Abstract
A 78-year-old man with alcoholic cirrhosis was admitted to our hospital for progressing systemic purpura and impaired consciousness. His first computed tomographic (CT) scan indicated no remarkable changes. Because his left thigh gradually became discolored and purpura progressed every hour, and lactic acidosis and shock state deteriorated, a second CT scan was performed approximately 4 hours later, which showed the inflammatory changes of subcutaneous tissue at the left thigh but considered not in need of surgical intervention. Although he was admitted to the intensive care unit and treated with antibiotics (meropenem, ciprofloxacin, minocycline, linezolid, and clindamycin), he was still in shock state. The vesicle newly appeared on his left thigh and systemic purpura increasingly progressed. A third CT scan (9 hours after arriving at the hospital) indicated massive gas at the fascia and muscle layer of his left thigh, then debridement and vacuum-assisted closure therapy was performed. The deep soft tissue was necrotic, and a large amount of foul-smelling pus was released after incising the fascia. Despite intensive care, he died 28 hours after admission. Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli was detected from the blood and pus, and genetic testing confirmed a single strain possessing a CTX-M-8-like gene. The diagnosis was necrotizing soft-tissue infection (NSTI) at the left thigh caused by ESBL-producing E. coli. We should note that ESBL-producing bacteria can be a causative organism of fatal community-acquired infections such as NSTI.
