posted
I wasn't sure where else to go, I know I'm pretty much a stranger here now.
My cousin is in bad shape, possibly dying and no one is certain why - I know you have access to research resources I don't I was hoping you might have some advice for us.
He appears to have necrotizing fascitis. The strange thing is, he was was just injured on Saturday. Usually this bacteria takes time to develop into a problem like this.
Here's the deal - he was skiing on Saturday in the lake, he fell, and struck his arm on something. He described it as feeling a shock and instant pain, and thought he'd broken his arm. He was bleeding, when they pulled him in the boat. He began throwing up from the pain almost immediately and couldn't walk to the car. They drove him straight to an emergency room (at a small regional medical center in Gadsden), where the arm was x-rayed and found to not be broken. There was a puncture wound in the arm about the size of a nail hole.
They sent him home, with some antibiotics and told him to call his doctor in Birmingham on Monday if it was no better. That night, he woke up vomiting and crying out in pain. His wife rushed him back to the hospital where he had a 103 degree fever, the arm was red and swollen and his pain was severe enough to require morphine.
A CAT scan this morning revealed a gaseous pocket inside the arm and he was taken to surgery. The doctor says the puncture wound was almost through and through - within an eigth of an inch of coming out the other side of his arm. There was a peach-sized pocket of gas and pus from the bacterial toxins. They debrided the arm, and have him on high doses of pain meds and antibiotics, still waiting for a culture to see what it is he has. The infection has spread from the forearm to the shoulder, very quckly and aggressively. The doctors admitted not ever seeing anything that moved that fast.
Sara, have you ever heard of something like this developing so fast? Is there anything else that could possibly be going on? He's at a local hospital, a good hospital, I've had surgery there and all four kids were delivered there, but should he be transferred to UAB?
Anything you might offer that could help us, or reassure us, would be great. Those of you that have met cherie, my aunt (Fael on this board) - this is her oldest son. She is very scared, as are we all.
Please help if you can.
And, I'm panicking now, because I examined my kids and they have lots of minor cuts and abrasions, and now I'm paranoid. Does the fact that I'm most likely a silent carrier of strep put them at risk?
[ August 02, 2004, 06:07 PM: Message edited by: Belle ]
Posts: 14428 | Registered: Aug 2001
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I'm not a medical mind, but given the nature of the injury and the fact it happened in the lake leads me to believe the wound was at greater risk of becoming infected, moreso than any casual cut or scrape.
posted
The only comfort I can offer you now is that your children are very unlikely to have gotten the infection. When I looked necrotizing fascitis up, I found:
quote:This disease rarely occurs in children. Pediatric cases have been reported from countries where poor hygiene is prevalent.
My heart goes to you and your family, Belle. I will be sure to send all my prayers to your cousin as well as to Fael. Hang in there. Posts: 181 | Registered: Aug 2001
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posted
I can only hope for comfort for you and cherie and your cousin. What a devastatingly frightening thing for all of you and I hope the doctors will be able to soon allay those fears.
Posts: 14745 | Registered: Dec 1999
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posted
OK, here is some stuff from my UpToDate Doctor program.
Early recognition of necrotizing fasciitis is very important since there may be a remarkably rapid progression from an inapparent process to one associated with extensive destruction of tissue, systemic toxicity, loss of limb or death...features to look for include unexplained pain, blister and bullae formation, and signs of systemic toxicity.
Erythema may be present diffusely or locally but, in some patients, excruciating pain in the absence of any cutaneous findings is the only clue of infection. Within 24 to 48 hours, erythema may develop or darken to a reddish-purple color, frequently with associated blisters and bullae; bullae can also develop in normal appearing skin. The bullae are initially filled with clear fluid but rapidly take on a blue or maroon appearance. Once the bullous stage is reached, there is already extensive deep soft tissue destruction such as necrotizing fasciitis or myonecrosis; such patients usually exhibit fever and systemic toxicity.
In addition to pain and skin findings, fever, malaise, myalgias, diarrhea, and anorexia may also be present during the first 24 hours. Hypotension may be present initially or develop over time.
TREATMENT — Treatment consists of early and aggressive surgical exploration and debridement of necrotic tissue, antibiotic therapy, and hemodynamic support as needed. In addition, the various types of infection require some specific modalities. The best indication for surgical intervention is severe pain, toxicity, fever and elevated CPK with or without radiographic findings.
Surgery — A delay in surgical diagnosis and debridement probably increases mortality although, for obvious reasons, a controlled trial to address this question cannot be performed. The goals of initial surgery are to establish a diagnosis and, if necrotizing fasciitis is present, to perform aggressive surgical debridement of the involved fascia. Reexploration should be performed in 24 hours; repeat explorations and debridement may be necessary on a daily basis until all necrotic tissue has been removed
So, he needs prompt surgery (I know he already did) and probably repeat trips to the OR to keep that thing under control. They do not want it to get into the neck tissues; from there it can go into the head. He ought to have an infectious disease doctor on the case as well as a good surgeon. I cannot tell you whether the care he is getting is good enough; you guys will have to ask a lot of questions and be on top of things. Cutting it out and sacrificing the arm and shoulder, if necessary, should be strongly considered if it truly is necrotizing fasciitis. There is a possibility he won't make it, even if they do everything 100% correct. Finding out the name of the organism will help.
As for you and your kids' risk factors? Don't worry. Your cousin got a puncture wound and something bad got trapped in there and spread like wildfire. Your strep strain is a different strain, and probably NOT virulent the way his is. And your strain and his strain have nothing to do with each other, as far as I would guess. Now, anyone could catch his strain, but since he got his from a specific portal of entry, then I doubt your family has had exposure to it. And even if you guys DO get colonized, your individual risks of devoping this sort of infection is very very low.
posted
I have nothing to offer but my prayers for your cousin, for you, and for your family. I hope everything turns out all right.
Posts: 3546 | Registered: Jul 2002
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posted
I'm still wondering if it truly is necrotizing fasciitis or if it is a related infection. The presence of gas in the wound makes me less likely to blame strep; I don't think strep causes gas formation. There are other bacteria that DO cause gas formation in necrotizing fasciitis. Also, claustridial or nonclaustridial gas gangrene of a puncture wound would look similar. And Claustridium histolyticum specifically is found in water.
posted
Theca, thanks for weighing in, I really appreciate it.
I've been reading all night, and finding case histories where this type of rapid progression happened, so I suppose it isn't all that abnormal with this stuff.
When I first heard his symptoms, I thought snakebite. I just didn't think a few hours was enough time for there to be a massive infection.
When they went in for the first surgery, the doctor was thinking possibly snakebite as well.
They did tell Cherie that future surgeries were pretty much a given, and that they could expect him to be in the hospital for a while. He is still in enormous pain, which from what I've read is pretty common with this type infection.
They do have an infectious disease specialist on board. They are baffled as to what caused the puncture, the surgeon said there was no debris or anything in the wound to give a clue.
I guess it's good he did progress so quickly, and was hospitalized less than 24 hours after the incident.
I know I'm overreacting. But, I found myself going over the kids legs looking for any mosquito bites they might have scratched open, or any scrapes or bruises. My kids play outside every day, riding their bikes and scooters and running through the trees, they are covered with tiny nicks and scrapes. I always clean any open sores, and treat the mosquito bites to keep them from scratching if possible (and use bug and sun screen, but they get bitten anyway) but this has got me spooked, bad. I don't usually react to stuff this way. I'm kind of worried about my reaction, honestly. It's 2:42 and I'm still up, can't sleep.
Posts: 14428 | Registered: Aug 2001
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posted
Belle, I can completely understand your reaction to this--it seems fairly normal, honestly, given the circumstances. I do think that Theca and Trevor are right, though, and that your family is at pretty low risk. I'm so glad that Theca was here to give you a good, detailed response. I'll be thinking of your cousin. Keep us posted on how he's doing (and how Fael and the rest of you are holding up emotionally).
posted
(((Belle))) never a stranger here. I've missed you.
There was a case like this on TV once. Young hiker comes in with a painful red spot under skin and they have to amputate. I don't know which show it was.
I don't know if it will help your anxiety to remember that riding in a car is still the most hazardous undertaking most of us engage in.
What is odd is the sudden pain he felt when it happened. I pray he'll make it. Again it's good to see you, even though this isn't necessarily a good time for you.
Posts: 11017 | Registered: Apr 2003
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Just thought I'd weigh in on the Hyperbaric treatment issue. Although you're well aware I have no medical background I do have some personal experience with this treatment.
My mother had breast cancer several years ago and had a portion of her breast removed. Sor quite some time she made no progess in the healing of the wound - it just sat open, apparently.
Eventually she was slated for a combination of kelp being packed in the wound and hyperbarid treatment.
Her recovery was nothing short of sensational, the wound rapidly healing, and as an odd side-effect, her terrible eyesight going to near 20/20 for a few weeks before returning to normal.
Just thought you might like to hear a completely unimportant non-medical POV...
Belle - I hope your brother recovers, I'm sure he's getting great treatment.
Posts: 2245 | Registered: Nov 1998
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I have also missed you, and will be praying for your cousin and for Fael and the rest of your family. This must be terribly frightening for all of you.
Posts: 9866 | Registered: Apr 2002
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cultures were taken and haven't heard results yet.
Only other piece of information that i didn't have yesterday is that at the site of the injury, when the boat swung around and picked him up out of the water, there was a dead catfish floating nearby, one of the guys in the boat remembers remarking they needed to get the wound cleaned up since he was in the area of the dead fish.
Don't know if that is significant or not.
I'm better today, I realize this is a very rare thing, (even rarer in kids) and there's nothing you can really do to prevent it except practice normal hygiene and wound care as I would to prevent any type of infection. I was just freaked last night, spent too much time reading case histories and survivor stories.
Posts: 14428 | Registered: Aug 2001
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Lakes are a hotbed of possible infections and the dead fish in such close proximity only heightens the possibility of infection.
Given the nature of his wound, it again amplifies any possible infection - whereas a relatively simple cut or scrape doesn't give the same instant access to the body.
Your kids will be fine - although I realize this may be cold comfort the next time someone skins their knee and your heart stops.
posted
Swelling and hives, starting from the injection site and spreading rapidly. I worked for a phamaceutical company, and one of our registered pharmacist employees stopped me in the hall, when he saw me scratching my arm, and asked what was wrong. he looked at it, dosed me with benadryl and drove me back to the doctor's office.
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posted
Belle, it is good to see you here again. I have been wondering about you, how you are, if/when you would return to Hatrack.
I am so sorry about the scary circumstances of your cousin. I don't have much in the way of medical knowledge, all I can say is that I am sorry and that I hope things work OK for him and all of you. It is so hard not knowing what is going to happen. Posts: 7050 | Registered: Feb 2004
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posted
They are officially calling it necrotizing fasciitis now, but still no result on the culture to find out exactly what strain of nasty we're talking about.
The doctor did say it was a gangrenous bacteria though, I suppose because of the pocket of gas they found?
His fever is down, but still not normal. His white count looks better than yesterday's. They are still planning on going back in for more surgery.
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posted
Belle, I just read this thread to Bob (he's offline this week) and he asked me to tell you and Fael that you all will be in his thoughts and prayers.
Posts: 9866 | Registered: Apr 2002
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Question to medical types: apart from the fictional representation of this treatment, what are the possible benefits? Natural practice medico's talk about the use of maggots to debride - a certain type that only eat the dead flesh. Would that be possible, helpful? Or totally out of the realm of okay-ness? (Late night thinking)
Posts: 5609 | Registered: Jan 2003
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posted
Shan, I was thinking about maggots too (I've been reading a lot about their medical use recently). But I think they would be too slow for something like this. It takes days for maggots to clean a wound thoroughly, I believe.
Posts: 32919 | Registered: Mar 2003
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posted
I thought the same thing (What about maggots? Hmm...probably too slow for this situation). Plus, doesn't that bacterium produce a toxin that kills surrounding tissue? Wouldn't it kill the maggots, too?
[/weird rabbit-trails of thought]
I'm sorry to hear about his condition worsening. You'll all be in my prayers. (and yeah, I mean it, even though I'm a professed heathen).
Posts: 1664 | Registered: Apr 2004
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posted
Hey guys, nothing new but on the maggot thing - they say this stuff progresses at a rate of about 2cm an hour, probably too fast for maggots.
Don't they use maggots for flesh that has died for lack of proper circulation? (Or am I thinking they use leeches to remove blood that isnt' circulating.)
Anyway, it seems like this stuff may not leave the flesh in any condition the maggots want to eat. isnt' that a lovely thought?
Posts: 14428 | Registered: Aug 2001
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posted
Oh, I forgot to add. he can no longer feel his toes or fingers. From my understanding, that is from drugs used to help his blood pressure, which shunts blood away from the outer extremities.
Theca, CT, is that right?
Apparently, this is not an uncommon thing with NF and it's very common for patients to even lose some of their extremities because of the lack of circulation. Which means, amputations may happen of fingers and toes not affected by the bacteria, but which die because of the treatment.
If he survivies this, I wonder what bodes for his future? he's an IT guy, I found myself wondering if he'd be able to type.
I know, however, that prayers right now need to be mainly for survival and fingers, toes, and even his arm are expendable when compared to his life.
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posted
Belle, you don't have an address up, or I would email you. I normally only mention in joking that we use health magnets, but they might help the peripherals. It's a fact that magnets increase the flow rate of saline through tubules in laboratory conditions, and a lot of folks claim they seem to have a similar effect in capillaries.
Ironically, the magnet/maggot confusion is joked about frequently in the health magnet scene. Anyway, they sell them pretty much everywhere now so I don't feel like it's violating the terms of use to mention them.
P.S. I assume the are trying to starve the afflicted arm on purpose? So if they did wind up using any magnets, of course don't use them on the wounded arm. Not only would it be defeating the drug action, they could worsen bleeding. That's one thing I sincerely believe about natural alternatives- if they work at all there is logically some what they could hurt someone.
posted
Belle, I know what you're saying. My husband is working in masonry while he gets his cartooning business up and running, and our greatest fear is that something will happen to his right hand before he gets the business to a point where it can support us.
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posted
Amputation is an irrational fear of mine. I know of a gal who has cancer spreading in her upper arm, and if other treatments fail, they are going to amputate.
The irrational part of my feelings is that there is a part of me that would rather die than lose a body-part. Isn't that silly of me? I'm sure that you and your cousin would prefer that he survive no matter the outcome.
I am remembering you and your family in my prayers.
Posts: 7050 | Registered: Feb 2004
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posted
Sorry, I'm a little busy right now. The medications Belle is talking about are probably drugs used to raise blood pressure to a healthier level. He probably has low blood pressure from being so ill and infected. Side effect of pressor drugs is that the arteries become narrow, so that the extremities get less blood, appear pale and cool to the touch. The blood is being shunted centrally to preserve the brain and central organs, you see.
So anything that reverses that (like magnets, if they work like you said they do) will counteract the pressors. Not a good idea. Hopefully they can get the infection under control soon, then the blood pressure will improve, then he can get off the pressors before any permanent damage to his extremities. Permanent damage is pretty rare, in my experience, though.
Posts: 1990 | Registered: Feb 2001
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posted
Well, we have the information from the cultures finally. The doctor said the predominant bacteria was gram negative Proteus bacteria.
I did some quick reading and found it is more common in urinary tract infections. Maybe Theca or CT can shed some light on it?
Anyway, the doctor told Cherie several times "He's lucky he got to the hospital so fast." Apparently this is not a good thing to have.
I did read this, which didn't exactly fill me with encouragment:
quote:Because Proteus and Pseudomonas organisms are gram-negative bacilli, they can cause gram-negative endotoxin-induced sepsis, resulting in systemic inflammatory response syndrome (SIRS). SIRS has a mortality rate of 20-50%.
The surgery yesterday went well, they didn't find as much stuff as they thought and were encouraged. However, he had a very bad night last night, with them unable to control his fever and his pain.
Another surgery is scheduled for tomorrow and they have changed his antibiotic. He's still running a fever and they upped his morphine dosage so now he is pretty much out of it all the time.
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I'm still keeping you in my thoughts and prayers. Identifying the bacteria responsible is a huge step. I hope they are really getting out "ahead" of this infection and that they can make him more comfortable while doing so.
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