Toxic shock syndrome complicated by necrotising fasciitis: back to basics

Necrotising soft tissue infections (NSTIs) are uncommon but potentially fatal, and both their recognition and management represent significant challenges for clinicians. A 68-year-old male presented to the emergency department complaining of pain in his left lower limb following abrasion injuries sustained from a fall off a wooden ladder the previous evening. His injuries extended from the left anterior tibia up along the medial aspect of the left knee and thigh, and showed erythema, induration, and vesiculation. The patient had a history of hypertension and hypercholesterolaemia. On examination, he was hypotensive, tachycardic, and hypothermic. He rapidly deteriorated and developed acute kidney injury secondary to septic hypovolaemia, requiring haemodynamic support, long-term intravenous antibiotics, several surgical debridements, dialysis, and skin grafts, but he subsequently made a full recovery. The clinical, laboratory, and radiological findings in NSTIs can vary significantly, and definitive diagnosis is made by surgical exploration. Pain out of proportion to clinical findings, rapid clinical deterioration, and signs of systemic involvement are important clues for the clinician. This case demonstrates how rapid diagnosis and multidisciplinary management (in which surgery is the cornerstone) can lead to the most favourable outcome for patients.