Life-threatening Necrotizing Fasciitis Due to ‘Bath Salts’ Injection
by Russell Russo, MD; Noah Marks, MD; Katy Morris, MD; Heather King, MD; Angelle Gelvin, MD; Ronald Rooney, MD
Abstract
Necrotizing fasciitis is an orthopedic emergency. The ability to quickly and accurately diagnose this rapidly spreading disease can save a patient’s life and limb. However, the diagnosis is complex because necrotizing fasciitis usually manifests as a less severe cellulitis or abscess while the majority of the damages rage beneath the surface of the skin. Although the diagnosis is not new, the potential causes and vectors continually change. This article reports a new source of necrotizing fasciitis in an intramuscular injection of “bath salts,” a rapidly emerging street drug that is legal in some states and evades authorities with its innocuous name.
The patient presented 2 days after injection of bath salts with extensive cellulitis extending to the mid portion of her upper arm. The cellulitis initially responded to broad-spectrum intravenous antibiotics, but rapidly deteriorated 48 hours later, leading to a forequarter amputation with radical mastectomy and chest wall debridement to obtain healthy tissue margins and control the disease. The patient made a full recovery after further minor debridements, negative pressure dressings, directed antibiotic therapy, and skin grafting.
Case Report
A 34-year-old woman presented with a 2-day history of increasing right forearm pain and erythema. She reported the redness and pain began the morning after a party.
On further questioning, she reported injecting bath salts 2 nights prior to developing symptoms. She also reported the injection was intramuscular because she could not obtain intravascular access. The patient initially denied illicit drug use, but then reported cocaine, opiate, and benzodiazepine use in addition to the recent bath salts injection.
Hours later, when the patient was reexamined, she was found to have progressive erythema that had developed past the earlier skin markings and an area of skin sloughing around the injection site with a malodorous drainage. The diagnosis of a fast-spreading infection, such as necrotizing fasciitis, was assumed, and the patient immediately underwent emergent surgical debridement and exploration. She was placed on penicillin G and clindamycin for antibiotic coverage (Figure 1).
Figure 1: Patient at time of operative incision.
By the time surgery began, the erythema had spread farther proximally, and bullae were beginning to form at the injection mark on the dorsal forearm. An incision was made over the dorsal forearm in the Thompson approach. A large amount of pink, thin, purulent fluid was expressed with a foul odor. As the debridement continued, a large area of dark, noncontractile muscle surrounding the area of injection was present. After full dissection of the forearm, 30% of the skin and subcutaneous tissue remained viable, along with the contents of the volar forearm (Figure 2).
Figure 2: Photograph during forearm debridement.
No clear margins proximally of healthy muscle were available, so an incision was made in the anterolateral approach to the shoulder. In the time it took to expose the anterior upper arm, muscle in the forearm that had previously been contractile and pink had turned dusky and noncontractile. We disarticulated the shoulder to obtain clear margins of the disease to prevent disease progression. The general surgery team was placed on standby to aid with further chest wall and neck debridement as indicated, and massive blood transfusion protocols were instituted.
To prevent the spread of disease and obtain healthy viable tissue, a complete forequarter amputation was performed, removing both scapula and clavicle while debriding all noncontractile, unhealthy muscle. The general surgery team also elected to perform a right radical mastectomy and further chest wall debridement to prevent further progression of the disease. All bleeding vessels were ligated, and we obtained disease-free tissue throughout the wound bed. Sterile dressings were applied, and the patient was transferred to the intensive care unit for monitoring (Figure 3).
Figure 3: Photograph after debridement.
Bacterial isolates included alphahemolytic Streptococcus, Streptococcus viridans, Peptostreptococcus micros, Gemella morbillorum, and Actinomyces odontolyticus. Recent studies indicated that 82% of these infections were polymicrobial, with the most common organisms including Gram-negative enteric bacilli, enterococci, staphylococcal, and streptococcal species.
The patient underwent further debridement and negative pressure dressing changes in the following days and remained disease free, afebrile, and hemodynamically stable. She then underwent extensive split-thickness skin grafting after healthy granulatory tissue covered the expanse of the wound. She is currently undergoing rehabilitation and is in excellent health (Figure 4).
Figure 4: Photograph after skin grafting.
To our knowledge, our article is the first to report streptococcal necrotizing fasciitis and myonecrosis from intramuscular injection of bath salts, which are currently only banned in some US states. Despite the drug’s legal status, it must be treated as illicit, and one must be suspicious when examining a patient with this clinical history because the diagnosis of flesh-eating bacteria can masquerade as abscesses and cellulitis. 7 Treatment for this virulent disease remains a swift diagnosis with extensive surgical debridement to obtain complete control of the organism and prevent death. However, the best treatment is prevention with public, street-based education and early detection.
As this article was long and detailed I deleted much of it for brevity. The entire article can be read here:
http://www.orthosupersite.com/view.aspx?rid=91162 
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great post
