About Cassandra Mackey, MD

Assistant Professor
University of Massachusetts

SAEM Clinical Images Series: A Rash You Don’t Want to Miss

rash

A 54-year-old female with a past medical history of diabetes presented to the Emergency Department (ED) for evaluation of unresponsiveness. The patient was found unresponsive by her spouse, who notes she had missed several doses of insulin over the past few days. EMS notes the glucometer read ‘HIGH’ on fingerstick. The patient remains unresponsive on presentation and is unable to contribute further history.

Vital Signs: BP 148/105; HR 120; RR 24; Pulse Oximetry 98% on room air; Temperature 97.7°F

Constitutional: Patient is morbidly obese, unresponsive, and toxic-appearing.

Cardiovascular: Regular rhythm with tachycardia. No murmur.

Pulmonary: Pulmonary effort is normal. Lungs clear to auscultation bilaterally.

Abdomen: Abdomen is soft and non-distended. Unable to assess for tenderness given unresponsiveness.

Skin: Cool, pale, mottled. Large gangrenous, draining, foul-smelling wound on proximal left thigh. There is necrotic, malodorous, black skin noted over the left lower abdomen and left upper thigh.

Neurological: Unresponsive. GCS 3.

White blood cell (WBC) count: 20.5

Comprehensive metabolic panel (CMP): K 5.8; Cr 2.06; BUN 86; Glucose >600

Venous blood gas (VBG): pH<7; lactate 3.4; bicarbonate 7

These photographs show advanced Fournier’s Gangrene, a form of necrotizing fasciitis located in the genitals, perineum, or perianal region. Rapid involvement of our surgical colleagues is crucial, as these patients will not recover without the debridement of affected tissues. Aggressive fluid resuscitation and broad-spectrum antibiotics can be initiated after a surgical consult is made.

This patient presented with impressive visual evidence of advanced disease including severe ecchymosis, but our clinical suspicion must be high as Fournier’s is rapidly progressing and carries a high mortality rate (may be upwards of 30%). Earlier symptoms are genital or perineal pain which may be associated with itching, lethargy, or fever. The biggest exam finding to keep in mind is ‘pain out of proportion to the exam’ as up to 40% of these patients may present without localized symptoms. Advanced disease, as seen in this patient, can present with crepitus and severe ecchymosis of tissue involved. This patient was also found to be in DKA, as evidenced by her laboratory findings. This case should serve as a reminder that it is vital to perform a proper skin examination in patients presenting with hyperglycemia. Ultimately in this case, the patient was intubated for airway protection and started on vasopressors for cardiovascular support in the setting of septic shock. She went into VTach arrest and was successfully defibrillated before further decompensating and becoming asystolic.

Take-Home Points

  • The first task after suspected diagnosis of Fournier’s Gangrene is a page to your surgery service for evaluation and emergent debridement in the OR (depending on your institution this may be general surgery, urology, or both). After your patient is on the path to definitive management, you can begin aggressive fluid administration and broad-spectrum antibiotics (gram-positive, gram-negative, and anaerobic coverage needed).
  • Fournier’s Gangrene is a clinical diagnosis. Imaging may assist in atypical or borderline cases, but should never result in delay of surgical evaluation and treatment. Crepitus and ecchymotic tissue are very late findings; have high clinical suspicion inpatients with signs of swelling, erythema, and pain.

  • Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001. Epub 2013 Apr 8. PMID: 23578806.
  • Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med. 2011 Sep;39(9):2156-62. doi: 10.1097/CCM.0b013e31821cb246. Erratum in: Crit Care Med. 2011 Nov;39(11):2592. Dosage error in article text. PMID: 21532474.
  • Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review. Surg Infect (Larchmt). 2016 Oct;17(5):503-9. doi: 10.1089/sur.2016.049. Epub 2016 Aug 2. PMID: 27483003.
  • Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
  • Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. doi: 10.1016/j.jamcollsurg.2008.10.032. Epub 2008 Dec 12. PMID: 19228540.
  • Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. p.592- 593.

SAEM Clinical Image Series: Blisters, Bullae, and Badness

blisters bullae

A 3-year-old female with a history of epilepsy presents with a rash that began one day ago. The patient started becoming fussy four days ago, saying, “I don’t feel good,” and not wanting to play outside with her siblings or finish her meals. Family noticed the patient rubbing her eyes frequently and crying when she went to the bathroom. She felt warm so they gave her Tylenol and Motrin at home. Yesterday, they noticed a rash was starting to develop with itchy, painful red spots. This morning, the rash progressed to involve some blisters on the face, chest, and back.

Medications include Tylenol, Motrin, and lamotrigine, which was started by her neurologist three weeks ago. Family history is significant for epilepsy on the father’s side of the family.

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By |2021-01-05T13:23:34-08:00Jan 4, 2021|Academic, SAEM Clinical Images|

SAEM Clinical Image Series: An Oropharyngeal Mass

oropharyngeal mass

A fifty-year-old male presented to the emergency department (ED) unconscious with CPR in progress. Per EMS report, the patient was found down surrounded by emesis with no pulse or respirations. Fifteen minutes of CPR was performed prior to arrival in the ED with a King Tube in place. The King Tube was filled with emesis and increasingly difficult to bag. The King Tube was removed to attempt intubation and maximize oxygenation and ventilation.

When the Mac 4 blade was placed in the mouth, a large, pink, fleshy, and vascularized structure was seen in the mouth just anterior to where the uvula should have been located.  Attempts were made to compress the mass into the tongue, separate the tongue from the mass, and sweep the mass out of the way. All attempts failed to expose the epiglottis. An attempt was made to remove the mass, but it appeared to be part of the mouth.  The decision was made to proceed with a cricothyrotomy; a 6.0 tube was successfully placed, and the patient was able to be ventilated. Return of spontaneous circulation was never achieved and the patient expired in the ED.

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SAEM Clinical Image Series: Eye Trauma and Vision Loss

globe rupture open globe

The patient is a 44-year-old male with a past history of end stage renal disease on hemodialysis, diabetes, and hypertension who presents with acute visual loss after assault 2 hours prior. He was struck in the eye by his partner’s fist (adorned with a large ring), but denies severe pain. He does endorses instant difficulty with his vision. There is no use of contacts or glasses. No other injuries, headache, or loss of consciousness are reported.

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By |2019-11-10T21:42:57-08:00Oct 21, 2019|Ophthalmology, SAEM Clinical Images, Trauma|
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