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  • Advances in Plastic & Reconstructive Surgery€¦ · Figure 3: Debridement of the dorsum of left toes, foot, and leg extending proximal over the anterior left leg down to the muscle/fascia
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Advances in Plastic & Reconstructive Surgery © All rights are reserved by Dr. Marc R. Matthews et al. *Address for Correspondence: Dr. Marc R. Matthews, M.D., F.A.C.S, The Arizona Burn Center Valleywise Health Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008; Tel. # - [602] 344-5624; FAX – [602] 344-5705; E- Mail: [email protected] Received: February 18, 2020, Date Accepted: April 14 2020, Date Published: April 15, 2020. Asia N. Quan, Pharm.D, B.C.P.S., B.C.C.C.P 1 , Aaron C. Hechtman, D.O 2 , Douglas D. Opie, D.O 3 , Areta Kowal-Vern, M.D, F.C.A.P., F.A.S.C.P 4, 5 , Marc R. Matthews, M.D., F.A.C.S 2, 5 1 Department of Pharmacy, Valleywise Health Medical Center, Phoenix, AZ 2 Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ 3 Department of Surgery, Mountain Vista Medical Center, Mesa, AZ 4 Department of Research, Valleywise Health Medical Center, Phoenix, AZ 5 Arizona Burn Center, Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ Abstract Aesthetic and reconstructive surgery complications can entail critical infectious processes. Clinically suspected necrotizing fasciitis requires emergency operative debridement of all necrotic tissue and intravenous antibiotics for patient survival. Rarely identified with necrotizing fasciitis, Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the Enterobacteriaceae family. A 55-year old immunocompetent male developed necrotizing fasciitis of his lower extremity and required a below the knee amputation. Keywords: Leclercia adecarboxylata; Water-borne; Gastrointestinal infection; Necrotizing soft tissue infection; Necrotizing fasciitis Case Report ISSN: 2572-6684 Lower Extremity Necrotizing Fasciitis And Leclercia Adecarboxylata usually the most common areas involved in NF, and there has been a case of lower extremity calf augmentation and NF [8]. Case Report A 55-year-old healthy Caucasian male with no past medical history or comorbidities presented with a necrotic, non-healing wound of the left lower extremity after kicking a bed frame one week prior to admission. During that initial week, he experienced significant pain and difficulty ambulating. The leg and foot were soaked in magnesium sulfate [Epsom salt] baths; ibuprofen did not alleviate the pain. The pain, swelling, erythema, bullae, and black necrotic eschar prompted the patient to seek medical attention [Figure 1]. Figure 1: Black necrotic eschar on the dorsum of the left foot upon admission. On arrival, the patient was tachycardic [heart rate 119 bpm], hypertensive [BP 171/105 mmHg], afebrile, but in no acute distress. Laboratory studies demonstrated a leukocytosis, white blood cells 24 10 3 /uL with 14% bands [normal 3.7 to 11.4 10 3 /uL]; glucose 173 mg/dl [normal <100 mg/dl]; Hemoglobin was 14.5 g/dl [normal 10.8-15.3 g/ dl]. His calculated LRINEC [Laboratory Risk Indicator for Necrotizi ng Fasciitis] was only three which placed him in the lowest risk category for NF at less than 50% [11]. Radiographs of the left foot surface [Figure 2] consistent with NF. Introduction Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the Enterobacteriaceae family, cultured either as the main infective agent or within a polymicrobial environment, in both immunocompetent and immunosuppressed individuals [1]. First described by Leclerc [2] in 1962 as Escherichia adecarboxylata, detailed speciation by Tamura reassigned it to the Enterobacteriaceae genus in 1986 as Leclercia adecarboxylata [3]. It is commonly a poly- microbial infection [Type I] although mono-microbial [Type II] infections can occur. It requires support of the poly-microbial pool in general, but in immunocompromised individuals, this organism can survive by itself [1]. There have been more than 100 case reports noted in literature reviews; they reflect multiple sources of infection, [food, water, body fluids], wounds, sepsis, and organ systems [1, 4, 5]. Necrotizing Fasciitis [NF] is a devastating disease that may result in large surgical, disfiguring wounds, amputations, and even death, if not treated emergently with removal of necrotic infected tissue and intravenous antibiotics [6]. NF requires large scale debridements as the result of a breach in the host immunologic defenses from a variety of causes [6]. Risk factors for this disease are diabetes mellitus, alcoholism, chronic kidney disease, liver cirrhosis, surgical wounds and abrasions [6]. Marchesi et al. reviewed the literature and the necessary cautions, to consider the possible impact of NF on aesthetic, plastic, and reconstructive surgeries [7]. In this review, liposuction was the most common procedure, followed by blepharoplasty; buttocks and lower extremities were the most common anatomical regions affected by necrotizing fasciitis [7]. Of interest, lower extremities are Adv Plast Reconstr Surg, 2019 Page 324 of 326

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  • Advances in Plastic & Reconstructive Surgery © All rights are reserved by Dr. Marc R. Matthews et al.

    *Address for Correspondence: Dr. Marc R. Matthews, M.D., F.A.C.S, The Arizona Burn Center Valleywise Health Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008; Tel. # - [602] 344-5624; FAX – [602] 344-5705; E-Mail: [email protected]

    Received: February 18, 2020, Date Accepted: April 14 2020, Date Published: April 15, 2020.

    Asia N. Quan, Pharm.D, B.C.P.S., B.C.C.C.P1, Aaron C. Hechtman, D.O2, Douglas D. Opie, D.O3, Areta Kowal-Vern, M.D, F.C.A.P., F.A.S.C.P4, 5, Marc R. Matthews, M.D., F.A.C.S2, 51Department of Pharmacy, Valleywise Health Medical Center, Phoenix, AZ2Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ 3Department of Surgery, Mountain Vista Medical Center, Mesa, AZ 4Department of Research, Valleywise Health Medical Center, Phoenix, AZ5Arizona Burn Center, Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ

    AbstractAesthetic and reconstructive surgery complications can entail critical infectious processes. Clinically suspected necrotizing fasciitis requires emergency operative debridement of all necrotic tissue and intravenous antibiotics for patient survival. Rarely identified with necrotizing fasciitis, Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the Enterobacteriaceae family. A 55-year old immunocompetent male developed necrotizing fasciitis of his lower extremity and required a below the knee amputation.

    Keywords: Leclercia adecarboxylata; Water-borne; Gastrointestinal infection; Necrotizing soft tissue infection; Necrotizing fasciitis

    useful characterization of serotonin receptor subtypes in the treatment of

    Case Report ISSN: 2572-6684

    Lower Extremity Necrotizing Fasciitis And Leclercia Adecarboxylata

    usually the most common areas involved in NF, and there has been a case of lower extremity calf augmentation and NF [8].

    Case Report

    A 55-year-old healthy Caucasian male with no past medical history or comorbidities presented with a necrotic, non-healing wound of the left lower extremity after kicking a bed frame one week prior to admission. During that initial week, he experienced significant pain and difficulty ambulating. The leg and foot were soaked in magnesium sulfate [Epsom salt] baths; ibuprofen did not alleviate the pain. The pain, swelling, erythema, bullae, and black necrotic eschar prompted the patient to seek medical attention [Figure 1].

    Figure 1: Black necrotic eschar on the dorsum of the left foot upon admission.

    On arrival, the patient was tachycardic [heart rate 119 bpm], hypertensive [BP 171/105 mmHg], afebrile, but in no acute distress. Laboratory studies demonstrated a leukocytosis, white blood cells 24 103/uL with 14% bands [normal 3.7 to 11.4 103/uL]; glucose 173 mg/dl [normal

  • Asia NQ, Aaron CH, Douglas DO, Areta KV, Marc RM. Lower Extremity Necrotizing Fasciitis And Leclercia Adecarboxylata. Adv Plast Reconstr Surg, 2020; 4(1): 324-326.

    The patient was started on empiric antibiotics including intrave-nous tobramycin [APP/Fresenius, Lake Zurich, IL], linezolid [Auro-medics Pharma, New Windsor, NJ], and meropenem [Auromedics Pharma, New Windsor, NJ], and taken emergently to the operating room. He underwent sharp debridement [350 cm2] of the skin, subcutaneous tissue, muscle/fascia and tendons of the dorsal and plantar aspect of the left foot/leg up to the anterior, mid-tibial level [Figure 3 and 4].

    piperacillin-tazobactam [Sandoz, Princeton, NJ]. L. adecarboxylata was pan-sensitive to ampicillin

  • Consent for publication: Obtained with hospital admission consents.

    Competing interests: None.

    Authors’ information [optional]: Not Applicable.

    Asia NQ, Aaron CH, Douglas DO, Areta KV, Marc RM. Lower Extremity Necrotizing Fasciitis And Leclercia Adecarboxylata. Adv Plast Reconstr Surg, 2020; 4(1): 324-326.

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    References 1. Speigelhauer MR, Andersen PF, Frandsen TH, Nordestagaard RLM, Andersen LP.

    Leclercia adecarboxylata: a case report and literature review of 74 cases demonstratingits pathogenicity in immunocompromised patients. Infect Dis [Lond]. 2019; 51:179-188.[Crossref]

    2. H. Leclerc. Étude biochimique d’Enterobacteriaceae pigmentées: [Biochemical study ofpigmented Enterobacteriaceae] Ann Inst Pasteur.102, 1962; 726-740. [Crossref]

    3. Matsuura H, Sugiyama S. Sepsis and Leclercia adecarboxylata. QJM: Intl J Med. 2018;111: 733-734. [Crossref]

    4. Forrester DJ, Adams J, Sawyer RG.Leclercia adecarboxylata bacteremia in a traumapatient: case report and review of the literature. Surg Inf. 2012;13:63-66. [Crossref]

    5. Stone JP, Denis-Katz H, Temple-Oberle C, Mercier P, Mizzau JB, MithaAP.Leclercia adecarboxylata: The first reported infection of cerebrospinal fluid and asystemic review of the literature. J Neuroinfect Dis. 2014; 6:181. [Crossref]

    6. Stevens DL, Bryant AE. Necrotizing soft tissue infections. N Eng J Med. 2017; 377:2256-2265. [Crossref]

    7. Marchesi A, Marcelli S, Parodi PC, Perrotta RE, Riccio M, Vaienti L. Necrotizingfasciitis in aesthetic surgery: a review of the literature. Aesthetic Plast Surg. 2017;41: 352-358. [Crossref]

    8. Pérez-García A, Lorca-García C, Pérez-García M, Cuesto-Romero C. Necrotizingfasciitis following calf augmentation. Aesthetic Surg J. 2013; 33:293-294. [Crossref]

    9. TamV, Nayak S. Isolation of Leclercia adecarboxylata from a wound infection afterexposure to hurricane-related floodwater. BMJ Case Rep. 2012; bcr-2012-007298.[Crossref]

    10. Bonne S, Kadri SS. Evaluation and management of necrotizing soft tissue infections.Infect Dis Clin North Am. 2017; 31: 497-511. [Crossref]

    11. Neeki MM, Dong F, Au C, et al.Evaluating the laboratory risk indicator todifferentiate cellulitis from necrotizing fasciitis in the emergency department. West JEmerg Med. 2017; 18: 684-689. [Crossref]

    12. Adigun IA, Abdulrahaman LO. Necrotizing fasciitis in a plastic surgery unit: a reportof ten patients from Ilorin. Nigerian J Surg Res. 2004; 6: 21-24. [Crossref]

    Adv Plast Reconstr Surg, 2019 Page 326 of 326

    C:\Database\Applis\Pubmed download with keywords\Food Science\10.1080\23744235.2018.1536830C:\Database\Applis\Pubmed download with keywords\Food Science\10.1093\qjmed\hcy131C:\Database\Applis\Pubmed download with keywords\Food Science\10.1089\sur.2010.093C:\Database\Applis\Pubmed download with keywords\Food Science\10.4172\232314-7326.1000181C:\Database\Applis\Pubmed download with keywords\Food Science\10.1056\NEJMra1600673C:\Database\Applis\Pubmed download with keywords\Food Science\10.1007\s20066\-016-0754-2C:\Database\Applis\Pubmed download with keywords\Food Science\10.1177\1090820X12471528C:\Database\Applis\Pubmed download with keywords\Food Science\10.1136\bcr-2012-007298C:\Database\Applis\Pubmed download with keywords\Food Science\10.1016\j.idc.2017.05.011C:\Database\Applis\Pubmed download with keywords\Food Science\10.5811\westjem.2017.3.33607C:\Database\Applis\Pubmed download with keywords\Food Science\10.4314\njsr.v6i1-2.54778

    TitleAbstractIntroductionCase ReportDiscussionReferences


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