Necrotising fasciitis: clinical judgement and early multidisciplinary collaboration is the key.

Necrotising fasciitis is a bacterial infection of subcutaneous tissue and fascia, which can rapidly progress to septic shock. Diagnosis is frequently delayed or missed due to non-specific presentation. The laboratory risk indicator for necrotising fasciitis (LRINEC) stratifies risk based on biochemical results, but external validation revealed limited accuracy. A 78-year-old female with significant co-morbidities presented with right foot pain and erythema. Vital signs were normal and C-reactive protein was 18 mg/l. LNIREC was 0. She was treated for cellulitis, but within 24 h developed skin blistering and necrosis. After consideration of risks, washout and debridement was performed under popliteal block. Recovery was prolonged and complicated by nosocomial infection. This case highlights the importance of clinical suspicion for necrotising fasciitis and the complexity of management decisions considering recovery can be protracted.

Diagnostic complexity in the older patient: an unusual presentation of advanced biliary disease.

Biliary disease is common in the older population, and gallbladder dysfunction and increased bile lithogenicity predispose to calculi formation. This case demonstrates an unusual presentation of gallbladder empyema. A 90-year-old male with metastatic prostate cancer presented with hypoactive delirium. With no localising features, normal liver function tests but persistently raised inflammatory markers, he was initially managed as a urinary tract infection. Chest wall discomfort and swelling over the right costal margin later developed. Abdominal imaging demonstrated a massive gallbladder empyema invaginating through the lower right rib cage, causing the superficial swelling. Pre-morbid status prevented cholecystectomy and he was managed conservatively with percutaneous cholecystostomy and antibiotics. He was discharged to 24-h care 2 weeks after diagnosis with a long-term drain.