LAUSR

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 75yearold male patient presented to the emergency department complaining of a mildly painful swelling on the left side of his neck that developed over the past 3 days. He reported a maximum temperature of 37.5°C and no other symptom. The patient is a smoker and is under medication for hypertension and dyslipidaemia. Clinical examination revealed a swelling occupying the left anterior cervical triangle, warm and mildly tender to palpation, with erythema of the overlying skin. The left submandibular gland was palpated enlarged, although soft and painless. Rhinopharyngolaryngoscopy with flexible fiberscope showed mild protrusion of the posterior and the left lateral pharyngeal walls. The patient’s white cell count was 17.620 x 10/L and C reactive protein was 308 mg/L. A CT with intravenous contrast was performed, demonstrating submucosal gas accumulation and multiple microabscesses in the retropharyngeal space, along with soft tissue swelling of the left neck (figure 1A). Cervical necrotising fasciitis (CNF) was highly suspected and despite the patient’s mild symptoms, immediate surgical treatment was decided. Intraoperatively, necrotic tissue was recognised and removed. The retropharyngeal and left parapharyngeal, submandibular and submental spaces were explored and debrided (figure 1B,C). We subsequently contemplated closure by tertiary intention. Tissue necrosis was not extensive, bleeding edges have been encountered in every aspect of the wound, following excision of the last necrotic sites and the patient had been stable with mild symptoms. After taking all these facts into account, we decided to apply a few skin sutures, without subcutaneous layer. Penrose tubes were also placed. Postoperatively, the patient reported no pain and all his vital signs were normal. Tissue and pus cultures showed growth of Fusobacterium varium, with sensitivity to the antibiotic regimen already administered, which included meropenem, vancomycin and metronidazole. The surgical wound was attended many times a day, showing improvement (figure 1D). On the third postoperative day, an erythematous, tender swelling had developed at the level of the left clavicle, extending to the sternal notch (figure 2A,B). Despite this development, the patient still reported no pain, his vital signs were normal, as was the laboratory workout. A second CT demonstrated subcutaneous gas and small abscesses in the supraclavicular area and the anterior thoracic wall (figure 2C). A subcutaneous abscess was surgically drained followed by thorough debridement of the necrotic tissue. The patient showed progressive improvement and delayed closure of the wounds was performed after 4 weeks of hospitalisation (figure 2D). The patient was discharged 5 days later and showed no signs of recurrence or complications, on regular followup. CNF is a wellknown infection that spreads rapidly along the fascial planes, causing necrosis and an inflammatory response that ultimately compromises arterial perfusion. It can involve underlying muscles, subcutaneous fat and skin. Most authors conclude that CNF appears to have a predilection for immunocompromised patients. 3 It is most often associated with intense pain, even disproportionate to the clinical findings. With early diagnosis and treatment of CNF being of utmost importance, alertness is necessary when dealing with immunocompetent patients with mild