Female patient, 81 years old, with a history of hypertension, heart failure (CF II NYHA), mitral-aortic valve disease, cardiopathy and atrial fibrillation.
The patient was under oral anticoagulant treatment, with beta-blockers and angiotensin II receptor inhibitors, and during the year 2006, came in the period of five months, to controls and cures for a chronic ulcerated lesion in the right.
His last hospitalization took place in September 2003, due to his cardiac condition.
The patient was admitted in early May 2006, due to a fulminant picture of 24 hours of progressive pain in the right side, swelling and erythema around the ulcer lesion.
Physical examination revealed fever (37.6 °C axillary), tachycardia (126 beats per minute), marked edema in the right side of the halo, local heat and a 10 cm necrotic ulcerated lesion erythematous.
There was no hypotension, impaired consciousness, galloping rhythm or pulmonary congestion on admission.
Initial examinations indicated: white blood cells count 6.310/mm3, with left shift (10% bacilliform).
Doppler ultrasound showed deep venous thrombosis of the popliteal vein and right internal twin group with moderate subcutaneous cellular edema.
Prothrombin time was prolonged (20.9) with an INR value of 1.92 (subtherapeutic).
A chest X-ray showed consolidation images in the left lower pulmonary lobe.
In the hours after admission, the lesion progressed with greater pain and the appearance of bullae with hemorrhagic content and discharge of secretion from the purulent ulcer.
He developed consciousness compromise, arterial hypotension, respiratory failure and then shock.
Surgery was performed 15 hours after admission with the diagnosis of necrotizing fasciitis, and supracondylar amputation of the affected limb was performed.
No tissue cultures were taken.
An infected extremity was observed, with hemorrhagic bullae and areas of necrosis and bad odor.
In the amputation area there was abundant edema in the adipose tissue and little bleeding was observed at this site.
Since admission, the patient received antimicrobial treatment with ciprofloxacin 400 mg c/12 h ev and clindamycin 600 mg c/8 h ev.
In the post-operative setting, emphasis is placed on establishing a position, requiring the use of vasoactive drugs and ventilatory support, resulting in acute renal failure with anuria, severe metabolic acidosis and coagulopathy.
Hemodynamic catheterization revealed cardiogenic shock with low cardiac output (2.3 L/rnin), increased systemic vascular resistance (2.888 d.s.cm-5) and pulmonary capillary pressure (17 cm of water).
Pulmonary arterial pressure was elevated (57/40 mmHg).
The patient died 36 hours after admission due to multiple organ failure.
The hemocultives obtained at admission showed the presence of Serratia marcescens (sensitive to ciprofloxacin, aminoglycosides, cotrimoxazole first generation, appenemic and resistant to ciprofloxacin).
The culture obtained from the secretion of the right thigh before surgery was negative.
Necropsy was not performed.
