June 2014 Case of the Month- courtesy of Brandon Quarles

A 61yo undomiciled male with a history of DM presented with c/o R shoulder pain x 1 day.  He also reported subjective fevers.  He denied trauma, injections/IVDU, or history of skin infections.  On exam he had a swollen erythematous R shoulder with a fluctuant mass in the R axilla.   The following clips were obtained on bedside US:

The US images above demonstrate necrotizing fasciitis.   NF is a soft tissue infection with a high morbidity/mortality up to 75%, is typically polymicrobial and risk factors include trauma, DM, IVDU, immunosuppression.   Clinically, the site of infection is often erythematous with ill-defined borders, rapidly progresses, and late findings often include bullae, crepitus and blistering.  Such clinical findings are only reliable 64% of the time. Findings on bedside ultrasound include the “STAFF” signs: Subcutaneous thickening, Air, Abnormal thickening of the fascial layer.