A document by Joshua Levine. Click on the document to view its contents.

Title: AngioinvasiveTrichophyton rubrum associated necrotizing fasciitis in an immunocompromised patientAuthors: Michael J. Davis, DO, MPH1-3*; Katelyn J. Rypka, BS3-6*; Alexandra K. Perron, BA6; John Keilty, BS6; Benjamin Wils, MS 6; Joshua Levine, BA 6; Anthony T. Rezcallah, MD7-8; Robin Solomon, MD9; Noah Goldfarb, MD3-5†; Anjum Kaka, MD1, 3†Affiliations:1Department of Infectious Disease, Minneapolis VA Health Care System, Minneapolis, MN2Department of Infectious Disease, University of Minnesota, Minneapolis, MN3Department of Internal Medicine, Minneapolis VA Health Care System, Minneapolis, MN4Department of Dermatology, Minneapolis VA Health Care System, Minneapolis, MN5Department of Dermatology, University of Minnesota, MN6University of Minnesota Medical School, Minneapolis, MN7Department of Surgery, Minneapolis VA Health Care System, Minneapolis, MN8Department of Surgery, University of Minnesota, Minneapolis, MN9Department of Pathology, Minneapolis VA Health Care System, Minneapolis, MN*These authors contributed equally†These authors contributed equally

IntroductionPressure (decubitus) ulcers, also known as bedsores, are skin and soft tissue injuries that arise from constant or prolonged pressure exerted on the skin (Zaidi, 2022). An increasing number of people are affected by pressure injuries as our population grows and ages (Boyko, 2016). Pressure injuries frequently precipitate chronic wounds resulting in significant morbidity, mortality, and economic burden on both the patient and the healthcare system (Afzeli, 2020). Pressure injuries may develop in hospital and long-term care settings with orthopedic wards estimated to have the highest incidence of pressure injuries (Afzeli 2020). The reported prevalence of pressure injuries in long-term care facilities varies widely, ranging from 3.4-32.4% while hospital incidence rates range from 4% to 38% (Anthony 2019 & Afzeli 2020).The etiology of pressure ulcers is multifactorial with risk factors including but not limited to neurologic disease, cardiovascular disease, and malnutrition (Zaidi 2022). Prolonged external pressure for as little as two hours can lead to the formation of a pressure ulcer (Zaidi 2022). Physiologic factors that incite pressure injuries include reperfusion injury and impaired lymphatic drainage (Boyko, 2016).A number of complications may result from pressure ulcers with the most common being infection, which is often polymicrobial (Zaidi, 2022). The infection may spread to deeper tissues inciting periostitis, osteomyelitis, septic arthritis and the formation of sinuses from tissue loss (Zaidi 2022).Stage I and II pressure ulcers are managed conservatively with appropriate wound care and elimination of causative factors, while more severe ulcers (stage III or IV) or ulcers with concomitant necrosis, osteomyelitis, or systemic infection may often require operative intervention. More severe pressure ulcers may require adjunctive procedures such as bedside debridement, negative pressure wound therapy, fecal/urinary diversion, and ultimately operative care. Since complication rates after flap reconstruction of pressure injuries are high, affecting 59% of patients (Bamba 2017), those who are poor surgical candidates should generally not undergo reconstructive procedures.We present a unique case of a chronic ischial tuberosity pressure wound (ITPW) with multi-focal arterial and venous hemorrhage which required emergent exploration in the operating room.