32 Necrotising breast fasciitis due to empyema necessitatis

• DOI: 10.1093/bjs/znaf024.028
• Publication Date: 2025-02-24T17:22:32Z
• Authors: Rosa Claret De Ca...; Arantxa Clavell; Esther Cladellas; Lidia Blay; Sebastian Peñafiel; Samuel Garcia; Alba Herraiz; Alex Hugué; Pedro López-de Ca...; Joan Francesc Julian

Abstract The patient, a 73-year-old woman with multiple medical history, consulted the emergency department (ED) of second-level hospital due to severe left rib pain radiating abdomen. Initially, it was diagnosed as postherpetic neuralgia. However, during examination in ED, absence breath sounds were found lung base and hemithorax, leading chest X-ray which revealed massive pleural effusion. A thoracentesis performed confirmed presence empyema. patient admitted, treatment started empirical Ceftriaxone drain placed. Urokinase administered for 5 days removed. She presented torpid evolution persistent fever elevation acute phase reactants despite treatment. During admission, developed inflammation lower wall, cellulitis. Antibiotic coverage extended Linezolid Imipenem. worsened clinically, presenting hypotension tachycardia, suspicion necrotizing fasciitis. An urgent thoracic CT scan bilateral pneumonic infectious process pulmonary necrosis signs pleural-extraspleural fistula, classified pneumonia complicated by empyema necessitatis. Clindamycin added referred tertiary order be evaluated surgeons surgical debridement. Significant fibrous pleuropulmonary adhesions requiring costal resection. Malodorous fluid aspirated drains surgery, poor hemodynamic ventilatory tolerance, bipulmonary ventilation impossibility extubation after therefore she admitted ICU. Due evolution, required second septic control surgery one week later. thoracotomy again observed. Abundant purulent material evacuated cultures positive Parvimona mixed aero-anaerobic flora. vasoactive support first 72 hours, but this subsequently withdrawn without incident. follow-up showed worsening pneumonia. third fibropurulent tissue observed removed, abundant lavage placed muscular planes. Negative pressure therapy (VAC system) performed. After prolonged admission ICU favorable discharged ward.