Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

According to the most recent review on necrotizing fasciitis (NF), NF often presents with nonspecific findings such as pain, erythema, and swelling. Clinical features include pain out of proportion to physical examination, failure to respond to broadspectrum antibiotics, and the presence of cutaneous bullae on the skin. We report a rare case in which the diagnosis of NF was unexpected due to its atypical presentation and was ultimately prompted by further underlying exploration in the setting of diabetic ketoacidosis (DKA) and persistent Afib with RVR. Case Summary: A 61-year-old male with a history of type 2 diabetes mellitus presented with nausea, vomiting, and dizziness. He also admitted to mild right groin pain. On arrival, heart rate was 138 beats/minute, blood pressure of 144/82, respiratory rate of 18 breaths/minute, and pulse oximetry of 95% on room air. Laboratory evaluation revealed a glucose of 303 mg/dL, bicarbonate 19 mmol/L, anion gap 17 mmol/L, beta-hydroxybutyrate 4.01 mmol/L, and a white blood cell count (WBC) of 15 x 109/L. Ultrasound of his scrotum was initially obtained and was consistent with right epididymo-orchitis. In the setting of medical noncompliance, the clinical picture was consistent with DKA exacerbated by the diagnosis of epididymo-orchitis. His DKA was treated, and he was initiated on broad-spectrum antibiotics with near resolution of his leukocytosis. Despite these interventions, the patient developed persistent Afib with RVR, with heart rates as high as 220 beats/minutes. This was unresponsive to standard management, including diltiazem pushes, a diltiazem drip, normal saline fluid boluses, two synchronized cardioversions, and metoprolol pushes. There was only an initial response to metoprolol, but the patient eventually reverted back into Afib with RVR. Approximately 48 hours after arrival, mottling of the abdominal skin was observed. This raised clinical suspicion for a more insidious abdominal process, despite a lack of abdominal symptoms. A computed tomography of the abdomen and pelvis was obtained, revealing the diagnosis of necrotizing fasciitis, requiring urgent surgical intervention: a partial scrotectomy. This case highlights an uncommon presentation of NF where persistent Afib with RVR was the initial clue to systemic involvement, overshadowing the typical hallmarks of severe localized pain, cutaneous changes, or resistance to antibiotics. It underscores the importance of maintaining a broad differential diagnosis in patients with resistant arrhythmias and DKA, especially in the presence of systemic symptoms. Diagnosis was unexpected when there was initial improvement in WBC, a confounding diagnosis of epididymo-orchitis, minimal skin changes, and improvement in patient’s pain. Persistent Afib with RVR can occasionally serve as an indicator of severe underlying pathology, such as rapidly progressive infections like NF.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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