CASE REPORT
A 51-year old male presented to our clinic with severe neck pain and
massive swelling which was started as a furuncle-like lesion 14 days ago
on the nape of the neck with rapid progression. He had refused to seek
medical help due to the COVID-19 pandemic. He denied a history of DM and
any trauma or bite in this location; however, there was a long history
of occipital folliculitis. Besides, he had a history of hyperlipidemia
and coronary artery bypass grafting surgery 1 year ago.
On clinical examination, there was a huge carbuncle with purplish color
and multiple purulent sinus tracts (figure 1) with a limited range of
motion due to extreme pain. Also, there were patches of cicatricial
alopecia and tufted folliculitis on his occiput.
Laboratory exam revealed a blood glucose level of 537 g/dL and glycated
hemoglobin A1c (HbA1c) of 13%. White blood cell count (WBC) was 14.60
(normal 4.00-11.00 x103/ul), erythrocyte sedimentation rate (ESR) 67
mm/hour, and C-reactive protein (CRP) 37.1 mg/L.
A preliminary diagnosis of carbuncle in the setting of uncontrolled DM
was made. The differential diagnoses included actinomycosis, bite
reaction, gas gangrene, and cutaneous anthrax. The patient developed
rapid extension of erythema, warmness, and tenderness to the
interscapular area and shoulders, along with confusion, fever, and
tachypnea during the first hours of admission. So, NF was considered.
Soft tissue ultrasonography and neck computed tomography showed
significant soft tissue thickening and increased echogenicity with fat
lobulation. Some superficial foci of gas were noticed and interpreted as
sinus tracts. No obvious abscess or collection was detected.
TazocinĀ® (piperacillin/tazobactam) plus vancomycin was started
immediately after taking discharge samples for smear and culture and the
patient was sent to the operation room for surgical debridement.
Intraoperatively a wide horizontal incision was made throughout the
posterior neck. Extensive necrosis and pus formation extending deep into
the muscles were observed spreading wide beyond the visible erythematous
margin; therefore, a vertical incision was added to the interscapular
area allowing complete evacuation of pus and necrotic tissues.
Histopathologic examination revealed fibro adipose tissue with extensive
abscess formation and necrosis. Cultures demonstrated the growth of
staphylococcus aureus susceptible to methicillin, so the previous
antibiotics were continued. Skin biopsy was obtained from the occiput
that was compatible with folliculitis decalvans. Consecutive surgical
debridement sessions for the next 7 days removed the whole necrotic
tissues (figure 2). After ensuring that the necrosis spreading came to a
halt, vacuum therapy was administrated for 12 days till granulation
tissue filled the wound. After a total of 23 days of hospital admission,
he was discharged with a shallow ulcer without any complications. The
antibiotic regimen was changed to oral cotrimoxazole and clindamycin.
Also, routine wound care and insulin therapy was continued, and weekly
follow up for wound assessment was scheduled (figure 3). In 1 month
follow up the wound was completely repaired.