In the latest Case Record of the Massachusetts General Hospital, shock, abdominal-wall necrosis, and leukocytosis developed in a 30-year-old woman after a cesarean section and did not respond to antibiotics. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and abdominal-wall débridement were performed. Necrotizing soft-tissue infection (also known as necrotizing fasciitis) is a rare but well-known postpartum complication. The four tenets of care for necrotizing infections are: early detection, aggressive debridement, adequate antibiotic therapy, and physiological support. CT can be useful when evaluating a necrotizing soft-tissue infection, with sensitivity and a negative predictive value of virtually 100%. Management with antibiotics alone is associated with mortality rates approaching almost 100%. Early surgical exploration is associated with lower mortality rates (20 to 50%).
• What is the typical presentation and course of postpartum necrotizing soft tissue infection?
Signs and symptoms of necrotizing soft-tissue infection include fever, tachycardia, hypotension, erythema with induration that extends beyond the involved area, pain disproportionate to appearance, bullae, crepitus, subcutaneous gas, ecchymosis, and skin discoloration and necrosis. Postpartum necrotizing soft-tissue infection typically occurs within hours or a few days after delivery; typically organisms are identified by pathological examination, stains, or cultures. Most relapses of necrotizing soft-tissue infection occur hours or days after debridement, and late relapses are very rare.
• What are the clinical manifestations of Sweet’s syndrome?
Sweet’s syndrome (acute febrile neutrophilic dermatosis) is characterized by the presence of two major findings: the abrupt onset of erythematous-to-violaceous, edematous cutaneous lesions, and the histopathological finding of superficial dermal edema and a dense dermal neutrophilic infiltrate. Two of four minor criteria must also be present for the diagnosis: fever, leukocytosis, a rapid response to glucocorticoids and an underlying condition or exposure.
Morning Report Questions
Q: How is Sweet’s syndrome distinguished from other neutrophilic dermatoses?
A: Sweet’s syndrome is distinguished from other neutrophilic dermatoses (Behcet’s disease, pyoderma gangrenosum, and bowel-associated dermatosis-arthritis syndrome) by the appearance of cutaneous lesions and the presence of systemic symptoms, as well as extracutaneous involvement, including arthritis, arthralgias, myalgias, aseptic meningitis, ocular involvement, and on rare occasions, neutrophilic infiltration of the lungs, bones, kidneys, muscles, or pancreas. Pathergy, which is a characteristic reaction involving a nonhealing lesion that occurs in the setting of even minor trauma (e.g., vascular puncture sites), is an important clinical finding in neutrophilic dermatoses.
Q: What underlying conditions are known to be associated with Sweet’s syndrome?
A: Associated conditions include cancer, especially hematologic cancers, which are the most common in adults; infections, particularly upper respiratory and gastrointestinal infections but also infection with human immunodeficiency virus; medications, especially granulocyte colony-stimulating factor and all-trans retinoic acid, although many others have been reported; inflammatory bowel diseases; and pregnancy.