Abdominal necrotizing fasciitis causing acute myocardial infarction

Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high mortality rate.(1,2) NF is a severe form of soft-tissue infection. When NF is complicated with acute myocardial infarction (AMI), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI), the patient's chance of survival are diminished significantly.(3,4) We present a case of NF of the abdominal wall with acute non-ST segment elevated myocardial infarction (NSTEMI). No such case has previously been reported according to our review of the literature. Case: A 52-year-old female with a known case of hypothyroidism presented to the emergency department with severe abdominal pain for two days. She gave the history of abdominal hernia repair ten days back. She had sinus tachycardia but other vitals were normal, with no fever or leucocytosis. Computed Tomography (CT) of the abdomen showed anterior abdominal wall collections. Septic workup was done, cefuroxime and metronidazole were started. Her abdominal wall collection was drained under image guidance. After a few hours, her blood pressure dropped and was not responding to fluid challenges so a noradrenaline infusion was started and she was transferred to the surgical intensive care unit (SICU). Her blood work showed lactic acidosis. Her abdomen was tender all over with swelling and induration of the abdominal wall. Antibiotics were changed to meropenem and clindamycin to broaden the spectrum in view of the septic shock and she was immediately taken for exploratory laparotomy. The operative findings were suggestive of necrotizing fasciitis of the anterior abdominal wall and a bold and thorough debridement was done. She was kept intubated and ventilated for a second look and further debridement was conducted after 24 hours. Six-hours post-surgical debridement, electrocardiographic (ECG) changes were noticed, 12-lead ECG showed ST-segment depression in leads II, III, aVF, and V5-6, with raised cardiac biomarkers and lower cardiac index (Figures 1 & 2), diagnosed as NSTEMI. Heparin infusion, aspirin, and clopidogrel were started. Echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction: 45%) with septal dyskinesia. Dobutamine infusion (guided by the PiCCO study) was started, which improved her hemodynamic parameters. CT coronary angiography was inconclusive. These findings suggested that she suffered Type II myocardial infarction due to the stress. She developed oliguria which improved with the restoration of hemodynamics. Her lung condition also deteriorated (PaO2/FiO2 ratio dropped to 100), requiring maximum ventilatory support and she was managed as per ARDS guidelines.(5) Blood culture showed growth of Group F Streptococci and Prevotella melaninogenica. Meropenem was continued as the growths were sensitive to it. By day six, she started to be weaned off from the ventilator and vasopressors. She was extubated on day nine and transferred to the ward on day ten. She was later discharged home to be followed up in the surgical outpatient clinic. Her length of stay was 15 days. On a six-month follow-up, she was functionally independent, on aspirin, clopidogrel, and thyroxin therapy. Conclusion: Our patient had NF of the anterior abdominal wall leading to septic shock and complicated by NSTEMI, ARDS, and AKI. Timely source control, close monitoring, quick, and effective interventions appear to have resulted in her excellent recovery.