title: Necrotizing fasciitis in a young patient with acute myeloid leukemia - a diagnostic challenge.
abstract: BACKGROUND
  Necrotizing fasciitis is characterized by a fulminant destruction of the soft tissue with an alarmingly high mortality rate. One of the main reasons for the continued high mortality is due to the challenge to punctual recognize and diagnose this disease, as specific cutaneous signs can vary or even be missing early in its evolution - especially in case of simultaneous first manifestation of an acute leukemia.
  
  
  METHODS
  An untypical case of necrotizing fasciitis disease in a young patient with the first diagnosis of acute myeloid leukemia is presented. After her induction chemotherapy the only presenting clinical sign was fever in the presence of severe neutropenia without an evident infectious focus. After a few days a painless confluent, erythematous, pustular skin rash with a central necrosis on lateral thigh appeared. Escherichia coli was isolated from blood cultures. Surgical debridement was performed and showed subcutaneous tissue, fascia and underlying muscle around the site of initial cutaneous manifestation with typical necrosis on exploration. But, initially taken skin biopsy did not show any typical histopathological findings like bacteria or inflammatory cells confirming necrotizing fasciitis. Nevertheless, the intraoperative findings were impressive and highly indicative for a necrotizing soft tissue infection, so that the patient was treated according to clinical guidelines with extensive recurrent surgical debridement, broad-spectrum antibiotics and intensive care therapy. After recovering from NF, she successfully underwent further chemotherapy and stem cell transplantation.
  
  
  CONCLUSIONS
  The presented case highlights the risk of potential misinterpretation, delayed diagnosis and treatment of necrotizing fasciitis in patients presenting with an untypical clinical and histopathological manifestation of necrotizing fasciitis as a result of severe neutropenia following chemotherapy for acute myeloid leukemia.
authors.affiliation: Department of Trauma Surgery, University Hospital Munich, Ludwig-Maximilians-University, Nussbaumstr. 20, Munich 80336, Germany.
authors.forename: Mareen
authors.initials: M
authors.lastname: Brumann
authors.affiliation: Department of Trauma Surgery, University Hospital Munich, Ludwig-Maximilians-University, Nussbaumstr. 20, Munich 80336, Germany.
authors.forename: Viktoria
authors.initials: V
authors.lastname: Bogner
authors.affiliation: Department of Hematology and Oncology, University Hospital Munich, Ludwig-Maximilians-University, Ziemsenstr. 1, Munich 80336, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Völkl
authors.affiliation: Institute of Pathology, University Hospital Munich, Ludwig-Maximilians-University, Thalkirchnerstr. 36, Munich 80337, Germany.
authors.forename: Karl
authors.initials: K
authors.lastname: Sotlar
authors.affiliation: Department of Trauma Surgery, University Hospital Munich, Ludwig-Maximilians-University, Nussbaumstr. 20, Munich 80336, Germany.
authors.forename: Ekkehard
authors.initials: E
authors.lastname: Euler
authors.affiliation: Department of Trauma Surgery, University Hospital Munich, Ludwig-Maximilians-University, Nussbaumstr. 20, Munich 80336, Germany.
authors.forename: Wolf
authors.initials: W
authors.lastname: Mutschler
keywords: Acute myeloid leukemia; Diagnostic difficulties; Granulocytopenia; Necrotizing fasciitis; Soft tissue infection