(816) Fatal Disease Disguised as Arm Swelling in a Pediatric Patient

Introduction: Necrotizing fasciitis is an uncommon disease in children. It is most commonly caused by S. Pyogenes with an incidence of 0.08 per 100,000 per year. Mortality rate in pediatrics is high.

Description: A previously healthy 2 year old presented to an emergency room for fever. She had a 3 day history of right upper extremity swelling and tenderness along with rash and fever. She was discharged home with a diagnosis of viral illness. She continued to be febrile with worsening arm tenderness, swelling and developed fast, shallow breathing with lethargy which prompted re-presentation. There, she was hypotensive and tachycardic. She was given fluids, antibiotics, norepinephrine infusion and transferred to our facility for surgical evaluation. Pediatric ER vital signs were: T: 99F HR: 165 RR: 60, BP: 86/53 92 % RA. She was intubated for presumed septic shock, started on epinephrine infusion, stress dose steroids and she was emergently evaluated by plastic and vascular surgery. Her initial ABG showed: pH: < 6.98 PCO2: 55 PO2: 525 BE: -23 Lactate: 2.8. CBC showed: WBC: 5.9 Hgb: 6 Hct: 19 Platelets: 13. INR: 3.03 CRP: 17.10 Procalcitonin: 90.84. She received fluid resuscitation, sodium bicarbonate, PRBC, FFP and platelets. CTA showed complete occlusion of the proximal right brachial artery at mid arm. She was taken immediately to the OR. During the initial incision, she suffered a pulmonary hemorrhage and cardiac arrest. She received 4 rounds of CPR and the case was aborted. ABG at that time showed: pH 6.95 pCO2 > 133 pO2 30 Lactate 11.9 K 5. The PICU team was called to the OR to help with transporting the patient, however she continued to have profound hypoxemia, frank blood from her ETT and difficulties with ventilation. She had another bradycardic arrest, her pupils were fixed and dilated and after 6 rounds of CPR she remained asystolic. Decision was made to no longer pursue additional interventions. Blood cultures performed at the outside hospital later grew Streptococcus pyogenes.

Discussion: This case illustrates the importance of maintaining a high clinical suspicion for this insidious disease. Necrotizing fasciitis is often misdiagnosed, however, early recognition, antibiotics and surgical intervention are crucial life saving measures, that when delayed, can have deadly consequences.