Case Reports
Pulmonary Mucormycosis in a Patient With Uncontrolled Diabetes
Prompt diagnosis of a patient presenting with rhinocerebral, pulmonary, gastrointestinal, and central nervous system manifestations is critical...
Discussion
Necrotizing infection of the upper extremity is a rare pathology with a substantial risk of amputation and mortality that requires a high index of suspicion and expeditious referral to a hand surgeon. It is well accepted that the key to survival is prompt surgical debridement of all necrotic tissue, ideally within 24 hours of hospital arrival.2-4,6 Death is usually secondary to sepsis.3 The classic presentation of pain out of proportion to exam, hypotension, erythema, skin necrosis, elevated WBC count, and fever may not be present and can delay diagnosis.1-4,6
DM is the most common comorbidity, and reviews have found the disease occurs more often in males, both which are consistent with our study.1-3 Diabetic infections have been found to be more likely to present as necrotizing infection than are nondiabetic infections and be at a higher risk for amputation.7 The patients with the wrist disarticulations and forearm amputation had DM. A minor trauma can be a portal for infection, which can be monomicrobial or polymicrobial.1,4 Once the diagnosis is suspected, prompt resuscitation, surgical debridement, IV antibiotics, and early intensive care are lifesaving. Hyperbaric oxygen is not available at MRVAMC and was not pursued as a transfer request due to its controversial benefit.6
There were no perioperative 30-day mortalities over a 9-year period in patients identified as having necrotizing infection of the upper extremity. This is attributed to an aggressive and well-coordinated, multisystem approach involving emergency, surgical, anesthesia, intensive care, and infectious disease services.
The hand trauma triage system in place at MRVAMC was started in 2008 and presented at the 38th Annual VA Surgeons Meeting in New Haven, Connecticut. The process starts at the level of the ED, urgent care or primary care provider and facilitates rapid access to subspecialty care by reducing unnecessary phone calls and appointment wait times.
All hand emergencies are covered by the plastic surgery service rather than the traditional split coverage between orthopedics and plastic surgery. This provides consistency and continuity for the patients and staff. The electronic health record consult template gives specific instructions to contact the on-call plastic surgeon. The resident/fellow gets called if patient is in-house, and faculty is called if the patient is outside the main hospital. The requesting provider gets instructions on treatment and follow-up. Clinic profiles have appointments reserved for urgent consults during the first hour so that patients can be sent to pre-anesthesia clinic or hand therapy, depending on the diagnosis. This triage system increased our hand trauma volume by a multiple of 6 between 2008 and 2012 but cut the appointment wait time > 1 week by half, as a percentage of consults, and did not significantly increase after-hour use of the operating room. The number of faculty and trainees stayed the same.
We did find that speed to diagnosis for necrotizing infection is an area that can be improved on with a higher clinical suspicion. There is a learning curve to the diagnosis and treatment, which can be prolonged when the index cases do not present themselves often and the patients do not appear in distress. This argues for consistency in hand-specific trauma coverage. The patients were most often initially seen by the resident and examined by a faculty member within hours. There were 4 different plastic surgery faculty involved in these cases, and they all included resident participation before, during, and after surgery. Debridement consists of wide local excision to bleeding tissue. Author review of the operative notes found the numbers of trips to the operating room for debridement can be reduced as the surgeon becomes more confident in the diagnosis and management, resulting in less “whittling” and a more definitive debridement, resulting in a faster recovery.
The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) is a tool that helps to distinguish necrotizing infection from other forms of soft tissue infection by using a point system for laboratory values that include C-reactive protein (CRP), white blood count, hemoglobin, sodium, creatinine, and glucose values.8 We do not routinely request CRP results, but 1 of the 2 patients (patient 9) who had the full complement of laboratory tests would have met high-risk criteria. The diagnostic accuracy of this tool has been questioned9; however, the authors welcome any method that can rapidly and noninvasively assist in getting the patient proper attention.
The patients were not seen for long-term follow-up, but some did return to the main hospital or clinic for other pathology and were pleased to show off their grip strength after a 3-ray amputation (patient 1) and aesthetics after upper arm and forearm debridement and skin graft reconstruction (patient 4, Figure 4).
A single-ray amputation can be expected to result in a loss of grip and pinch strength, about 43.3% and 33.6%, respectively; however, given the alternative of further loss of life or limb, this was considered a reasonable trade-off.10 One wrist disarticulation and the forearm amputation were seen by amputee clinic for prosthetic fitting many months after the amputations once the wounds were healed and edema had subsided.