After 24 hours, the patient developed abdominal pain, started vomiting bile and increased C- reactive protein (330 mg/L, normal < 5 mg/L) was noted. Due to a stable condition of the patient, normal vital parameters and absence of visible signs of disease, no operative measures were undertaken. A gastric tube was placed and extra fluid was administered intravenously. After three days, an abdominal CAT-scan revealed a dilated small bowel and colon, multiple air-fluid levels, and free gas in the abdominal cavity, indicating anastomotic leakage. During emergency laparotomies, three and five days after initial surgery, anastomotic or air leakage was not observed. Intraperitoneal fluid was cultured and showed Escherichia coli, Streptococcus viridans and Enterococcus faecium. Vancomycine (1 gram) was administered. The patient was transferred to the intensive care unit (ICU) because of respiratory instability. A livid, non-blanchable skin lesion developed at the right flank (Figure 1A). The skin lesions rapidly spread in a few hours, expanding to the proximal upper legs (Figure 1B&C). She became inotrope-dependent and necrotizing fasciitis was suspected (Figure 2). During a third re-laparotomy, a large volume of brown, non-fecal fluid was aspirated and Extended-Spectrum Beta-Lactamase-producing E. coli (ESBL-EC) was cultured. Necrosis of subcutaneous fat and Scarpa’s fascia was observed (Figure 3), but the underlying deep fascia and musculature were not affected. No air bubbles were present. The strain of ESBL-EC could not be matched to cultures of other admitted ICU-patients. The pathology report revealed necrotizing subcutaneous inflammation and presence of gram-negative, rod- shaped bacteria. Imipenem and clindamycin were administered intravenously.
Hemodialysis was started because of multiple organ failure (MOF) and further expansion of skin lesions was observed. About 60% of the body surface of subcutaneous tissue and skin was removed, at which the cutting edges appeared vital and the deep fascia was intact. However, the patient developed hypothermia (30.5°C) and hypoglycemia and deceased due to an irreversible septic shock with MOF based on necrotizing cellulitis caused by mixed (facultative) anaerobes, including an ESBL-EC.
Precisely 0 MtFs have ever pondered how their transition could affect their kids, they just go through with it without a care in the world and force everyone else to adapt to them.
