Man with a swollen neck

A 46-year-old male presented to the emergency department with the chief complaint of "neck swelling." His examination revealed extensive erythema and edema of the anterior neck extending from the angle of the mandible to the suprasternal notch (Figures 1 and 2). He was hypoxic upon arrival, with no acute respiratory distress and improved with supplemental oxygen. Point-of-care ultrasound (POCUS) was performed (Video 1) and subsequent computed tomography of the neck was obtained (Figure 3). His blood glucose level was 600 mg/dL, lactic acid was 6.3 mmol/L, and he had a leukocytosis of 22.82 × 103/cm. This case describes necrotizing fasciitis (NF). NF is a life-threatening bacterial infection of deep soft tissues that causes rapidly progressive destruction of muscle fascia and subcutaneous fat.1 Early diagnosis and urgent surgical intervention have been shown to reduce morbidity and mortality, the latter ranging up to 36%.2, 3 This condition occurs more frequently in patients with diabetes, immunosuppression, and substance use disorders.4 Early recognition is a diagnostic challenge given the scarcity of pathognomonic findings, leading to common misdiagnoses such as cellulitis and abscess.5 Patients with NF can present with superficial findings limited to skin erythema and edema.1 POCUS can be a useful tool to identify features of NF, such as subcutaneous emphysema.2, 6 The diagnosis is definitively made through surgical intervention, which is the mainstay of treatment along with aggressive antibiotic therapy.7 This patient was started on broad-spectrum antibiotics and taken emergently to the operating room by otolaryngology.