CASE PRESENTATION
A 35 years old female presented to the emergency department with severe pain and yellowish discharge in the right thigh for 2 days. She had a history of chickenpox for 2 weeks and had taken ibuprofen nonsteroidal anti-inflammatory drug (NSAID), for pain control. She was awake, dehydrated, tachycardic (110-120/min), tachypneic (24-29/min), and febrile (39oc) with borderline blood pressure (90/50 mm Hg). On local examination, there were blackish lesions involving the posterior aspect of the right thigh, extending to the perineum, vulva, and buttocks, with multiple blisters and yellowish discharge. Her laboratory workup showed leucocytosis (19000/), hyperglycemia (RBS 16.2 mmol), impaired renal function (BUN14.5 and creatinine 124umols/L), and anemia (Hb 7.2gm %) with high C-reactive protein (324). She was diagnosed as a case of necrotizing fasciitis in the thigh by using LRINF (laboratory risk indicators for necrotizing fasciitis) score (table 1), started on Tazocin® (Piperacillin+Tazobactam), and continued resuscitation with fluids and packed red blood cells transfusion (pRBCs). She was taken for debridement of the thigh, necrotic tissues, and blackish skin lesions. Postoperatively, she was transferred to the surgical intensive care unit (SICU) in intubated and ventilated condition. In SICU, resuscitative measures were continued; she required noradrenaline to maintain the hemodynamics. Clindamycin was added, and dalteparin was started for deep venous thrombosis prophylaxis. On day 2, she underwent re-debridement and continued resuscitation and supportive care. Tissue culture showed growth of streptococcus pyrogens andpseudomonas aeruginosa , both sensitive to Tazocin®. By day 4, she was on enteral feeds, off vasopressors, and her trachea was extubated by day 5. The patient remained stable, all invasive lines were removed, and an oral diet was initiated. She was transferred to the surgical ward on day 7 and from there discharged home to be followed in outpatient clinics.