Eur J Clin Microbiol Infect Dis (2001) 20:509–521
Q Springer-Verlag 2001
therapy was started with clindamycin (600 mg i.v. every
8 h) plus penicillin G (4!106 U i.v. every 4 h). One
hour later, the patient’s temperature was 34.5 7C, pulse
120 beats/min, respirations 26 times/min, and blood
pressure 60/40 mmHg. At this time, the patient was
lethargic and disoriented. Her left leg had developed
bullae formation with a focal area of crepitation around
the ankle. She was then intubated and mechanical
ventilation was initiated. The clinical diagnosis of
necrotizing fasciitis was made. A Gram stain of an aspi-
Brief Reports
Community-Acquired Necrotizing
Fasciitis Caused by Serratia
marcescens: Case Report and Review
S. Liangpunsakul, K. Pursell
Serratia marcescens is a gram-negative bacillus that has rate of a bulla revealed numerous gram-negative bacilli
been recognized as a human pathogen since the 1960s with few leukocytes. Ceftriaxone (2 g i.v. every 4 h) was
[1]. This organism is known to cause a variety of infec- added to her therapy. Surgical debridement and left
tions including bacteremia, pneumonia, endocarditis, above-knee amputation was performed. A Gram stain
meningitis, and septic arthritis [2]. Community- of the deep tissue specimen also demonstrated gram-
acquired infections are uncommon and most often negative bacilli. Cultures of blood, fluid aspirated from
occur in immunocompromised or neutropenic persons a bulla, and surgical specimens yielded Serratia
[2, 3]. Serratia marcescens is also an unusual cause of marcescens (Biochemical Identification Card; Gram
soft tissue infections such as cellulitis and necrotizing Negative Identification Plus; bioMérieux Vitek, USA);
fasciitis [3]. We report a case of community-acquired anaerobic cultures of all samples were negative.
necrotizing fasciitis secondary to Serratia marcescens Despite aggressive therapy with surgery and antibiotics,
infection that occurred in an otherwise healthy woman. the patient remained hypotensive and developed
multiorgan failure. She died after 2 weeks of aggressive
A 66-year-old woman was admitted to the hospital treatment.
because of left leg pain. She had apparently been well
until 1 day earlier when she experienced rapid onset of Serratia marcescens belongs to the family Enterobacter-
pain, redness, and swelling in her left ankle. Six hours iaceae [1]. The majority of infections caused by this
later the pain, redness, and swelling had spread from organism are nosocomial in origin. Bouza et al. [4]
her left ankle to her left knee. No history of leg trauma reported the results of a survey of 146 hospitalized
or chronic leg ulcer was noted. The patient had patients who had Serratia bacteremia: only 8% of the
previously been healthy. Upon examination, her cases were community acquired. Serratia has been
temperature was 36 7C, pulse 112 beats/min, respira- reported as an uncommon cause of community-
tions 22 times/min, and blood pressure 100/80 mmHg. acquired soft tissue infection [3]. Necrotizing fasciitis
The patient was alert and oriented. Her left leg was caused by this organism is rare, especially in immuno-
markedly tender and swollen from the ankle to the competent persons.
knee, and the skin was erythematous with multiple
areas of bluish discoloration. No crepitation was noted Using Medline, we searched the English-language liter-
on palpation. The patient’s lungs, heart, and abdomen ature published between January 1966 and May 1999.
were normal.
The terms utilized in the search were Serratia
marcescens, soft tissue infection, cellulitis, and necro-
Laboratory tests revealed the following values: hemo- tizing fasciitis. Reference lists of the identified articles
globin, 14.4 g/dl; leukocyte count, 4,900/mm3 (54% were also reviewed to find additional cases.
granulocytes, 20% bands and 23% lymphocytes);
platelet count, 207,000/mm3; sodium, 139 mmol/l; We found nine instances of Serratia marcescens
potassium, 3.2 mmol/l; chloride, 106 mmol/l; carbon community-acquired soft tissue infection described in
dioxide, 18 mmol/l (30 mmol/l, 2 weeks before admis- the literature [3, 5–9]. Including our patient, the infec-
sion); blood urea nitrogen, 28 mg/dl; serum creatinine, tions occurred in five males and five females whose
1.4 mg/dl (0.7 mg/dl, 2 weeks before admission); and median age was 57.5 years (range, 23–88 years)
creatine kinase, 65 U/l. A left lower extremity radio- (Table 1). Risk factors included chronic leg edema,
graph revealed soft tissue swelling without evidence of history of trauma, chronic leg ulcer, chronic renal
gas. Blood was drawn for culture, and intravenous (i.v.) failure, and diabetes mellitus. The common clinical
presentation was cellulitis (80%). Of the eight patients
who presented with cellulitis, one died secondary to
S. Liangpunsakul, K.J. Pursell (Y)
Infectious Disease Department (M/C 735), 888B CME,
University of Illinois at Chicago, Chicago, IL 60612, USA
e-mail: KJPursel6uic.edu
septic shock and multiorgan failure, and the others
survived after antibiotic therapy. Only two cases (1 of
which is ours) of necrotizing fasciitis caused by Serratia
marcescens have been reported. Our patient died
despite aggressive treatment with surgery and antibio-
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