Abstract
Necrotizing fasciitis (NF) in the setting of diabetic ketoacidosis (DKA) and septic shock presents a formidable challenge to limb preservation. This case describes a 64-year-old female with longstanding uncontrolled diabetes who presented in profound metabolic and septic compromise, with extensive soft tissue gas and polymicrobial infection of the right foot and leg. Emergent radical debridement and partial foot amputation were performed within hours of arrival, with vascular surgery consulted for below-knee amputation (BKA) due to concern for non-salvageability. This case highlights the impact of early aggressive debridement, serial washouts, and strategic wound optimization, culminating in successful split-thickness skin grafting. Despite the severity of infection and systemic compromise, amputation was limited to the first ray and second digit. At 2.5 months postoperatively, the patient regained ambulatory function and expressed high satisfaction with limb preservation. The graft healed fully, and no further surgical intervention was required. This outcome underscores the critical role of interdisciplinary coordination, surgical persistence, and timely decision-making in complex NF cases.
Level of evidence
IV
Literature review
Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection marked by widespread fascial necrosis, systemic toxicity, and high mortality. Although relatively uncommon, NF carries significant clinical urgency. In the United States, the estimated annual incidence ranges from 0.4 to 0.53 cases per 100,000 people, with higher rates observed in patients with diabetes, immunosuppression, and peripheral vascular disease. In diabetic patients, particularly those presenting in diabetic ketoacidosis (DKA), NF poses an amplified threat due to impaired immune response, microvascular compromise, and delayed presentation. Mortality rates in this population range from 25 to 35 %, with early diagnosis frequently missed in up to 85–100 % of cases.
Early aggressive surgical debridement remains the cornerstone of NF management. Multiple studies underscore that time-to-operating room is a decisive factor in survival and limb preservation. Gelbard et al. (2018) found that delays beyond 12 h from diagnosis significantly increased mortality and complication rates. Wong et al. (2024) described a four-step approach to debridement, including diagnosis, extent mapping, radical excision, and post-excision wound care, emphasizing that systematic, aggressive excision is essential to halt disease progression.
In limb-threatening cases, especially involving the foot and ankle, early radical debridement can be limb-saving. Narayanan et al. (2021) demonstrated successful salvage using dermal regeneration matrices following prompt excision of necrotic tissue, even in anatomically complex zones. Similarly, Sevimli et al. (2016) reported that recurrent aggressive debridement, paired with interdisciplinary care, enabled limb preservation in a patient with extensive lower extremity NF.
Risk stratification tools have also been developed to support early recognition. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, introduced by Wong et al., incorporates C‑reactive protein, white blood cell count, hemoglobin, sodium, creatinine, and glucose to help differentiate NF from other soft tissue infections. Although not definitive, LRINEC can aid clinical suspicion, particularly in high‑risk diabetic patients who may present atypically.
Microbiologically, NF is classically categorized into Type I (polymicrobial) and Type II (monomicrobial) infections. Type I infections, which are more common in diabetic patients, typically involve a combination of gram‑positive cocci, gram‑negative rods, and anaerobes. Type II infections are most often caused by Group A Streptococcus, sometimes in combination with Staphylococcus aureus. Emerging literature also highlights increasing involvement of MRSA and gram‑negative organisms such as Klebsiella pneumoniae in metabolically unstable hosts.
Negative pressure wound therapy (NPWT) has become an important adjunct following early source control. NPWT promotes granulation tissue formation, reduces edema, enhances perfusion, and maintains a clean wound environment between serial debridement. Several studies have demonstrated that NPWT can accelerate wound bed optimization and improve graft take, particularly in large or complex defects following radical excision. Its use is especially valuable in diabetic patients, where microvascular compromise may delay granulation and increase the risk of infection recurrence.
Advanced wound coverage techniques, including split-thickness skin grafting (STSG), are increasingly viable following early source control. Zhu et al. (2019) documented successful STSG in a patient with Klebsiella pneumoniae NF and DKA, reinforcing that grafting is feasible even in metabolically unstable hosts.
This growing body of evidence affirms that early, aggressive debridement is not only life-saving but limb-saving, especially when paired with strategic reconstruction and interdisciplinary coordination. In high-risk diabetic patients, surgical urgency must be matched by surgical persistence.
Case presentation
A 64-year-old female with a longstanding history of poorly controlled Type 2 Diabetes Mellitus (HbA1c 11.9 %), who had not engaged with medical care in over two decades, presented to the Staten Island University Hospital Emergency Department in diabetic ketoacidosis (DKA) and septic shock. She reported falling out of bed earlier that day and being unable to rise, citing progressive weakness and poor appetite over the preceding 4–5 days. She described a foul-smelling wound on her right lower extremity, which had worsened significantly in the past 24 h. Living alone, she expressed concern about her ability to care for herself.
She endorsed localized pain in the affected limb but denied fevers or chills. Notably, she had been self-managing discomfort with lidocaine patches applied to her right leg, though not directly over the wound. On arrival, vital signs were concerning: blood pressure 73/67 mmHg, heart rate 94 bpm, respiratory rate 18, and temperature 98.1°F. Laboratory evaluation revealed marked leukocytosis (WBC 38.47 × 10⁹/L), profound hyponatremia (Na⁺ 119 mmol/L), and severe hyperglycemia (glucose 557 mg/dL).
Initial radiographs demonstrated subcutaneous gas tracking along the medial aspect of the right foot, with extension into the anterior tibial soft tissues. Duplex ultrasound excluded deep vein thrombosis and peripheral arterial disease. Computed tomography revealed osseous erosions of the first metatarsal head and proximal phalanx base, with intraosseous gas in both proximal and distal phalanges, findings consistent with osteomyelitis and septic arthritis. Additionally, extensive soft tissue gas was present at the ankle level, both subcutaneous and intramuscular, with proximal extension along the anterior compartment to the level of the proximal femur.
On physical examination, the medial foot and ankle exhibited large bullae, severe edema, and soft tissue swelling, particularly around the first toe and medial ankle. These findings were highly concerning for necrotizing fasciitis ( Table 1 ). Sepsis protocol was initiated immediately, including aggressive fluid resuscitation, high-dose intravenous broad-spectrum antibiotics (clindamycin, cefepime, vancomycin), and strict glucose control via continuous intravenous insulin infusion.
Table 1
Correlations of diagnostic findings and clinical implications concerning for NF.
| Domain | Findings | Clinical Implications |
|---|---|---|
| History | Fall, poor appetite, foul-smelling wound, delayed care, lives alone | High risk for delayed presentation and systemic compromise |
| Vitals | BP 73/67, HR 94, RR 18, Temp 98.1°F | Hemodynamic instability consistent with septic shock |
| Labs | WBC 38.47, Na⁺ 119, Glucose 557 | Severe leukocytosis, hyponatremia, and hyperglycemia in DKA |
| XR | Subcutaneous gas in medial foot and anterior tibial soft tissues | Suggestive of gas-forming infection; concern for NF |
| Duplex | No DVT or PAD | Confirms vascular access for limb salvage |
| CT- Bone | Osseous erosions, intraosseous gas in 1st metatarsal and phalanges | Osteomyelitis and septic arthritis |
| CT- ST | Extensive gas from ankle to proximal femur, large bullae, edema | Necrotizing fasciitis with deep fascial and muscular spread |
Surgical procedure
First Stage– Source Control: Emergent radical debridement was performed in collaboration with the plastic surgery team, with initial concern for non-salvageability of the limb ( Fig. 1 ). The patient taken to the operating room within the 12 hour golden period and was placed in the supine position on the operating table. General anesthesia was administered. No tourniquet was used to avoid obscuring proximal disease extension and to allow continuous assessment of tissue perfusion throughout the procedure. Involvement included the dorsal hallux, medial midfoot, and plantar first metatarsophalangeal joint, with hemorrhagic blistering and purulent drainage. The necrotic first ray and second digit were resected. Medial ulcerations revealed exposed midtarsal and subtalar joints with dishwater drainage and ankle joint purulence. A longitudinal incision connected medial and lateral fasciotomy sites, allowing thorough debridement of necrotic fascia, muscle, and skin using electrocautery and a hydrosurgical debridement system ( Fig. 2 ). All sites were irrigated with pulse lavage, hemostasis achieved, and the limb dressed with saline wet-to-dry sterile dressing and ace bandage up to the level of knee. Multiple deep culture and tissue biopsies were obtained with results of numerous Escherichia coli , rare Enterococcus faecalis, and few MRSA.
