doi: 10.1111/j.1346-8138.2009.00669.

x Journal of Dermatology 2009; 36: 423–426

CASE REPORT
Blackwell Publishing Asia

Necrotizing fasciitis and myonecrosis “synergistic

necrotizing cellulitis” caused by Bacillus cereus
Asuka SADA,1 Noriyuki MISAGO,1 Takeshi OKAWA,1 Yutaka NARISAWA,1 Shuya IDE,2
Masaki NAGATA,3 Shinji MITSUMIZO4
1
Division of Dermatology, Department of Internal Medicine, Departments of 2Orthopeadics, 3Infection Control Unit and 4Anesthesiology and
Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan

ABSTRACT
Our patient was a 37-year-old man with diabetes mellitus and hepatopathy as underlying diseases. Swelling,
erythema and pain appeared in the left upper limb on the day before the initial examination. On examination, diffuse
purpura was noted on the left upper limb, and, as it rapidly extended to the left upper trunk, emergency surgery
was performed. Intraoperatively, gas-producing necrosis was observed not only in subcutaneous tissues but also
from the fascia to muscle tissues, and the condition resembled clostridial gas gangrene. However, as the culturing
of samples from the lesion yielded Bacillus cereus, a diagnosis of necrotizing fasciitis and myonecrosis (synergistic
necrotizing cellulitis) due to B. cereus was made. While the patient developed a serious condition due to sepsis
and disseminated intravascular coagulation, he could be saved by early debridement and intensive treatment with
an appropriate selection of antibiotics.
Key words: Bacillus cereus, necrotizing fasciitis, myonecrosis.

INTRODUCTION mellitus and alcoholic hepatopathy. Pain appeared

Bacillus cereus is an aerobic Gram-positive rod
distributed very widely in nature and is commonly
known as a cause of food poisoning.1–3 However, it
has recently been recognized as a cause of infection
in neonates and immunocompromised individuals
and has been reported to cause skin and soft tissue
infections, pneumonia, meningitis, endocarditis,
bacteremia and sepsis.1,2,4–9 In skin and soft tissue
infection caused by Bacillus cereus, gas production
and myositis may occur, and the condition is often
confused with clostridial gas gangrene.4,5,10–12 We
report a patient with diabetes and hepatopathy who
developed necrotizing fasciitis and myositis due to
B. cereus and entered a critical condition.
CASE REPORT
The patient was a 37-year-old Japanese man who
had been treated for 2 months due to diabetes
in the left upper limb in the evening on the day
before the initial examination. A fever and swelling
and pain of the left upper limb developed the next
day, when the patient consulted our hospital. On
examination, diffuse purpura, swelling and fever
were noted in the left upper limb and axilla, and the
patient complained of intense pain and tenderness
(Fig. 1a,b). On arrival, consciousness was clear, but
the blood pressure was 67/42 mmHg, and the heart
rate was 136 b.p.m., indicating shock. Body tem-
perature was 37.9°C. The purpura rapidly extended
to the left upper trunk within 2 h of arrival, and
purpura also appeared on the lower limbs (Fig. 2c).
The level of consciousness gradually decreased to
coma. The results of blood tests were as follows:
white blood cells, 5900/μL; red blood cells,
337 × 104/μL; hemoglobin, 10.4 g/dL; hematocrit,
30.7%; platelets, 15.6 × 104/μL; prothrombin time,
33.7%; activated partial prothrombin time, 49.9%;
total protein, 3.8 g/dL; albumin, 1.9 g/dL, total

Correspondence: Asuka Sada, M.D., Division of Dermatology, Department of Internal Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga 849-8501,
Japan. Email: sadaasu@cc.saga-u.ac.jp
Received: 19 December 2008; accepted: 11 March 2009.

© 2009 Japanese Dermatological Association 423

A. Sada et al.
Figure 1. (a,b) Diffuse purpura, swelling and fever were
noted from the left upper limb to the axilla. (c) After 2 h,
purpura also appeared in the crus.
bilirubin, 6.8 mg/dL; aspartate aminotransferase,
232 IU/L; alanine aminotransferase, 47 IU/L; lactate
dehydrogenase, 403 IU/l; alkaline phosphatase,
726 IU/L; γ-glutamyltransferase, 964 IU/L; blood
urea nitrogen, 7.2 mg/dL; creatinine, 0.97 mg/dL,
creatine phosphokinase, 5783 IU/L; Na, 128 mEq/L;
K, 2.8 mEq/L; Cl, 86 mEq/L; C-reactive protein,
6.15 mg/dL; HbA1c, 8.7%. Magnetic resonance
imaging disclosed wide subcutaneous edema from
the left upper limb to shoulder and inflammation
involving not only the fascia but also intermuscular
tissues (Fig. 2). No clear image of gas was observed.
424
Figure 2. Magnetic resonance imaging suggested wide
subcutaneous edema and inflammation involving inter-
muscular tissues from the left upper limb to shoulder
(arrow).
When samples from the lesion were examined by
Gram staining, a large number of Gram-positive rods
were detected. The administration of vancomycin
and clindamycin was immediately initiated to cover
a wide spectrum of Gram-positive rods. Emergency
surgery was performed, revealing necrosis partly
extending from the subcutaneous tissues to deep
areas of muscle tissue (Fig. 3a). Bubbles were iden-
tified in areas with particularly severe myonecrosis,
and an irritative odor was noted, suggesting a
gas-producing bacterium as the pathogen (Fig. 3b).
Because this finding, along with the results of Gram
staining, suggested clostridial gas gangrene, the
antibiotic was changed intraoperatively from vanco-
mycin to penicillin G, which is more effective against
clostridia. The general condition was poor even after
the initial surgery, and while the patient continued to
be managed in the Intensive Care Unit, additional
debridement was performed. On the third hospital
day, only B. cereus was detected on bacterial culture
despite the initial expectation. The antibiotic was
immediately changed from penicillin G to vancomycin.
Thereafter, the general condition and laboratory results
gradually improved, and the patient was discharged
on the 94th hospital day after several debridement
and skin graft operations. Presently, the patient
has returned to his original work while continuing
rehabilitation of the left upper limb.
© 2009 Japanese Dermatological Association

Figure 3. (a) Inflammation extended from subcutaneous
tissue to deep areas of muscle tissues, which were necro-
tized. (b) Bubbles were observed in areas with marked
muscle necrosis.
DISCUSSION
There have been a large number of reports on type
I – the gas-producing or mixed-infection type –
necrotizing fasciitis, which complicates diseases
such as diabetes mellitus. Type I necrotizing fasciitis
in which necrosis extends beyond the fascia to
muscle tissues is called synergistic necrotizing
cellulitis.13 From clinical findings, the case presented
here is considered to correspond to this type. Usually,
synergistic necrotizing cellulitis is caused character-
istically by mixed infection involving several bacterial
species including anaerobic and Gram-negative
species similar to type I necrotizing fasciitis, and
Bacteroides, in particular, is often reported as a
pathogen.13 However, the present patient showed
infection of Gram-positive rods alone, which sug-
gested clostridial gas gangrene. This is considered
to have been due to the following characteristics of
the species B. cereus.
Bacillus cereus is a Gram-positive rod found
throughout the environment. Recently, instances of
© 2009 Japanese Dermatological Association
Bacillus cereus necrotizing fasciitis
severe B. cereus infection have been reported, and
its pathogenicity, particularly in an immunocompro-
mised state, is being recognized.4–8 B. cereus
produces enterotoxins, hemolysin, phospholipase,
lecithinase among others, which are involved in
hemolysis and tissue necrosis.4,9,12 Skin and soft tissue
infection by this species is often confused with
clostridial gas gangrene, because the pathogen is a
Gram-positive rod, and gas production and myositis
may be observed.4,5,10–12 Penicillin is usually selected
for the treatment of clostridial gas gangrene, but
B. cereus shows resistance to β-lactam antibiotics
as it produces β-lactamase.4,9,11,12 Because the early
selection of an appropriate antibiotic leads to an
improvement in the outcome of severe infections,
differentiation between the two conditions is extremely
important. Clostridial gas gangrene often occurs
after trauma in patients with no underlying disease,
and the primary site of inflammation is the muscle
parenchyma. In contrast, skin and soft tissue infection
by B. cereus occurs with sepsis in immunocompro-
mised patients, and inflammation often develops from
the subcutaneous to muscles (presenting features
of synergistic necrotizing cellulitis). These are
considered to be points of differentiation between
the two conditions.5
Skin and soft tissue infection of B. cereus should
be accurately understood, even though it is a rare
disease, and antibiotics should be selected carefully
in consideration of the possibility of B. cereus for
patients with synergistic necrotizing cellulitis. The
patient reported here also had hepatopathy and poorly
controlled diabetes mellitus as underlying diseases
and exhibited severe symptoms due to sepsis.
However, the patient could be saved by early debri-
dement, an appropriate selection of antibiotics, and
intensive treatment by cooperation among various
departments.
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© 2009 Japanese Dermatological Association