To the editor:
Necrotizing fasciitis is a condition with a high mortality.1 which is frequently complicated by acute renal failure,2 and seems to be favored in the presence of an underlying immunosuppression.3 We present a patient with hypocomplementemic mesangiocapillary glomerulonephritis, who developed necrotizing fasciitis. A 62 year-old patient had a history of high blood pressure, smoking habit, dyslipidemia, and idiopathic type I mesangiocapillary glomerulonephritis, with previous serum creatinine levels of 1.9 mg/dL and nephrotic syndrome. Six months earlier, two stents were placed in the right common iliac artery and the right external iliac artery, because of stenosis due to arteriosclerosis. He went to the Emergency Room because of pain and swelling on the right inguinal area. Two hours later, the patient presented great local edema and increasing pain. On CT scan superficial and deep cellulitis, together with myositis at the proximal right thigh and internal compartment, could be seen. Blood analysis revealed leucopoenia (2,680/mm3), serum creatinine levels of 6.2 mg/dL and CK levels of 333. In the following hours, the patient developed septic shock with respiratory distress and acute renal failure, and he was transferred to the Intensive Care Unit. Once the hemodynamic situation was stabilized, the patient underwent urgent fasciotomy with decompression of the medial and anterior compartments. The muscle had a ground-glass appearance, the fascias were enlarged and there was a small amount of gas (fig. 1). Muscular biopsy showed inflammatory infiltrate with marked neutrophilic predominance and the culture yielded E. coli sensitive to piperacillintazobactam and amikacin. Fourteen days later, fasciectomy and debridement of the necrotic ulcer were required, and signs of necrotizing fasciitis were found. At this moment, Stenotrophomonas maltophilia sensitive to cotrimoxazol was cultured. The evolution was very slow and the patient was discharged from the hospital after 6 months of in-hospital stay, two of them at the Intensive Care Unit. During the process, the renal function was not recovered and continuous hemodiafiltration and later hemodialysis were required.
Necrotizing fasciitis is an infrequent disease with a rapid onset, in which early diagnosis is paramount. It is characterized by rapid destruction of tissues, toxic systemic signs and high mortality.1 The infection that localizes in subcutaneous tissue progressively destroys the fascia and fat tissue, and sometimes involves the skin. It can occur in immunocompetent people, however the risk is higher in immunosuppressed patients.3 The diagnosis is made by means of a CT scan,4 but if the clinical picture is suspected the surgical intervention should not be delayed.1,3
A survey performed in Ontario in 19973 showed that in 71% of the cases at least one underlying chronic condition was present, such as heart disease, peripheral vascular disease, pulmonary disease, renal failure, diabetes mellitus, alcohol abuse, and immunodepression from different causes. The mean age was 57.5 years, with male predominance. Acute renal failure was seen in 35% of the cases, while respiratory distress syndrome was seen in 14%. The global mortality rate was 34%, but was closed to 100% in those patients that were not operated.
In the reported case, as well as in other recently described,5 previous renal failure and alteration of the immunity could have promoted the fasciitis. Surgical intervention in the first 24 hours played a decisive role for the resolution of the clinical picture. In spite of the loss of renal function and the prolonged hospital stay, the patient has currently an acceptable quality of life.
