By Santa J. Bartholomew M.D. FAAP, FCCM
A nine-month male infant came to the ER his mother complaining of high-grade fever with vomiting and hypoactivity after one-day post-operation due to a left non-palpable undescended testis. The fever was registered as 39 ◦C axillary and the patient also irritable and found to be in severely dehydrated. He was admitted as a case of viral gastritis in another hospital.
During his hospitalization at the outside hospital (thirteen days), he also developed watery diarrhea which was associated with poor feeding and abdominal distention. His condition continued deteriorating, showing signs and symptoms of abdominal distention, rigidity, tenderness, high-grade fever, decreased urine output, drowsiness, and bloody stools. The infant was referred to the referral hospital where he had his teste operated on for further investigations and management.
On arrival, laboratory tests and a detailed physical examination were performed. The patient looked ill, tachypneic and grunting with a blood pressure of 90/40 mmHg, abdominal distention, rigid abdomen (more on the left side where a left inguinal incision of 5 cm was present), and tenderness. He was semiconscious with a GCS (Glasgow Coma Scale) of 8.
Laboratory findings showed that he had a low hemoglobin level of 7.5 g/dL, a high WBCs count of 15.5 ×103/μL and a low platelet count of 54 ×103/μL. He also had low potassium (2.7 mmol/L), high urea (33 mg/dL), high ammonia (80.5 μ/dL), high AST (192 U/L) and ALT (739 U/L), high PT (33 s) and INR (2.32) and low albumin (2 g/dL). Blood gases also showed metabolic acidosis with compensatory respiratory alkalosis in which the pH was 7.35 with a pCO2 level of 16 mmHg and a HCO3 level of 9 mEq/L.
An abdominal ultrasound showed dilated peristaltic bowel loops with good vascularity and no intussusceptions or volvulus. It also showed hepatomegaly (10 cm). More radiological images were performed, and an abdominal and chest CT scan showed a congested groin in which the left inguinal and left abdominal wall were extending to the lower chest fatty plane containing few air bubbles, suggesting fasciitis with turbid fluid. Diffuse bowel loop dilation was also noticed primarily due to ileus and an enlarged liver of 10 cm. There was evidence of bilateral pulmonary lower lobe infiltrates with ground glass appearance and/or atelectasis. Skin desquamation on both feet was seen on postoperative day 10.
The surgical wound was opened, which secreted dirty fluid, and another incision was made over the most indurated area, which also secreted dirty fluid. We kept the wound and the incision opened with drains on them and took a wound swab for culture, which later showed Staphylococcus aureus infection.
We also took a nasal swab and blood and urine cultures, giving positive results only in the nasal swab for Staphylococcus aureus. After an antibiotic sensitivity test for the bacteria, we started the patient on clindamycin and Zosyn. NPS (nasopharyngeal swab) for COVID-19 was also taken and was positive, so the patient was also started on azithromycin and an Albuterol nebulizer. On the second day of admission, a central line was inserted under US guidance, and the patient was sent to the OR (operating room), where we did a surgical debridement of the wound under general anesthesia because there was infected necrotic tissue in the left inguinal region extending to the loin but with a healthy fascia.
A second swab culture from the wound was taken during the surgery and showed no bacterial growth. After the surgery, the patient had an endotracheal tube (ETT) and was connected to a mechanical ventilator under sedation for four days, remaining hemodynamically stable and weaning gradually under the sedation until extubation. Meanwhile, there was daily wound care and dressing) until the wound became healthy and without discharge so we could close the wound over a drain.