Abstract / Summary
Abstract Background Necrotizing fasciitis is a rapidly progressive soft-tissue infection associated with substantial morbidity, limb loss, and mortality when diagnosis and surgical treatment are delayed. Postpartum necrotizing fasciitis is rare and is most commonly reported following cesarean delivery, episiotomy, or perineal infection. Distal lower-limb involvement with unilateral foot gangrene after vaginal delivery is particularly unusual. Case presentation A 15-year-old previously healthy postpartum adolescent from a rural community presented approximately two weeks after an unsupervised home vaginal delivery with progressive right lower-limb pain, swelling, foul-smelling discharge, inability to ambulate, and black discoloration of the right foot. On admission, she appeared critically ill and markedly pale. Laboratory investigations showed severe anemia with a hemoglobin concentration of approximately 4 g/dL, a C-reactive protein concentration of 70 mg/L, a white blood cell count of 7,000/µL, and coagulopathy with an international normalized ratio of 2.0. Computed tomography demonstrated extensive soft-tissue gas in the right foot and a posterior calf intramuscular abscess extending toward the plantar foot. Computed tomography angiography showed preserved major arterial flow without major arterial occlusion. Deep tissue cultures grew Pseudomonas aeruginosa and Escherichia coli . The patient underwent resuscitation, packed red blood cell transfusion, correction of coagulopathy, broad-spectrum intravenous antibiotic therapy, serial surgical debridements, and right transmetatarsal amputation for irreversible forefoot gangrene. Negative-pressure wound therapy was used to promote granulation tissue formation. During the fourth week of hospitalization, definitive closure of the transmetatarsal stump and skin grafting of the posterior ankle/Achilles soft-tissue defect were performed. Infection was controlled, wound healing was satisfactory, and limb function proximal to the amputation level was preserved at discharge. Infection was controlled, wound healing was satisfactory, and limb function proximal to the amputation level was preserved at discharge. At the 1-month postoperative follow-up, the transmetatarsal amputation stump and posterior ankle/Achilles wound remained satisfactorily healed without wound breakdown or clinical evidence of recurrent infection. Conclusions Postpartum necrotizing fasciitis should be considered in patients presenting with rapidly progressive limb pain, swelling, skin necrosis, or gangrene, even after vaginal delivery and in the absence of leukocytosis or major arterial occlusion. Early resuscitation, correction of physiological abnormalities, culture-guided antimicrobial therapy, aggressive surgical source control, and staged wound reconstruction are essential for controlling infection and preserving functional limb length.