Figure 1.

Case vignette #1. (A) on admission; (B) before skin graft surgery; (C) four months after skin graft surgery. A 28-year-old lactating mother had toothache for 3 weeks. She first sought help from a traditional healer, who applied leaves on the skin and gave her several smoke baths. Because the swelling and pain increased, she went to another hospital first where she received metronidazole, ceftriaxone IV, and surgical debridement. As the situation deteriorated, the patient was referred to our district hospital. On admission, the patient was alert and stable, she had no difficulty breathing. The mouth opening was 50 mm (interincisal distance). Her vital parameters were stable, and she was afebrile. She had a deep and expansive necrotizing lesion on her chest, starting at the jaw reaching up to both upper parts of the areolae mammae (A). There was no drainage of pus into the mouth. Her hemoglobin was 5.6 g/dL, a malaria RDT was positive, and an HIV-test was negative. A provisional diagnosis of necrotizing fasciitis due to a dental abscess secondary to a tooth infection was made. The patient was stabilized with 2 units of fresh blood and empirical intravenous antibiotics were administered (ceftriaxone 2 g OD, and metronidazole 500 mg TID). She was treated for concomitant malaria with co-artem standard-dose BID. The patient underwent debridement under ketamine anesthesia within 3 hours. Postoperatively, she developed septicemia indicated by a HR 162 bpm, BP 98/60 mm of Hg, RR 25 bpm, Sat 90%, Temp 38.9°C. The urine output remained adequate with > 30 cc/h. Gentamicin 240 mg OD and aggressive fluid resuscitation were initiated. The patient stabilized within two days. A skin graft operation was performed on D32 post-admission (B), using both upper legs as donor sites. On D35, the skin graft was infected, and 80% of the graft failed. Small graft “islands” remained, and further growth was established. The patient discharged herself against medical advice. Six months later, she returned to our facility. At that time, she had no complaints, her chest wound was fully granulated and scarred. There was no pain or dysfunction (C). This figure appears in color at www.ajtmh.org.