Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death.
BACKGROUND
Subcutaneous emphysema is an uncommon clinical finding associated both with benign sources and potentially deadly necrotizing infections. Wide ranges of causes exist including trauma, iatrogenic injuries, factitious disorders and necrotizing infections.


METHODS
A 49-year old male presented to the emergency room with extensive subcutaneous emphysema following blunt trauma. The orthopaedic surgery service was consulted for treatment of suspected necrotizing fasciitis due to his subcutaneous emphysema. A careful patient history and physical examination correlated with laboratory and radiographic findings revealed rib fractures and a long-standing, undiagnosed pneumothorax as the cause for emphysema. Treatment of the underlying condition with chest tubes led to eventual resolution of the emphysema, though multisystem organ failure ultimately resulted in patient death.


CONCLUSIONS
This case illustrates the importance of rapidly and appropriately evaluating trauma patients, and in this case specifically diagnosing and treating the underlying cause of subcutaneous emphysema. The late diagnosis of pneumothorax resulted in delayed definitive treatment, which may have contributed to the patient's ultimate demise. In acute and sub-acute trauma situations a high level of suspicion for life threatening injuries must be maintained. Decision making for initial treatment should be based on the basic tenants of Advanced Trauma Life Support to primarily address these injuries and help prevent further disability or death.
Department of Orthopaedics, Naval Medical Center, 34800 Bob Wilson Drive, Suite 112, San Diego, CA 92134-1112, USA.
Lucas S
LS
McDonald
Department of Orthopaedics, Naval Hospital Jacksonville, 2080 Child Street, Jacksonville, FL 32214, USA.
Paul G
PG
Shupe
Department of Orthopaedics, Kaiser Permanente Hospital, 4647 Zion Avenue 92120 San Diego, CA, USA.
Kian
K
Raiszadeh
Department of Orthopaedics, Kaiser Permanente Hospital, 4647 Zion Avenue 92120 San Diego, CA, USA.
Anshuman
A
Singh
Necrotizing fasciititis; Pneumothorax; Subcutaneous emphysema