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doi: 10.1111/j.1346-8138.2009.00669.x Journal of Dermatology2009; 36 : 423426

2009 Japanese Dermatological Association 423

Blackwell PublishingAsiaCASE REPORT

Necrotizing fasciitis and myonecrosis synergisticnecrotizing cellulitis caused by Bacillus cereus

Asuka SADA, 1 Noriyuki MISAGO, 1 Takeshi OKAWA, 1 Yutaka NARISAWA, 1 Shuya IDE, 2 Masaki NAGATA, 3 Shinji MITSUMIZO 41Division of Dermatology, Department of Internal Medicine, Departments of 2Orthopeadics, 3Infection Control Unit and 4 Anesthesiology and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan

ABSTRACT

Our patient was a 37-year-old man with diabetes mellitus and hepatopathy as underlying diseases. Swelling,erythema and pain appeared in the left upper limb on the day before the initial examination. On examination, diffusepurpura was noted on the left upper limb, and, as it rapidly extended to the left upper trunk, emergency surgerywas performed. Intraoperatively, gas-producing necrosis was observed not only in subcutaneous tissues but alsofrom the fascia to muscle tissues, and the condition resembled clostridial gas gangrene. However, as the culturingof samples from the lesion yielded Bacillus cereus , a diagnosis of necrotizing fasciitis and myonecrosis (synergisticnecrotizing cellulitis) due to B. cereus was made. While the patient developed a serious condition due to sepsisand disseminated intravascular coagulation, he could be saved by early debridement and intensive treatment withan appropriate selection of antibiotics.

Key words: Bacillus cereus, necrotizing fasciitis, myonecrosis.

INTRODUCTION

Bacillus cereus is an aerobic Gram-positive roddistributed very widely in nature and is commonlyknown as a cause of food poisoning. 13 However, it

has recently been recognized as a cause of infectionin neonates and immunocompromised individualsand has been reported to cause skin and soft tissueinfections, pneumonia, meningitis, endocarditis,bacteremia and sepsis. 1,2,49 In skin and soft tissueinfection caused by Bacillus cereus , gas productionand myositis may occur, and the condition is oftenconfused with clostridial gas gangrene. 4,5,1012 Wereport a patient with diabetes and hepatopathy whodeveloped necrotizing fasciitis and myositis due toB. cereus and entered a critical condition.

CASE REPORT

The patient was a 37-year-old Japanese man whohad been treated for 2 months due to diabetes

mellitus and alcoholic hepatopathy. Pain appearedin the left upper limb in the evening on the daybefore the initial examination. A fever and swellingand pain of the left upper limb developed the nextday, when the patient consulted our hospital. On

examination, diffuse purpura, swelling and feverwere noted in the left upper limb and axilla, and thepatient complained of intense pain and tenderness(Fig. 1a,b). On arrival, consciousness was clear, butthe blood pressure was 67/42 mmHg, and the heartrate was 136 b.p.m., indicating shock. Body tem-perature was 37.9 C. The purpura rapidly extendedto the left upper trunk within 2 h of arrival, andpurpura also appeared on the lower limbs (Fig. 2c).The level of consciousness gradually decreased tocoma. The results of blood tests were as follows:

white blood cells, 5900/ L; red blood cells,337 10 4 / L; hemoglobin, 10.4 g/dL; hematocrit,30.7%; platelets, 15.6 10 4 / L; prothrombin time,33.7%; activated partial prothrombin time, 49.9%;total protein, 3.8 g/dL; albumin, 1.9 g/dL, total

Correspondence: Asuka Sada, M.D., Division of Dermatology, Department of Internal Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga 849-8501, Japan. Email: sadaasu@cc.saga-u.ac.jpReceived: 19 December 2008; accepted: 11 March 2009.

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bilirubin, 6.8 mg/dL; aspartate aminotransferase,232 IU/L; alanine aminotransferase, 47 IU/L; lactatedehydrogenase, 403 IU/l; alkaline phosphatase,726 IU/L; -glutamyltransferase, 964 IU/L; blood

urea nitrogen, 7.2 mg/dL; creatinine, 0.97 mg/dL,creatine phosphokinase, 5783 IU/L; Na, 128 mEq/L;K, 2.8 mEq/L; Cl, 86 mEq/L; C-reactive protein,6.15 mg/dL; HbA1c, 8.7%. Magnetic resonanceimaging disclosed wide subcutaneous edema fromthe left upper limb to shoulder and inflammationinvolving not only the fascia but also intermusculartissues (Fig. 2). No clear image of gas was observed.

When samples from the lesion were examined byGram staining, a large number of Gram-positive rodswere detected. The administration of vancomycinand clindamycin was immediately initiated to covera wide spectrum of Gram-positive rods. Emergencysurgery was performed, revealing necrosis partlyextending from the subcutaneous tissues to deepareas of muscle tissue (Fig. 3a). Bubbles were iden-tified in areas with particularly severe myonecrosis,and an irritative odor was noted, suggesting agas-producing bacterium as the pathogen (Fig. 3b).Because this finding, along with the results of Gramstaining, suggested clostridial gas gangrene, theantibiotic was changed intraoperatively from vanco-mycin to penicillin G, which is more effective againstclostridia. The general condition was poor even afterthe initial surgery, and while the patient continued tobe managed in the Intensive Care Unit, additionaldebridement was performed. On the third hospitalday, only B. cereus was detected on bacterial culture

despite the initial expectation. The antibiotic wasimmediately changed from penicillin G to vancomycin.Thereafter, the general condition and laboratory resultsgradually improved, and the patient was dischargedon the 94th hospital day after several debridementand skin graft operations. Presently, the patienthas returned to his original work while continuingrehabilitation of the left upper limb.

Figure 1. (a,b) Diffuse purpura, swelling and fever werenoted from the left upper limb to the axilla. (c) After 2 h,purpura also appeared in the crus.

Figure 2. Magnetic resonance imaging suggested widesubcutaneous edema and inflammation involving inter-

muscular tissues from the left upper limb to shoulder(arrow).

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