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Fusobacterium emphysematous pyomyositis with necrotizing fasciitis of the leg presenting as compartment syndrome: a case report
© The Author(s). 2017
Received: 4 April 2017
Accepted: 17 October 2017
Published: 28 November 2017
Fusobacterium necrophorum is a common agent of disease in humans, but the occurrence of primary infections outside the head and neck area is extremely rare. While infection with Fusobacterium necrophorum has a rather benign course above the thorax, the organism is capable of producing very severe disease when located in unusual sites, including various forms of septic thrombophlebitis. No infections of the leg have been documented before; thus, antibiotic coverage for Fusobacterium is currently not recommended in this area.
A 50-year-old homeless African-American man presented complaining of severe pain in his right lower extremity. A clinical workup was consistent with emphysematous pyomyositis and compartment syndrome; he received limb-saving surgical intervention. The offending organism was identified as Fusobacterium necrophorum, and the antibiotic coverage was adjusted accordingly.
Bacteria typically involved in necrotizing infections of the lower extremity include Group A ß-hemolytic Streptococcus, Clostridium perfringens, and common anaerobic bacteria (Bacteroides, Peptococcus, and Peptostreptococcus). This case report presents a case of gas gangrene of the leg caused by Fusobacterium necrophorum, the first such case reported. Fusobacterium should now be included in the differential diagnosis of necrotizing fasciitis of the extremities.
Epidemiology and risk factors of necrotizing fasciitis
Group A Streptococcus (GAS)
Beta-hemolytic streptococci (alone or in combination with other species, most commonly Staphylococcus aureus)
Peripheral vascular disease (PVD)
Skin injury (laceration or burn)
Injection drug use
Laboratory Risk Indicator for Necrotizing Fasciitis score
C-reactive protein, mg/L
Total white cell count, per mm3
All surgical samples were collected using an eSwab Transport System (CoPan Diagnostics Inc., Murrieta, CA, USA), which handles all aerobic, anaerobic, and fastidious microorganisms. Blood cultures were placed in designated aerobic and anaerobic blood culture bottles (BacT/ALERT, Durham, NC, USA). The clinical laboratory at Saint Anthony Hospital outsources its microbiology to another laboratory in the Chicago area (LabCorp, 321 W Lake Street Suite C, Elmhurst IL, 60126). After samples are received from the operating room, they are packaged as per LabCorp specifications, and a courier is summoned. The estimated travel time is less than 4 hours. For surgical samples two different media cultures are used: for aerobic samples the swab containing the specimen is immersed in a gel-based transfer media; for anaerobic samples the Port-A-Cul transport system (BD – Beckton Dickinson, Franklin Lakes, NJ, USA) is used. Once the samples arrive at LabCorp they are processed as per proprietary procedures. Anaerobes in this sample were identified using RapID-ANA Kit (Thermo Fisher Scientific, Waltham, MA, USA). In addition, LabCorp results confirmed the presence of beta-hemolysis in the cultured plates.
Initial Gram stains of the pus collected showed only rare WBCs and no microorganisms. Blood cultures taken prior to surgical intervention (both bottles) and cultures from his right lower extremity wounds following the initial fasciotomy demonstrated Fusobacterium necrophorum, which was beta-lactamase negative and sensitive to cefoxitin, chloramphenicol, clindamycin, penicillin, doripenem, and metronidazole (determined by broth microdilution). No additional microorganisms were identified. The sputum cultures showed no growth.
Follow ups and outcome
This case report presents a rare type I idiopathic necrotizing lower extremity infection from Fusobacterium necrophorum: Gram-negative, obligate anaerobe, non-spore forming, pleomorphic bacillus . It has been isolated from the normal flora in the oral cavity, gastrointestinal tract, and genitourinary tract . When involved in disease and infection, necrotic lesions and deep abscess formation can occur, and bacteremia is not uncommon . Fusobacterium necrophorum is a well-established agent of disease above the diaphragm: it is commonly associated with Lemierre’s syndrome, a septic infection caused by thrombose formation within the jugular vein after colonization of a peritonsillar abscess [11–13]. In recent epidemiological surveillance studies, Fusobacterium has been determined to be the predominant organism causative of pharyngitis in a university clinic with 21% of the cases . Much more rarely though, Fusobacterium necrophorum has been described as a potential causative agent of infections below the diaphragm. Beldman et al. described a case of septic arthritis of the hip caused by Fusobacterium necrophorum following a tonsillectomy  and Patel et al. also reported in an abstract a case of necrotizing fasciitis and pyomyositis in the thigh caused by Fusobacterium necrophorum in a healthy adult . To the best of our knowledge, no other reports have been described directly linking Fusobacterium necrophorum as the causative organism for necrotizing infections below the knee in the literature. Early diagnosis and treatment is critical due to the rapid extensive tissue destruction that ensues with these infections, and thus maintaining a high index of suspicion is vital for the survival of these patients. A high index of suspicion is required when choosing antibiotic coverage for necrotizing fasciitis and pyomyositis, and additional case reports of this occurrence may define a pattern of risk factors that should prompt Fusobacterium coverage.
Our patient did not have any of the described risk factors for necrotizing fasciitis: diabetes mellitus, documented instances of recent and chronic intravenous drug abuse, age greater than 50, hypertension, and malnutrition/obesity . There were no obvious entrance wounds; thus, hematogenous spread of the infection from a possible pneumonic source or from oropharyngeal foci could not be ruled out, and has been described before [17, 18].
In the preparation of this case report the CARE guidelines were followed (surgical extension, which is available at http://www.scareguideline.com; the SCARE checklist is available in Table 3 of ).
Fusobacterium necrophorum which is often associated with Lemierre’s syndrome and fasciitis, pyomyositis, or osteomyelitis occurring above the diaphragm, can also cause necrotizing infections of the lower extremities. Treatment involves early and aggressive surgical exploration, debridement of necrotic tissue, hemodynamic support, and antibiotics.
Since the patient was lost to follow up, an updated perspective of his previous and current condition is impossible.
The authors wish to acknowledge the following individuals for their contributions to this case report: Dr Dipali Banerjee, MD, for her assistance in the pathology department while answering the reviewer’s comments; Dr Mario Masrur, MD, for his assistance with the clinical and surgical details while answering the reviewer’s comments.
No source of funding has been designated from the University of Illinois for this case report.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current case report.
JAB co-drafted the manuscript, participated in the design and coordination, and helped to draft the manuscript. IMI summarized the patient’s chart, participated in the design of the study, and revised the manuscript for errors and formatting (based upon the SCARE statement). LJ performed the literature review and participated in the design of the manuscript. AG conceived the case report and participated in its design and coordination. EJ drafted the manuscript and helped with the literature review. ESS co-conceived the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The case was reviewed and approved by the Institutional Designated Officer (Chief Legal Counsel), Mrs. Aileen Brooks JD, at Saint Anthony Hospital during the initial stage and prior to submission.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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