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Page 2 of 4 Amer et al. J Cancer Metastasis Treat 2018;4:34 I http://dx.doi.org/10.20517/2394-4722.2018.09

A B

Figure 1. (A) Post debridement; (B) post skin grafting

CASE REPORT
A 52-year-old female presented to our emergency department complaining of painful right lower limb
swelling, generalized weakness and fever for 2 days. There were no history of trauma, intervention or
insect bites and no other chronic medical illness. The lady was diagnosed with breast cancer 6 months
prior to this admission and she had breasts conserving wide local excision of the tumor, followed by 7 cycles
of adriamycin and cyclophosphamide, then 3 cycles of docetaxel. The last cycle of the taxane was just
12 days prior to her admission. On examination, she looked unwell, tachycardia with generalized swelling
and tenderness in the medial aspect of the right thigh. There was no distal neurovascular compromise
and no palpable lymphadenopathy. Her complete blood picture and inflammatory markers were normal
on admission.

Following aggressive resuscitation in the intensive care unit, she was taken to the operating theatre where
extensive debridement of necrotic tissue was done from the right thigh. This was repeated four times on
different occasions till nice granulation tissue was obtained, which was then covered by split skin graft
[Figure 1]. The histopathology features showed focal ulceration, marked hemorrhage, congestion, full
thickness necrosis, fibro purulent exudate and micro abscesses formation along with degenerating muscle
fibers consistent with necrotizing fasciitis.

DISCUSSION
Necrotizing fasciitis is an uncommon infection with high mortality rate caused by wide spectrum of
[2]
micro-organisms, of which two thirds are polymicrobial (type A) and one third is monomicrobial, mainly
cocci (type B) . It involves inflammation and necrosis of subcutaneous tissue, fascia, and muscles and later
[3]
of skin. High index of suspicion is needed for early diagnosis. Appearance of swelling, tachycardia, tense
oedema, ecchymosis, blister or bullae, crepitus and hypotension are late signs .
[4]

Scoring system suggested by Wong et al. based on the level of haemoglobin, leucocyte count, C reactive
[5]
protein, creatinine, glucose, and sodium will aid with the diagnosis. Diagnosis, however, is usually
confirmed intraoperatively when we find the classical foul smell “dish water” discharge, necrosis with
positive “finger test”.

Aggressive and radical debridement is critical for improving the outcome and lowering mortality rate .
[6]

In our patient, there was no other predisposing factor found for the development of necrotizing fasciitis apart
from the fact that the patient was on docetaxel at the time of infection, where she received 3 cycles 12 days