A 24-year-old male patient with no morbid history.
He came to our hospital because of an injury by running over the left foot with loss of tissue.
Before admission, the patient was admitted to another health center where a broad wound healing and hemostasis were performed, after which he was referred for surgical resolution.
The patient was admitted consciously (Glasgow 15), afflicted ventilation with a BP of 80/60 mm Hg, HR: 115 per min, RR: 21 per min, with a permeable airway, spontaneous cervical immobilization.
On examination of the left lower limb, active bleeding of the left foot was evident, with loss of skin, subcutaneous cellular tissue and muscle from the inframaleolar area to the tip of the foot, with absence of the first molars second distal third.
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Hemodynamic stabilization was performed with crystalloid injection with good response.
A blood count with 20,310/mm3 leukocytes, neutrophils 86%, bacilliforms 2% stood out.
An X-ray of the extremity revealed, in addition to blade tissue lesions, a slightly diastase internal tibial malleolus fracture.
An angiotomography of the lower limbs showed a decrease in the caliber of the anterior tibial vessels, with vasospasm and compression due to the presence of edema of adjacent soft tissues without contrast extravasation.
A first surgical exploration was performed with total left foot deformation plus a plantar region flap with placement of a device for assisted closure of negative pressure wounds.
Empirical antimicrobial treatment with ampicillin/sulphate iv was started.
The patient recovered satisfactorily in the first 48 h, with a single record of post-surgical oral temperature of 37.5°C, which was attributed to the inflammatory process.
On the third day of hospitalization it was planned to perform a self-injection, a procedure that was replaced by a surgical debridement, finding in the surgery scarce amount of granulation tissue with moderate secretion of odor.
A secretion culture was obtained after the procedure.
Gram stain showed few cells with moderate amounts of polymorphonuclear cells (PMN) and gram-negative bacilli.
At 24 h, the culture showed the development of a gram-negative bacillus, negative lactose.
From the fifth day of hospitalization, the patient developed fever up to 3 8°C, poor condition of the healing tissue, increased secretion and bad odor.
Laboratory parameters showed leukocytosis of 12,800/mm3 and a CRP of 308 mg/L. Blood cultures were negative.
It was decided to perform a short amputation under the knee joint of the left lower limb with Lisfranc technique due to deterioration of her clinical condition and suspicion of infection at the site of coiling.
Finally, the culture of secretion, on the fifth day of hospitalization, analyzed by the methods: mental retardation, coughing/Alert® 3d 60 (Biomérieux, Franceika), showed growth of cefdecea lapagei susceptible to cefazol.
The isolate was confirmed by the Microbiology Center Centro de Microbiología (Centro de Microbiología, Hospitalzandes, Quito).
Three days after surgery and intravenous treatment, the patient was discharged with no signs of infection and decreased inflammatory parameters.
