SHM Converge Scientific Abstract ePoster Gallery-Atypical Multifocal Myonecrosis Masquerading as Necrotizing Fasciitis Following Cocaine Exposure: A Case Report

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This case report describes a 43-year-old man who presented with rapidly worsening right arm pain and swelling, hemorrhagic bullae, pain out of proportion to exam, elevated CK, acute kidney injury, and an LRINEC score of 6—features highly concerning for necrotizing soft tissue infection (NSTI). Because NSTIs are surgical emergencies, he underwent urgent operative exploration. Surprisingly, the fascia was intact, but the muscle in the extensor compartment was extremely friable and necrotic, suggesting a non-infectious process.<br /><br />Further workup showed multifocal myonecrosis on MRI involving the paraspinal, gluteal, and thigh muscles. Autoimmune testing, cultures, and PCR studies were negative. A urine drug screen was positive for cocaine, raising concern for cocaine- or adulterant-related tissue injury, possibly from a toxic or ischemic mechanism such as levamisole exposure.<br /><br />The report highlights the diagnostic challenge of distinguishing necrotizing fasciitis from non-infectious muscle necrosis, since both can present with severe pain, swelling, bullae, and abnormal labs. It emphasizes that the LRINEC score alone cannot reliably separate infectious from non-infectious causes. Early surgical exploration remains critical when NSTI is suspected, but clinicians should also consider cocaine exposure in atypical cases of soft-tissue necrosis.<br /><br />Overall, this case underscores that multifocal myonecrosis can closely mimic necrotizing fasciitis, and that preserved fascia, negative cultures, and multifocal muscle involvement should prompt consideration of toxic or ischemic myonecrosis rather than infection.

Asset Subtitle

John H. Major

Meta Tag

Author List Adriana J. Sotelo, Denny Joseph, John H. Major, Pranayvir S. Lotey

Category Clinical Vignettes

Concept Necrotizing Soft Tissue Infection

Concept Muscle Necrosis

Concept Noninfectious Cause

Concept LRINEC Score

Concept Surgical Exploration

Distinguished Non-Finalist

Presenter Organization McGovern Medical School at UTHealth Houston

Presenting Author John H. Major

Track Adult

Keywords

necrotizing soft tissue infection

myonecrosis

cocaine exposure

levamisole

necrotizing fasciitis

LRINEC score

acute kidney injury

hemorrhagic bullae

muscle necrosis

ischemic injury

Necrotizing Soft Tissue Infection

Muscle Necrosis

Noninfectious Cause

LRINEC Score

Surgical Exploration