This article aims to highlight the importance of diagnosing serious soft tissue infections and instigating treatment rapidly.DECLARATIONSCompeting interestsNone declaredFundingNoneEthical approvalWritten informed consent to publication was obtained from the patient or next of kinGuarantorJPContributorshipJP summarized the case and performed the literature review; SS supervised and proofread the manuscriptReviewerFadi HajjajIntroduction Section:Synergistic gangrene is an uncommon soft tissue infection classically occurring at surgical sites. Primary cases are rare but a high index of suspicion is paramount in treating the disease successfully. We present the first case of primary synergistic gangrene affecting the breast which was successfully managed through a combination of resuscitation, parenteral antibiotics and surgery. It is reasonable to suggest that such cases may increase in incidence and all physicians treating soft tissue infections must be aware of this potentially fatal pathology.Case presentation Section:A 39-year-old woman with a history of type 2 diabetes, deep vein thrombosis, gastritis, schizophrenia and self-harm presented to the medical admissions unit with a one-week history of a right sub-mammary abscess followed by spreading cellulitis of the breast. On examination she was septic with a pyrexia of 39.2, blood pressure of 127/65 and tachycardia of 110. Examination of the breast revealed widespread cellulitis involving the nipple and sub-mammary area spreading to the axilla. Initial blood tests showed a white cell count of 23.8 (neutrophils 19.9) and CRP of 428. Simple cellulitis was diagnosed by the admitting physicians and she was commenced on parenteral antibiotics and fluid resuscitation. Her condition worsened despite intravenous benzyl penicillin and flucloxacillin. A surgical opinion was sought on day three when she had evidence of synergistic gangrene. The cellulitis had now spread and there were areas of growing necrotic ulceration (Figure 1). Resuscitation was commenced and antibiotic therapy was adjusted to imipenem and clindamycin based on local necrotizing fasciitis guidelines. She was taken to theatre within a few hours where a partial mastectomy was performed and the wound was left open and packed (Figure 2). Postoperatively she remained stable on intensive care. The following day she returned to theatre for further debridement. DownloadOpen in new tabDownload in PowerPointFigure 1 Preoperative and postoperative images of the right breast. Note the presence of the ulcerative necrotic areas which had rapidly appeared. Radical debridement was performed to eliminate all the diseased tissue and further debridement was performed the following dayDownloadOpen in new tabDownload in PowerPointFigure 2 After initial debridement. Extensive removal of diseased tissue was performed and is necessary to control the spread of infection. Secondary closure was subsequently performed on day 13 after her initial procedureThe wound was monitored closely and a vacuum dressing was applied to aid healing. Signs of sepsis improved and she returned to the ward on the fifth postoperative day. Nutritional supplements and adequate hydration were continued during her recovery. Secondary closure was performed on day 13 after the initial operation and there was no further breakdown or compromise of the remaining tissues.Preoperative cultures taken from the ulcers identified a mixture of gram positive and negative bacteria including Bacteroides spp (sensitive to metronidazole, clindamycin and imipenem). Histology confirmed widespread microscopic changes and abscess formation consistent with gangrene. There was no evidence of malignancy. Blood markers of infection progressively improved and there were no signs of secondary organ failure during her recovery.She was discharged 22 days after her initial admission. Intravenous antibiotics were administered for a total of 10 days after the first debridement which were changed to
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