Help with Micro case study!!

Nursing Students Student Assist

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Hello I have a question that I could use help with...

"Awomen is brought to the er with an extremely swollen lower leg. you see what appears to be an old surgical wound with rough scar tissue surrounded by a purpleish-red skin. She's in a lot of pain and her husband speaks for her. 3 weeks ago she had a group of moles removed from the area, it appeared to heal but 3 days agoth insision area looked bigger than smaller.she didn't return to the Dr., hoping her condition would improve by itself. In the past 3 days the area began to swell and became very hot.

The patient is sent to surgery and the wound is debrided. Gram positive cocci growing in chains are reovered from the wound. She goes to the ICU and put on highdose iv antibiotics for the next 18 hrs. the next evening her leg is amputated below the knee.she remains in the hospital for 2 months after the surgery and requires long term antibiotics and multiple sin grafts."

1.What condition does she have? What features suggest that it is not Clostridium perfringens gangrene?

I feel that this necrotising fasciitis is from a "group a streptococcus"

My question is Why can't it be Clostridium p gangrene? The only way I know it isnt, is because that gasous gangrene is a bacillus. If you look at 1. the word "featureS" is used...

If someone could give me guidance I would be most gratefull.

Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I have seen one case of gangrene of the leg during my career. It was in the leg of a lady who had refused treatment after a blood clot to her leg pretty much cut off all the circulation. As things got worse she was also refusing an amputation. While she had swelling of her entire leg the one thing about it was that the skin of her leg had a number of huge grayish colored blisters that had formed. You could touch her skin and it felt boggy like there was fluid just sloshing around just under her skin. We were very, very careful not to break any of those blisters open or cause a tear in the skin.

I believe that you are probably dealing with necrotizing fasciitis. It usually affects the limbs and a surgical insult can set it off. If she had gas gangrene (clostridium perfringens) that open wound of hers would stink to high heaven and be putting out the worst purulent drainage you could think of, enough to make you want to gag.

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Specializes in Gerontological, cardiac, med-surg, peds.

I believe you are on the right track with necrotizing fasciitis from Group A streptococci. Clostridium perfringens gangrene is gram positive, but a bacillus, like you pointed out. Here are some useful weblinks:

http://www.emedicine.com/med/topic394.htm

http://www.emedicine.com/derm/topic743.htm

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I have seen one case of gangrene of the leg during my career. It was in the leg of a lady who had refused treatment after a blood clot to her leg pretty much cut off all the circulation. As things got worse she was also refusing an amputation. While she had swelling of her entire leg the one thing about it was that the skin of her leg had a number of huge grayish colored blisters that had formed. You could touch her skin and it felt boggy like there was fluid just sloshing around just under her skin. We were very, very careful not to break any of those blisters open or cause a tear in the skin.

I believe that you are probably dealing with necrotizing fasciitis. It usually affects the limbs and a surgical insult can set it off. If she had gas gangrene (clostridium perfringens) that open wound of hers would stink to high heaven and be putting out the worst purulent drainage you could think of, enough to make you want to gag.

So, what happened?

Did she eventually have her led amputated...?

Did she survive?

I've seen plenty of pictures, pretty nasty.

I'm glad I keep my blood sugars in good control.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

She had another little stroke. The doctors had been working on the husband and after the second little stroke he finally realized that if they didn't get that leg off that she was going to die from the infection as it would likely go septic. Yes, she had the leg amputated and survived for a number of years. We had her as a patient periodically for other medical problems. Her husband was very indulgent (I guess that's the right way to put it) of her though. Even though she really wasn't thinking clearly, he permitted her to position herself any way she wanted and she got a contracture in the stump. She had an above the knee amputation and the stump was contracted at almost a 90 degree angle to her body. It was sad. I believe that somewhere along the way they found that she also had an astrocytoma type of brain cancer. This is a type that is slow growing. A few years later I went in to work part time at a nursing home and I recognized her right away because of that stump sticking up in the air! However, she wasn't one of the patient's I had charge of. She eventually died at the nursing home. I'm writing this and thinking, wow! how interesting I was able to recall a patient's history like this. I lived in a fairly isolated desert community, so there were only a few hospitals and facilities for people to go to, so that is why I was able to kind of follow her progress although I never sought to do that specifically. She just kind of turned up from time to time where ever I happened to be working.

As far as complications of diabetes go, one of my cats got me in the lower leg a couple of years ago. It wasn't deliberate, but it happened faster than I could do anything to prevent it. It took months to heal. That was when they discovered my blood sugars were a little higher than they should have been. Once they got the sugars under control, the resulting ulcer healed pretty quickly with leg elevation, compression stockings and antibiotics. I am very careful about the cats walking across or into my lap now since a little scratch can happen so quickly. I often wonder if it had been more in my foot or a toe if I would have fared as well. Did you know that actress Mary Tyler Moore (she may be a little too old for you to remember) is a Type I diabetic? She has been actively involved in the Juvenile Diabetes Foundation for many years. She has spoken publicly about an ulcer on her toe where she really sweated out the possible loss of parts of her lower limb. For an active actress like her it would have been devastating.

Good luck with your case study.

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