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“Rapidly Progressive Soft Tissue Infection of the Upper Extremity with Aeromonas Sobria after Aquatic Injury”Jorge Lujan-Hernandez MD, Eleanor Goldwasser MD, Douglas M. Rothkopf MD, Raymond M. Dunn MD.Division of Plastic Surgery, University of MassachusettsName of Presenter: Jorge Lujan-Hernandez, M.D.PGY-1 , Plastic Surgery Jorge.lujan-hernandez@857-205-7877Introduction: Soft tissue infections of the upper extremity commonly arise from traumatic inoculation and are most frequently caused by aerobe/anaerobe organisms such Group A Streptococcus and Staphylococcus Aureus or Clostridium. However, after injuries in fresh or sea water, the organisms, presentation and susceptibility to antibiotics can vary, potentially delaying optimal treatment of a rapidly progressive entity. Case Description:A 20-year-old male, otherwise healthy, sustained two penetrating lacerations to his right distal forearm while swimming at a reservoir. He was evaluated two hours after the injury at an outside hospital where the wound was irrigated and closed with sutures. Less than 20 hours after the injury, he presented to the Emergency Department with severe pain, erythema and purulence in the wound site, as well as subjective fever. Physical exam demonstrated a closed wound 2.5 cm long in the distal volar forearm, with surrounding erythema. There was significant tenderness to palpation, which increased with passive extension, as well as purulence expressed from wound. A second wound, 4cm long and closed with sutures was found in the thenar eminence, with normal appearance. Complete Blood Count showed leukocytosis of 26,000. Forearm X-Rays showed mild subcutaneous air. Cultures were obtained in the emergency department and antibiotic therapy was initiated immediately with intravenous Vancomycin and Piperacillin-Tazobactam(Zosyn) for broad-spectrum coverage. He was immediately taken to the operating room for washout and volar forearm fasciotomy. The patient was noted to have rapidly progressing erythema up to the axilla. Intra-operatively, significant purulence and early volar forearm compartment syndrome was found. The wound was left open for drainage. Cultures 48 hours later grew Gram negative bacilli consistent with Aeromonas Veronii Sobria, resistant to Vancomycin and Zosyn. Antibiotic coverage was changed to IV Aztreonam and PO Clindamycin. Four days after initial surgery, delayed primary closure was performed. The patient was ultimately discharged home in stable condition on PO Ciprofloxacin per infectious disease recommendations. Discussion: Upper extremity soft tissue infections typically can be of mono or polymicrobial origin, and present within one to three days after traumatic injury. However, after injuries in an aquatic environment, Vibrio and Aeromonas species are more common for sea and fresh water, respectively. Aeromonas V. Sobria is an unusual and aggressive subtype that can cause necrotizing fasciitis and sepsis, however it is most commonly reported in immunosuppressed patients. Aeromonas V. Sobria infections are rarely documented in healthy individuals causing anything more severe than diarrhea. These organisms, as is the case for all in the Aeromonas family, do not respond to typical antibiotics for soft tissue infection and the clinical course can be more extreme, with rapid progression to tissue necrosis, shock and death. Conclusion:Aeromonas Sobria is an aggressive, unusual pathogen in healthy patients, present in fresh water. History of injury in an aquatic environment and culture data are key for identification of the causal agent and should dictate acute clinical management and antibiotic therapy. Coverage should include quinolones or sulfas if suspecting Aeromonas, and adjusted depending on culture and sensitivity. Early operative exploration and washout along with appropriate antimicrobial therapy are the cornerstones of successful treatment of these aggressive and possibly life threatening infections. ................
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