POSTPARTUM NECROTIZING FASCIITIS tions 20/min, pulse 120/min, and temperature 97.5F. Significant laboratory studies included a white blood cell count of 45,000/pl (87% neutro- phils), hemoglobin 15.6 g/dl, platelets 194,000/lal, COz of 22 mmol/1, glucose 126 mg/dl, creatinine 1.1 mg/dl, and albumin 2.2 g/dl. She was admitted with an initial diagnosis of pcrineal ccllulitis at the epi- siotomy site. Broad-spectrum antibiotics (ampicillin, genta- micin, clindamycin) were empirically initiated in addition to local wound care (sitz baths and beta- dine). No debridement was undertaken. Despite this, the patient complained of increasing pelvic and left leg pain and inability to ambulate. As her pain was felt to be out of proportion to her physical findings, a physical therapy consult was obtained to aid in ambulation. Over the next 2 hospital days, the crythema and induration progressed, extending from the perineum to the inner thigh and to the buttock region. On postpartum day 6, wound and vaginal cultures returned, identifying growth of Streptococcus boris and Enterococcus. Based on sensi- tivity results, antibiotic treatment was altered to replace ampicillin with ticarcillin/clavulanic acid. On the 8th postpartum day, the patient dis- played increasing anesthesia over the perineum, with extensive swelling and induration. The pa- tient was still unable to ambulate despite physical therapy consultation. She remained afebrile but her white blood cell count had risen to 50,000/pl (74% neutrophils). Other significant laboratory findings were as follows: lactate dehydrogenase 206 U/1 (94-172 U/l), creatinine kinase 537 mg/dl (38- 173 mg/dl), SGOT 54 U/1 (12-48 U/l), and calcium 6.8 mg/dl (8.7-10.7 mg/dl). At this time, the patient was referred to our facility for further care. At the time of admission (postpartum day 9), a diagnosis of necrotizing fasciitis was made. This large area was discolored (purple to red), non- tender, and indurated (Fig. 1). There was marked vulvar edema with bullae, crepitus, and paresthe- sia. It involved the perineum and extended bilat- erally superiorly to just below the axilla and infe- riorly to just above the knees. Vital signs were blood pressure 123/75 mmHg, respirations 14/min, pulse 110/rain, and temperature 99.7F. Significant laboratory findings were a white blood cell count of 55,000/pl (91% neutrophils), hemoglobin 13.4 g/dl, platelets 229,000/pl, COz of 22 mmol/1, glucose 133 mg/dl, and creatinine 0.7 mg/dl. Intravenous peni- 342 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY LYNCH E T AL. cillin G, gentamicin, and clindamycin were admin- istered at maximal dosages. Five hours after trans- fer, a combined plastic surgery and gynecology team performed a radical debridement of all ne- crotic tissue of the abdomen, perineum, and thighs (Fig. 2). An intraoperative infectious disease consult was obtained and aggressive intensive care was contin- ued postoperatively (postpartum day 10). The an- tibiotic coverage was broadened with piperacillin/ tazobactam, vancomycin, and gentamicin at the recommendation of the infectious disease consul- tant. Despite this, the patient deteriorated. Her blood urine and wound cultures drawn after hospital transfer continued to be negative. She was intu- bated and required fluid support and blood prod- ucts. Thirty-six units of packed red cells and 9 units of fresh frozen plasma were administered over the next 24 h. A second debridement was per- formed on the lth postpartum day with removal of minimal tissue. The patient continued to experi- ence massive fluid losses from the open debride- ment sites. On the 12th postpartum day, the pa- tient’s situation worsened and she eventually ex- perienced cardiopulmonary arrest. Resuscitation attempts failed and the patient died 48 h after hos- pital transfer. Postmortem examination revealed necrotizing fasciitis and necrotizing myositis. Status post ex- tensive debridement of the perineum, lower ab- dominal wall, and left inner upper thigh, the sur- gical wounds were grossly free of necrosis and in- fection. There was diffuse alveolar damage present with pulmonary microthrombi consistent with sep- sis with acute respiratory distress syndrome (ARDS), and an incidental finding of a serous cyst- adenoma of the left ovary. DISCUSSION Necrotizing fasciitis was first reported as "hospital gangrene" in 1871 by confederate army surgeon Joseph Jones, M.D. z It was subsequently further described by Meleney in 1924 and is therefore also known as Meleney’s gangrene.3 Meleney was the first to describe the necessity for early surgical in- tervention in the treatment of this disease.4 Nec- rotizing fasciitis is often associated with patients who are immunocompromised, diabetic, or have other predisposing conditions including trauma,