200 - Necrotizing Fasciitis and Bilateral Trans-tibial Amputation Following COVID-19: A Case Report

Case Diagnosis: Bilateral trans-tibial amputation secondary to COVID-19 virus.

Case Description: A 53-year-old male with a history of hypertension presented to the emergency department complaining of worsening bilateral lower extremity pain and non-healing wounds following recent COVID-19 infection requiring hospitalization. Imaging was suggestive of necrotizing fasciitis and osteomyelitis of bilateral lower extremities. Vascular surgery was consulted and ultimately performed bilateral trans-tibial amputation. Following the procedure and post-operative stabilization, the patient was admitted to the inpatient rehabilitation service. While admitted, the patient gained functional independence with respect to bed and transfer mobility. His rehabilitation course was otherwise uncomplicated, apart from experiencing mild phantom limb pain which was managed effectively with Gabapentin. Upon discharge home, the patient followed closely with outpatient rehabilitation where he continued physical therapy and was eventually fitted for bilateral trans-tibial endoskeletal prosthesis.

Discussions: Since the emergence of the COVID-19 pandemic, amputation rates have increased greater than two-fold, suggesting possible correlation. Further, those infected with COVID-19 who had eventual amputation were found to have increased risk of mortality as compared to amputees of non-COVID-19 related origin. Additionally, there have been increasing reports of COVID-19-induced necrotizing fasciitis. While many severe limb infections develop during hospital admission from COVID-19, many also develop after COVID-19 recovery, as was the case in our patient. Our patient developed progressive pain, erythema, and soft tissue swelling for two months after COVID-19 infection, eventually leading to necrotizing fasciitis requiring amputation.

Conclusions: Necrotizing fasciitis is an exceedingly rare complication of COVID-19 that may present months following recovery from initial illness. For those with severe COVID-19 infection, patient education is critical in preventing further complications as in this case. Ultimately, a multidisciplinary approach and early rehabilitation are essential in reducing long-term morbidity and mortality in patients who undergo amputation following infection with COVID-19.