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Title: Een 67-jarige man met een rode, gezwollen arm en verwardheid
Journal: Tijdschrift voor Geneeskunde
Volume: 67    Issue: 13   Date: 2011   
Pages: 668-671
DOI: 10.2143/TVG.67.13.2001004

Abstract :
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A 67-year-old man with a red and swollen arm and confusion
A 67-year-old patient was brought to the emergency department with a red, swollen left arm since two days and confusion since one day. At presentation, he mentioned only moderate pain. His arm was red and swollen, while blisters filled with clear fluid were noticed. The patiënt had fever and was confused, but hemodynamically stable.
Antibiotics were started. Still he could not move his arm anymore the following day. The blisters were more numerous and now also filled with dark hemorragic fluid. Moreover the patient developed renal insufficiency, tachypnea, tachycardia and marbling of the lower limbs. Surgery was performed immediately, resulting in an amputation of the left arm due to extensive muscular necrosis.
A necrotising fasciitis is an uncommon entity, but remains a life and limb threatening condition. Necrotising fasciitis is a deep-seated infection of the subcutaneous tissue which progresses rapidly. The presence of tenderness on physical examination beyond the borders of the erythema or out of proportion to the appearance of the area, the rapid progression with formation of hemorragic blisters and bullae, the occurrence of a systemic inflammatory response syndrome or the presence of acute organ dysfunction, indicate a more ominous process.
A high index of clinical suspicion remains very important as well as a quick referral to a surgery department to perform a diagnostic and/or therapeutic debridement.

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