<em>Escherichia Coli</em> Induced Necrotizing Fasciitis

Case Report

Austin Crit Care Case Rep. 2017; 1(1): 1003.

Escherichia Coli Induced Necrotizing Fasciitis

Maertens T¹*, Van de Moortel L5, Verbeke J1, De Neve N1, Aelbrecht M2, Decavele L3, De Kesel P4 and De Decker K1

¹Department of Anaesthesiology and Intensive Care Medicine, OLV-Hospital, Aalst, Belgium

²Department of Dermatology, OLV-Hospital, Aalst, Belgium

³Nurse, Clinical Wound Specialist, Department of Wound Care, OLV-Hospital, Aalst, Belgium

4Department of Microbiology, Onze Lieve Vrouw Hospital, Aalst, Belgium

5Departement of Anaesthesiology, University Hospital, Ghent, Belgium

*Corresponding author: Tom Maertens, Department of Anaesthesiology & Intensive Care Medicine, OLVHospital, Belgium

Received: March 21, 2017; Accepted: July 20, 2017; Published: July 27, 2017


We report the case of a 78-year-old man who presented with fever and unilateral leg pain. Because of rapid progression toward septic shock, the patient was transferred to the ICU. The patient died within 48 hours after ICU admission. Post mortem blood cultures appeared to be positive for Escherichia Coli.

Keywords: Necrotizing fasciitis; Soft skin tissue infection; Escherichia coli infection; Feptic shock; Fatal sepsis


ICU: Intensive Care Unit; NF: Necrotizing Fasciitis; NSTI: Necrotizing Soft Tissue Infection; COPD: Chronic Obstructive Pulmonary Disease; CT: Computed Tomography; INR: International Normalized Ratio; CNF: Cytotoxic Necrotizing Factor; PCR: Polymerase Chain Reaction; MRI: Magnetic Resonance Imaging; EXPEC: Extra-Intestinal Pathogenic E. Coli; CRP: C-Reactive Protein


Necrotizing Fasciitis (NF) is an uncommon life-threatening Necrotizing Soft Tissue Infection (NSTI) which is caused by virulent toxin-producing bacteria. NSTI’s are defined as infections of any of the layers within the soft tissue compartment. Their prevalence is rare (around 1000 cases worldwide annually) but up to 20% of these patients die [1]. The latter results from delayed diagnosis due to a difficult differential diagnosis with other soft tissue infections and due to the rapid progression and evolution into septic shock. Patients with NF can be divided into 2 groups according to the causative pathogen: Type 1 is caused by polymicrobial infections and type 2 is caused by monomicrobial infections [2]. Escherichia coli have been isolated from polymicrobial or Fournier’s gangrene, but have rarely been reported in monomicrobial necrotizing fasciitis.

Case Presentation

A 78-year-old man consulted his general practitioner because of fever and unilateral leg pain since one day, for which he was treated with paracetamol. His medical history revealed COPD Gold III, peripheral vascular disease (stenting of the aortic bifurcation) and primary myelofibrosis (since 5 years). As he had persisting fever (up to 38.8°C) he was referred to the emergency department.

On arrival, his blood pressure was 108/56 mmHg and heart rate was 119 beats per minute. His right thigh and abdomen were examined by echography. As this could not show relevant abnormalities, CT scan of the abdomen was performed, showing no focus of infection (no psoas abscess, no signs of fasciitis). Deep venous thrombosis and phlebitis were also excluded. Cultures were taken and broad spectrum antibiotics (piperacillin/tazobactam) were started, given the observed leucopenia (2810 cells/mm3), thrombocytopenia (18000 cells/μL) and a spontaneous rise in INR (1.6) in the initial lab results.

The next day, the patient was transferred to the intensive care unit because of rapid progression towards septic shock. On arrival, the patient was awake and complained of pain on the medial side of the right thigh. Although still hemodynamically stable, peripheral cyanosis was present with metabolic lactic acidosis (lactate 8.23 mmol/l) developing overnight and finally leading to a circulatory arrest (based on pulseless electrical activity). After successful resuscitation, including intubation and administration of 1 mg of epinephrine (twice), spontaneous circulation could be restored after 7 min of advanced life support. High doses of vasopressors were needed in order to maintain adequate blood pressures. The skin lesions on the thigh enlarged rapidly, forming enormous fluid containing bullae (Figure 1,2). The high doses of catecholamines triggered episodes of atrial fibrillation, which were treated with amiodarone. Despite early initiation of renal replacement therapy, the addition of hydrocortisone and amikacin, septic shock did not decline. Within 24 hours the patient was in multiple organ failure with ischemic hepatitis, hyperbilirubinemia, and persisting lactic acidosis (under dialysis) being most prominent. The patient died within 48 hours after ICU admission. Post mortem blood cultures appeared to be positive for Escherichia Coli. The Cytotoxic Necrotizing Factor (CNF) 1 toxin gene could not be identified by Polymerase Chain Reaction (PCR) [3].

Citation:Maertens T, Van de Moortel L, Verbeke J, De Neve N, Aelbrecht M, Decavele L, et al. Escherichia Coli Induced Necrotizing Fasciitis. Austin Crit Care Case Rep. 2017; 1(1): 1003.