Necrotizing Fasciitis Following Peripheral Intravenous Cannulation in Laos
Article information
Abstract
A year on from the end of coronavirus disease pandemic, there has been a resurgence in interest in international travel from South Korea. In the event of unexpected illness whilst abroad, there is a lack of information regarding the provision of medical services, repatriation, and treatment outcomes, both abroad and upon return to South Korea. A 39-year-old male experienced swelling, redness, and severe pain in his right upper arm, axilla, and anterior chest wall after undergoing intravenous cannulation in Laos. He received treatment in South Korea, 5 days after symptom onset, delayed by his travel back to South Korea. Upon diagnosis of necrotizing fasciitis emergency surgery was conducted promptly. Subsequently, he underwent multiple surgeries. The patient’s wound was closed 13 days postadmission. He was discharged on the 33rd day without complications, although continued rehabilitation was required.
Introduction
Indochina, including Laos, is a popular destination for South Korean travelers post-COVID-19 pandemic. Interest in traveling to the countries within the Indochina region has revived [1,2]. The Ministry of Foreign Affairs of South Korea actively provides advice and precautions concerning endemic diseases globally, including dengue fever, Zika virus, and malaria [3]. Nonetheless, there is a dearth of information regarding the acquisition of medical services for travelers who fall ill unexpectedly. Moreover, there is a lack of detailed studies concerning the treatment outcomes of such travelers, regardless of whether they receive treatment abroad or upon return to South Korea.
Necrotizing fasciitis (NF) demands immediate diagnosis and treatment due to its potentially severe consequences [4,5]. When NF occurs during international travel, deciding whether to seek treatment locally or to return to South Korea poses significant dilemma.
A case of NF, that occurred subsequent to intravenous cannulation in Laos, and was treated after the patient’s return to South Korea.
Case Report
A 39-year-old male traveling in Laos visited a local clinic due to mild myalgias. He subsequently underwent intravenous cannulation in his right upper arm for fluid therapy. His myalgias subsided during treatment, and he was discharged without hospitalization. However, he began experiencing pain at the cannulation site on the night of his discharge, with symptoms gradually worsening. Concerned about the unfamiliar medical procedures in Laos and the potential risk of delayed repatriation to South Korea due to the need for hospitalization, he opted to return to South Korea for treatment. Although he intended to return to South Kora earlier, he could only manage to fly back 5 days after symptom onset due to difficulty in booking a flight.
Despite seeking care at a major civilian hospital in South Korea upon his return, he encountered delays in receiving prompt and appropriate treatment. Consequently, he was transferred from the civilian hospital to the Armed Forces Capital Hospital.
The patient presented with swelling, redness, and severe pain in his right upper arm, axilla, and anterior chest wall (Figure 1). Upon admission, his vital signs were: blood pressure 122/80 mmHg; respiratory rate of 20 breaths per minute; pulse of 96 beats per minute; and a temperature of 37.5 °C. Laboratory findings including white blood cell count 16,390/uL; hemoglobin 12.4 g/dL; creatinine kinase 1,002 IU/L; C-reactive protein 29.1 mg/dL; and procalcitonin 3.550 ng/mL. The computed tomography (CT) scans revealed gas within a fluid collection along the subfascial planes of the right upper arm, axilla, and chest wall (Figure 2). NF was diagnosed based on these findings, and emergency surgery was promptly initiated.
In emergency room. Swelling, redness, and severe pain in patient’s right upper arm, axilla, and anterior chest wall.
Chest and right shoulder computed tomography scans. Gas within a fluid collection along subfascial planes in the right upper arm, axilla, and anterior chest wall. White arrows: gas forming.
During the initial emergency surgery, marked swelling, redness, and a sensation of heat were observed in the aspect area, with bullae present on the right antecubital region. The modified Henry method and a deltopectoral approach were employed. A longitudinal incision was made, extending from the proximal end of the deltopectoral incision to access the anterior chest wall. On making an incision in the distal 1/3 of the upper arm, a substantial amount of yellow pus with foul odor was encountered. During soft tissue dissection, copious pus was discovered along the neurovascular bundle, with significant amounts of necrotic tissue surrounding the brachial plexus, axillary artery, and vein being removed. In addition, pus and necrotic tissue beneath the pectoralis muscle were identified and excised (Figure 3A). The 1st surgery concluded with the application of a compressive dressing without wound closure.
Operative findings. (A) During initial emergency surgery, we identified and removed pus and necrotic tissue beneath the pectoralis muscle; (B) on following day; (C) subsequently, we repeated the same procedures 7 times over the course of one week; and (D) on the 13th day after admission, we closed the patient’s wound.
The following day, an additional debridement procedure was conducted (Figure 3B), and negative pressure wound therapy was applied. Subsequently, the same procedures were repeated 7 times over the course of 1 week (Figure 3C). On the 13th day of hospitalization, the patient’s wound was closed (Figure 3D). After the wound closure, the patient engaged in rehabilitative exercises. On the 33rd day of hospitalization, he was discharged without complications, although ongoing rehabilitation was necessary.
During the initial surgery, bacterial cultures were performed and confirmed the presence of Klebsiella pneumoniae and Streptococcus anginosus. He received empirical intravenous antibiotics starting with a loading dose of teicoplanin at 6 mg/kg every 12 hours 3 times, followed by a maintenance dose of 6 mg/kg once daily. Additionally, he was given clindamycin at 600 mg twice daily. On the 3rd day of hospitalization, after consultation with the Infectious Disease Department, the antibiotic regime was altered by discontinuing clindamycin and introducing meropenem at 1 g, 3 times daily to treat a polymicrobial infection. On the 14th day of hospitalization, the antibiotics were changed again, discontinuing teicoplanin and meropenem and initiating ceftriaxone at 2 g once daily. Intravenous antibiotics were discontinued on the 24th day of hospitalization.
Discussion
Peripheral intravenous catheter-related soft tissue infections typically begin with local skin and soft tissue inflammation, which can progress to cellulitis or even tissue necrosis, requiring surgical intervention [7]. The insertion and maintenance of peripheral venous catheter by untrained personnel are associated with an increased risk of infection compared with trained personnel [8–10].
NF is rapidly progressing bacterial soft tissue infection that can lead to sepsis, systemic toxicity, multiorgan failure, and a potentially fatal outcome. The estimated incidence in the western world ranges from 0.24 to 0.5 per 100,000 people annually, making it one of the most challenging emergencies healthcare providers face. An official report regarding NF in Laos has not been identified. A recent review of NF reported that global mortality rates for NF range from 32% to 50% [4]. The primary cause of death is often sepsis, leading to multiorgan failure. Factors contributing to poor prognosis include advanced age, the infectious organism, uncontrolled diabetes, immunosuppression, and delays in surgical intervention [4,5].
In 2020, the Korea Health Industry Development Institute published a report on the healthcare system and status in Laos [11]. As of 2018, Laos had 3,419 doctors, equating to 0.49 doctors per 1,000 individuals. The country had 6,971 nurses and 1,711 pharmacists, with a total of 10,429 hospital beds equipped with modern facilities. Additionally, major medical centers in Vientiane, the capital city of Laos, and in other major cities are equipped to handle serious and emergency conditions [11].
South Koreans traveling abroad who need medical services due to illness should have access to information treatment abroad and transportation back to South Korea. The South Korean government has protocols for repatriating Korean patients who fail ill abroad. The first step for a Korean citizen requiring repatriation is to contact the Korean consulate and follow the consulate’s guidance [12]. Unfortunately, Korean travelers often lack adequate information about these procedures and face language barriers. Despite offering translation services in 7 languages (English, Japanese, Chinese, Spanish, French, Russian, and Vietnamese) the South Korea Ministry of Foreign Affairs finds these services insufficient [13]. Korean Air, South Korea’s largest airline, reported transporting 800 patients with emergency illnesses back to South Korea from January to July 2019 [14]. However, more patients may have returned without consulate intervention, even under perilous conditions. We recommend that the Korean government conduct a public awareness campaign and prepare comprehensive protocols for Koreans travelling abroad who fall unexpectedly ill.
The patient in this case, a civilian referred from a civilian hospital, received treatment at a military hospital. Although primarily serving military personnel, military hospitals also provide crucial medical services to civilians in emergencies. However, most civilians in South Korea are unaware that military hospitals offer such services in emergency situations.
NF induced by intravenous cannulation is a rare occurrence. In this report, we describe the successful treatment of NF despite delays in diagnosis and treatment, which were prolonged due to the time taken to return to South Korea from a foreign country.
Notes
Author Contributions
Conceptualization: KL. Methodology: KL. Formal investigation: YK, CL, and KL. Data analysis: YK, GM, and KL. Writing original draft: YK and KL. Writing – review and editing: YK, CL, and KL
Conflicts of Interest
The authors have no conflicts of interest to declare.
Funding
None.
Ethical Statement
This study was approved by the Institutional Review Board of Armed Forces Capital Hospital (no.: AFCH 2024-05-004). The requirement for informed consent was waived due to the retrospective nature of the study.
Data Availability
All relevant data are included in this manuscript.