Necrotising soft-tissue infection.

DESCRIPTION A 55-year-old woman presented with a 3-day history of progressively worsening pain, swelling and ‘unpleasant crackling feeling’ on her left upper limb. These complaints had begun after she noticed a small reddish lesion on her left elbow. The patient had received a diagnosis of systemic lupus erythematosus 15 years before coming to us and was taking methylprednisolone and acenocoumarol, the last for previous deep vein thrombosis associated with protein S deficiency. There was history of neither acute or chronic trauma nor diabetes (in the patient or in her family). She was allergic to penicillin. On admission, blood pressure and temperature were normal but heart rate was 99 beats/min. Her left upper extremity showed erythema, an elbow wound (figure 1), and generalised tense oedema and crepitus, the last also being evident on the ipsilateral supraclavicular region. Plain radiographs of the left upper limb and chest identified abundant subcutaneous gas (figure 2 and 3), a very specific finding of necrotising soft-tissue infection (NSTI). The patient was immediately started on intravenous clindamycin and vancomycin and then urgent, extensive surgical