Advances in Plastic & Reconstructive Surgery © All rights are reserved by Dr. Marc R. Matthews et al. *Address for Correspondence: Dr. Marc R. Matthews, M.D., F.A.C.S, The Arizona Burn Center Valleywise Health Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008; Tel. # - [602] 344-5624; FAX – [602] 344-5705; E- Mail: [email protected] Received: February 18, 2020, Date Accepted: April 14 2020, Date Published: April 15, 2020. Asia N. Quan, Pharm.D, B.C.P.S., B.C.C.C.P 1 , Aaron C. Hechtman, D.O 2 , Douglas D. Opie, D.O 3 , Areta Kowal-Vern, M.D, F.C.A.P., F.A.S.C.P 4, 5 , Marc R. Matthews, M.D., F.A.C.S 2, 5 1 Department of Pharmacy, Valleywise Health Medical Center, Phoenix, AZ 2 Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ 3 Department of Surgery, Mountain Vista Medical Center, Mesa, AZ 4 Department of Research, Valleywise Health Medical Center, Phoenix, AZ 5 Arizona Burn Center, Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ Abstract Aesthetic and reconstructive surgery complications can entail critical infectious processes. Clinically suspected necrotizing fasciitis requires emergency operative debridement of all necrotic tissue and intravenous antibiotics for patient survival. Rarely identified with necrotizing fasciitis, Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the Enterobacteriaceae family. A 55-year old immunocompetent male developed necrotizing fasciitis of his lower extremity and required a below the knee amputation. Keywords: Leclercia adecarboxylata; Water-borne; Gastrointestinal infection; Necrotizing soft tissue infection; Necrotizing fasciitis Case Report ISSN: 2572-6684 Lower Extremity Necrotizing Fasciitis And Leclercia Adecarboxylata usually the most common areas involved in NF, and there has been a case of lower extremity calf augmentation and NF [8]. Case Report A 55-year-old healthy Caucasian male with no past medical history or comorbidities presented with a necrotic, non-healing wound of the left lower extremity after kicking a bed frame one week prior to admission. During that initial week, he experienced significant pain and difficulty ambulating. The leg and foot were soaked in magnesium sulfate [Epsom salt] baths; ibuprofen did not alleviate the pain. The pain, swelling, erythema, bullae, and black necrotic eschar prompted the patient to seek medical attention [Figure 1]. Figure 1: Black necrotic eschar on the dorsum of the left foot upon admission. On arrival, the patient was tachycardic [heart rate 119 bpm], hypertensive [BP 171/105 mmHg], afebrile, but in no acute distress. Laboratory studies demonstrated a leukocytosis, white blood cells 24 10 3 /uL with 14% bands [normal 3.7 to 11.4 10 3 /uL]; glucose 173 mg/dl [normal <100 mg/dl]; Hemoglobin was 14.5 g/dl [normal 10.8-15.3 g/ dl]. His calculated LRINEC [Laboratory Risk Indicator for Necrotizi ng Fasciitis] was only three which placed him in the lowest risk category for NF at less than 50% [11]. Radiographs of the left foot surface [Figure 2] consistent with NF. Introduction Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the Enterobacteriaceae family, cultured either as the main infective agent or within a polymicrobial environment, in both immunocompetent and immunosuppressed individuals [1]. First described by Leclerc [2] in 1962 as Escherichia adecarboxylata, detailed speciation by Tamura reassigned it to the Enterobacteriaceae genus in 1986 as Leclercia adecarboxylata [3]. It is commonly a poly- microbial infection [Type I] although mono-microbial [Type II] infections can occur. It requires support of the poly-microbial pool in general, but in immunocompromised individuals, this organism can survive by itself [1]. There have been more than 100 case reports noted in literature reviews; they reflect multiple sources of infection, [food, water, body fluids], wounds, sepsis, and organ systems [1, 4, 5]. Necrotizing Fasciitis [NF] is a devastating disease that may result in large surgical, disfiguring wounds, amputations, and even death, if not treated emergently with removal of necrotic infected tissue and intravenous antibiotics [6]. NF requires large scale debridements as the result of a breach in the host immunologic defenses from a variety of causes [6]. Risk factors for this disease are diabetes mellitus, alcoholism, chronic kidney disease, liver cirrhosis, surgical wounds and abrasions [6]. Marchesi et al. reviewed the literature and the necessary cautions, to consider the possible impact of NF on aesthetic, plastic, and reconstructive surgeries [7]. In this review, liposuction was the most common procedure, followed by blepharoplasty; buttocks and lower extremities were the most common anatomical regions affected by necrotizing fasciitis [7]. Of interest, lower extremities are Adv Plast Reconstr Surg, 2019 Page 324 of 326