A Man With Severe Back Pain

A 63-year-old man with rheumatoid arthritis presented to the emergency department with new-onset severe low back pain starting 6 hours before presentation. Vital signs were normal and physical examination revealed a 2-cm sacral pressure ulcer. Laboratory testing was remarkable for a WBC count 1.1×10 ³ /μL and a lactate level of 9.7 mmol/L. Initial chest and lumbar spine radiograph results were normal. The patient was admitted to the medical ICU for suspicion of sepsis and subsequently developed respiratory distress and hypotension requiring intubation and vasopressor support. Postintubation chest radiograph revealed left axillary subcutaneous emphysema ( Figure 1 ). Physical examination revealed left groin crepitus, prompting further imaging. Abdominal and femoral radiographs showed diffuse involvement consistent with fulminant necrotizing soft tissue infection ( Figures 2 and 3 ). The patient was deemed too unstable for surgical intervention, experienced a cardiac arrest, and ultimately died.