key: cord-0986074-ld3pn9cl
authors: Hattori, Yoshitsugu; Tamemoto, Tomoyuki; Niu, Atsushi
title: Trauma-induced Necrotizing Soft-tissue Infection following COVID-19 Treatment
date: 2022-01-25
journal: Plast Reconstr Surg Glob Open
DOI: 10.1097/gox.0000000000004108
sha: 3e34695f535d092f09d40397fa5ca1b4047eaee3
doc_id: 986074
cord_uid: ld3pn9cl

nan

S ince the coronavirus disease 2019 (COVID-19) outbreak, various therapeutic strategies have been reported to combat it. 1 Glucocorticoids, such as methylprednisolone and dexamethasone, have been incorporated into most protocols for the treatment of COVID-19 pneumonia, especially in moderate and severe cases. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death. 2 However, they also have immunosuppressive effects and predispose the patients to infectious diseases. 3 We encountered a case of traumainduced severe necrotizing soft-tissue infection (NSTI) in an otherwise healthy patient who had recently recovered from COVID-19 pneumonia.

A 45-year-old febrile man presented to the emergency department with right arm swelling and pain (Fig. 1) . He had an unremarkable medical history. Three weeks before his presentation, he suffered from severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and was hospitalized for COVID-19 pneumonia. He received methylprednisolone for 10 days (starting with 80 mg/day and tapered gradually) until 1 day before discharge. One day after his discharge, he went for a walk in an attempt to regain physical strength, but lost his balance and fell into a bush. He sustained abrasions on the right arm, but he did not visit the hospital because he thought it was a trivial injury. Three days after the injury, erythema and tenderness were noted in the affected arm. The lesions worsened, and the patient consulted the emergency department after 3 days. Computed tomography examination of the right arm revealed subcutaneous gas and diffuse soft-tissue inflammation (Fig. 2) . He was diagnosed with NSTI on his right arm and subsequent septic shock. Emergent debridement of the necrotic tissue was performed, and broad-spectrum antimicrobial therapy, including meropenem and vancomycin, was initiated. He also required catecholamine therapy in the intensive care unit. The wound cultures of surgical specimens were positive for group B streptococcus, Streptococcus constellatus, and anaerobic gram-positive cocci. After the infection was sufficiently controlled, the soft-tissue defect, following radical debridement, was treated with skin grafting.

To the best of our knowledge, no reports have described a case of trauma-induced NSTI following COVID-19 treatment. The patient in our study did not have any significant medical history such as diabetes, and methylprednisolone administered for the treatment of COVID-19 pneumonia was considered to have negatively affected his immunity against bacterial infection. 4 is a life-threatening condition and the mortality rate remains high. Early and complete debridement is essential for the treatment of NSTI. Concomitantly, appropriate broad-spectrum antibiotic coverage, combined with adequate organ support and close monitoring, promotes patient survival. 5 After the treatment of SARS-CoV-2 infection with glucocorticoids, even minor trauma can develop into a life-threatening infection such as NSTI. Therefore, adequate patient education regarding the compromised immune status is mandatory. In case of injury, appropriate wound management and risk assessment of the patients are required; appropriate empiric treatment and careful follow-up may be necessary to avoid devastating infections.

A living WHO guideline on drugs to prevent covid-19

RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19

Association between administration of systemic corticosteroids and mortality among critically ill patients with COVID-19: a meta-analysis

Necrotizing soft-tissue infection: diagnosis and management

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections

The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the study participant, including consent to participate and to publish the findings. Approval was obtained from the internal review board.

The authors have no financial interest in relation to the content of this article.