Synchronous Multifocal Necrotizing Fasciitis: A Case Report.

CASE: An immunocompetent 43-year-old man was diagnosed with necrotizing fasciitis of his forearm. Despite receiving appropriate treatment, his clinical condition continued to deteriorate. Further evaluation revealed subsequent proliferation of the infection to multiple noncontiguous areas of the body consistent with a rare condition known as synchronous multifocal necrotizing fasciitis. Prompt identification, followed by serial debridements of all affected areas, ultimately saved the patient's life. CONCLUSION: This unusual multifocal presentation of necrotizing fasciitis can produce diagnostic uncertainty and delay life-saving treatment. Early recognition, followed by prompt treatment, is paramount for reducing morbidity and mortality associated with this devastating infection.

Elevated Environmental Carbon Dioxide Exposure Confounding Physiologic Events in Aviators?

INTRODUCTION: Physiological events (PEs) are a growing problem for US military aviation with detrimental risks to safety and mission readiness. Seeking causative factors is, therefore, of high importance. There is no evidence to date associating carbon dioxide (CO2) pre-flight exposure and decompression sickness (DCS) in aviators. MATERIALS AND METHODS: This study is a case series of six aviators with PE after being exposed to a rapid decompression event (RDE) with symptoms consistent with type II DCS. The analysis includes retrospective review of flight and environmental data to further assess a possible link between CO2 levels and altitude physiologic events (PEs). IRB approval was obtained for this study. RESULTS: This case series presents six aviators with PE after being exposed to a rapid decompression event (RDE) with symptoms consistent with type II DCS. Another three aviators were also exposed to a RDE, but remained asymptomatic. All events involved tactical jet aircraft flying at an average of 35,600' Mean Sea Level (MSL) when a RDE occurred, Retrospective reviews led to the discovery that the affected individuals were exposed, pre-flight, to poor indoor air quality demonstrated by elevated levels of measured CO2. CONCLUSION: PEs are a growing safety concern for the aviation community in the military. As such, increasing measures are taken to ensure safety of flight and completion of the mission. To date, there is no correlation of CO2 exposure and altitude DCS. While elevated CO2 levels cannot be conclusively implicated as causative, this case series suggests a potential role of CO2 in altitude DCS through CO2 direct involvement with emboli gas composition, as well as pro-inflammatory cascade. Aviators exposed to elevated CO2 in poorly ventilated rooms developed PE symptoms consistent with DCS, while at the same command, aviators that were exposed to a well ventilated room did not. This report is far from an answer, but does demonstrate an interesting case series that draws some questions about CO2's role in these aviator's DCS experience. Other explanations are plausible, including the accurate diagnosis of DCS, health variables amongst the aviators, and differences in aircraft and On-Board Oxygen Generation Systems (OBOGS). For a better understanding, the role of environmental CO2 and pre-flight exposure as a risk of DCS should be reviewed.