Case Report: Skin infections are most often caused by Gram-positive bacteria. We report a case of necrotizing fasciitis (NF)caused by E. coli in a renal transplant patient.
Case: A 36yo male with hx of renal transplant and failing second transplant presented with redness, edema, and pain in his right arm without fever or chills. He had recently been treated for E. coli urosepsis and MRSA pneumonia. PMH: ESRD s/p transplantation 12 yrs prior, diabetes, HTN, pulmonary embolus, gastric bypass surgery, and chronic pancreatitis. Meds: prednisone, darbepoetin alfa, mycophenolate mofetil, esomeprazole, oxycodone, and warfarin among others. Patient is disabled, lives with his wife and denies alcohol, tobacco, or illicit drug use. PE: BP 94/57, P 98, T 37, RR 16, O2 sat 90% on RA. HEENT, CV, ABD exams normal; lungs: few crackles without rales; extremities: erythema of right upper extremity (RUE) from elbow to hand, tender to palpation with some bullae and no crepitis. Labs: gluc 129, BUN 64, Cr 4, WBC 4.3, Hct 27, plt 125k; wound and blood cultures positive for E. coli. Despite antibiotics, the patient developed necrotizing fasciitis requiring surgical debridement and later skin grafting.
Discussion: Skin infections are not frequent in transplant recipients but when they do occur are most often due to Gram-positive organisms such as Staphylococcus and Streptococcus species. We describe here a renal transplant recipient with a failing second transplant requiring higher doses of immunosuppressants who presented with E. coli urosepsis and erythematous-bullous lesions that rapidly evolved to hyperacute necrotizing fasciitis. Gram-negative bullous cellulitis with necrotizing fasciitis is a rare condition associated with a poor prognosis which can be lethal if not identified and treated promptly. Treatment includes aggressive surgical debridement, IV antibiotics and consideration of hyperbaric oxygen therapy. Physicians caring for transplant or other immunosuppressed patients should keep necrotizing fasciitis in mind with any bullous cellulitis presentation since early diagnosis and aggressive therapy may be lifesaving as it was in our case.