Rare case of progressive Klebsiella pneumoniae Necrotizing Fasciitis of the Lower Extremities: A report

KP-NF is an emerging clinical entity and is associated with a compromised host immunity and high mortality rates. Clinicians must be aware that not all may present with the typical fulminant features and should maintain a high index of suspicion.

Bing Howe Lee et al report a case of 50-year-old Chinese woman with rapidly progressive KP-NF, presenting atypically with innocuous skin symptoms. She had newly diagnosed diabetes mellitus. She had extensive subcutaneous crepitus in her lower limbs with subcutaneous gas on x rays. Despite aggressive surgical debridement, she succumbed to septic shock and multiorgan failure. This case report has been published in 'JBJS Case Connect 2023.'

50-year-old Chinese woman presented to the Sengkang General Hospital, Singapore with a 1-week history of progressive bilateral lower limb pain associated with swelling and fever. She had no medical history. She had been consuming herbal traditional Chinese medicine for a year. On admission, she was normotensive but febrile (temperature was 38deg C) and tachycardic (heart rate ranged 110-120 beats per minute). She was nontoxic looking. There were no erythema, blisters, bullae, or open wounds on both legs. However, diffuse subcutaneous crepitation was felt over bilateral feet, calves, and proximally to the mid-thighs. There was no signs of compartment syndrome. Distal pulses of the lower limbs were well palpated. Lung auscultation revealed bibasal crepitation.

Laboratory findings were suggestive of a severe infection. Laboratory risk indicator for necrotizing fasciitis score was 9. Significantly, she also had diabetic ketoacidosis and undiagnosed diabetes mellitus (HbA1c 15.4%). Radiographs showed extensive subcutaneous gas in both legs. Chest radiograph showed airspace opacities over the right mid and left lower lung zones. Swabs for COVID-19 and respiratory viruses polymerase chain reaction were negative.

Patient was admitted to the surgical high-dependency ward. She did not require inotropic support. An antibiotic regimen for NF, as per local hospital guidelines (intravenous [IV] ceftazidime, benzylpenicillin, and clindamycin), was initiated immediately. She was referred to the intensive care unit (ICU) team for optimization of her diabetic ketoacidosis, before surgical debridement. However, her condition deteriorated with hemodynamic instability. An emergent surgical debridement and fasciotomy of bilateral lower limb were performed 4 hours after admission. Intraoperatively, extensive NF of the lower extremities was noted, worst over the lateral compartment of both calves, with foul-smelling purulent dishwater fluid. Fasciotomy and debridement were performed for all compartments of the thighs, calves, and feet. Patient required single inotropic support and was transferred to the ICU postoperatively.

She developed worsening sepsis and required escalation to dual inotropes. Antibiotics were escalated to IV meropenem, vancomycin, and clindamycin, and changed to IV augmentin on postoperative day (POD) 1, when intraoperative cultures, blood cultures, and endotracheal aspirate culture grew pansensitive KP. Histology of the lower limbs fascia confirmed the diagnosis of NF. A relook surgical debridement was planned on POD 2. However, she deteriorated on the night before surgery, complicated by septic shock, disseminated intravascular coagulation (DIVC), and multiorgan failure. She developed ventricular tachycardia 2 hours later and unfortunately demised.

The authors concluded – “KP-NF is an emerging clinical entity and is associated with a compromised host immunity and high mortality rates. Clinicians must be aware that not all patients may present with the typical fulminant features as seen in KP-NF and should maintain a high index of suspicion. Urgent surgical debridement remains the cornerstone of treatment and surgeons should maintain a low threshold for early repeat debridement or amputation.” 

Further reading:

Atypical Presentation of Klebsiella pneumoniae Necrotizing Fasciitis of the Lower Extremities: Silent but Deadly Bing Howe Lee et al JBJS Case Connect 2023;13:e23.00130 http://dx.doi.org/10.2106/JBJS.CC.23.00130