An 84-year-old woman who lived alone and independent was brought to our emergency department (ED) after her neighbor was worried when seeing no sign of life in the morning and alarmed her family. Several hours passed and eventually the family arrived at her premises together with the112 ambulance attendants to find her lying on the floor of her bedroom. Arriving at the emergency department at 2 pm the patient was conscious, complained of mild pain all over her body (VAS score of 3/10) but could not specify this any further. Direct questioning revealed no past medical history, no known allergies and no changes in her medication for years (she took an anti-arytmica, SOTALEX ®).
Vital signs were stable: blood pressure (BP) of 149/61 mm Hg, pulse 60 beats per minute, oxygen saturation of 98%, and body temperature 35,4°C. Heart, lung and abdominal examination were without any particularities. Neurologic examination on arrival showed a normal level of consciousness (Glasgow Coma Scale (GCS) = 15/15) and no paralysis. She had a normal speech, although communication was difficult because of hearing loss. She seemed orientated without any confusion although she couldn’t explain or remember why she was found lying on the floor.
Further observations at physical examination were:
1) a cold right foot and lower leg with delayed capillary refill and absence of peripheral pulses
2) light reddish coloring on the medial side of the left lower leg, without blisters or crepitation’s palpable, peripheral pulses were palpable and the limb had a normal temperature
3) painful mobilization of both hips
4) at the back there were no signs of infections on the skin and the spine was not painful at palpation.
Lab results of the arterial blood sample were available within the hour after her arrival. This showed a pH of 7,36 (reference range, [RR] 7,35 − 7,45), pO2 of 63,7 mmHg (RR 83-108mmHg), Hemoglobin of 10,5 g/dL (RR 12-16g/dL), Sodium of 140 mmol/L (RR 136–146 mmol/L), Potassium of 3,9 mmol/L (RR 3,4–4,5 mmol/L), lactate of 2,3 mmol/L (RR 0,5 − 1,6 mmol/L), ureum of 80,6 mg/dL (RR < 71 mg/dL), creatinine 2,2 mg/dL (RR 0,5 − 0,9mg/dL). The working diagnosis was an arterial thrombosis of the right leg and fluid resuscitation was started, following a contrast nephropathy scheme (glucose 5% with Sodiumbicarbonate 150 mEQ at 210ml/hour) in order to perform a contrast CT scan of the lower limb. The vascular trainee was informed of the presence of the patient at the ED. In the meantime further blood results were available and showed elevated troponin T levels (0.037 ng/mL, RR < 0.030 ng/mL), high NT-proBNP (34600pg/mL RR < 125pg/mL), high level of D-dimer (> 8000 ng/mLfib.eq RR < 500ng/mLfib.eq) and a high C-reactive Protein (CRP) level of 205 mg/L(RR < 5 mg/L), CL level of 1757 U/L (RR < 167 U/L), LDH level of 365 U/L (RR < 250 U/L), SGOT level of 55 U/L (RR < 32U/L). The range of the CT scan was extended in search of a focus of an infection and at 17.15 pm a cat scan of the thorax, abdomen and the limbs was performed.
A clinical re-evaluation was performed by the vascular trainee the moment the patient returned from the radiology department. By then almost four hours passed since her arrival. A progression of the skin discoloration on the left leg is seen, initially located on the medial site now progressing to posterior and to the lateral site, almost causing a circular purple discoloration. Bullae formation was now present, still without any signs of crepitation and the area was delineated (Fig. 1,2).
1 gram Amoxicillin clavulanic acid is given intravenously Neurological reevaluation showed less and delayed response (GSC:14/15). The images of the CT scan became available the moment the vascular surgeon arrived at the emergency department, only 30 minutes later.
The CT scan showed several abnormalities illustrated in the figures below, respective descriptions are listed below each figure.
Given the rapid evolution of the skin on the left lower calf in combination with gas in the muscle compartments (Figs. 6, 7 and 8) and retroperitoneal space, our first working hypothesis of arterial thrombosis was abandoned and replaced by an anaerobic infection, most probably with a clostridium strain, to explain the clinical situation. No clear focus of entry could be found, no external wounds were visible. The spread of gas surrounding the iliac vessels and inside the distal superficial femoral artery on the right side and retroperitoneal space (Figs. 4 and 5) made us broaden our differential diagnosis. Possible necrotizing fasciitis due to group A streptococcus pathogen or a retroperitoneal perforation of the de novo found colon tumor (Fig. 3), a complicated spondylodiscitis (Fig. 5) with hematogenous spreading of emboli was considered. Other less likely options were a pyomyositis which causes muscle abscesses mostly by S. aureus or viral myositis and rhabdomyolysis.
While discussing possible differential diagnosis and if there were any therapeutic options the patient deteriorated further with a GCS of 8, anisocoria, deviation of the eyes to the right side and Cheyne stokes breathing. Her blood pressure stayed long stable but eventually dropped to 90/50 mmHg with a heart rate of 70 beats per minute and oxygen saturation of 94%. Still there was no fever. Arterial blood sample showed elevating lactate levels to 3,6 mmol/L, pH level of 7,25 and pO2 level of 58,8mmHg.
A multidisciplinary team consisting of the emergency physician, the vascular surgeon and the neurosurgeon on call decided that there was an inability to intervene with surgical debridement because of the multiple distant spread gas seen on CT scan. Because of her rapid declining state and lack of therapeutic options; additional investigation such as a skin biopsy of the left leg and a CT scan of the brain to visualize air were not executed. In consensus with the family a palliative comfort treatment was decided upon and the patient died 10 hours after her initial arrival in the hospital.
Blood cultures, available postmortem, revealed Clostridium septicum and confirmed our diagnosis of spontaneous myonecrosis.