rate of 4 ml per minute). Arterial blood gas analysis was performed, revealing altered values: pH 7.32, pCO2 41.1 mmHg, and pO2 49.1 mmHg. Blood tests revealed increased...