plasters have been frequently associated with known complications such as infection , and compartment syndrome or deep vein thrombosis . however , life - threatening complication of necrotizing fasciitis ( nf ) has not been frequently attributed to plaster . we had a case of a 62-year male developing a lethal nf triggered by a below knee plaster for undisplaced fracture medial malleolus after twisting injury . he had no history suggestive of diabetes , renal impairment , and predisposing allergic factors or any comorbidity . despite early diagnosis and aggressive management with above knee amputation a similar case of reported lethal nf triggered by plaster has also been reviewed in this report . this case highlights a life - threatening rare complication of plaster and author recommends thorough clinical history taking , precleaning of limb , use of sterile water and use of adequate wrap around skin for gypsum plasters as prevention apart from high index of suspicion for early diagnosis , and rapid management . necrotizing fasciitis ( nf ) , commonly known as flesh - eating disease is a rare infection of the deeper layers of skin and subcutaneous tissues which easily spreads across the fascial plane within the subcutaneous tissue . the most consistent feature of nf was first described in 1952 as necrosis of the subcutaneous tissue and fascia with relative sparing of the underlying muscle . a 62-year - old male came to author at a suburban secondary care private hospital for an ankle twisting injury in february 2016 . on the bases of undisplaced fracture medial malleolus in x - ray , after 36 h of plaster , he presented with symptoms of itching , pain , swelling , and erythema up to distal thigh . slab was removed and the clinical diagnosis of necrotizing was made on the bases of fever , progressive swelling , crepitus , blisters getting peeled off easily with serous discharge , and sequential discoloration of tissue from pinkish to velvety followed by blackening due to necrosis along with foul smell ( fig . 1 ) . sequential development of necrotizing fasciitis after application of below knee plaster ( slab ) . laboratory results showed erythrocyte sedimentation rate 103 mm / h ( normal : 1 - 7 ) , c - reactive protein 281 mg / dl ( 0 - 5 ) , white blood cells 19,400/l ( 3000 - 10,000 ) ( 97% neutrophils , 1.9% lymphocytes ) , hemoglobin 9.6 g / dl ( 11.5 - 15.5 ) , platelet 90,000/l ( 1,50,000 - 4,00,000 ) , na 138 mmol / l ( 135 - 145 ) , creatine kinase 474 iu / l ( 26 - 140 ) , urea 11.8 mmol / l ( 1.7 - 8.3 ) , alanine transaminase 84 iu / l ( 10 - 35 ) , total bilirubin 1.8 mg / dl ( 0.3 - 1.9 ) , albumin 17 g / l ( 34 - 50 ) , creatinine 1.8 mg / dl ( 0 - 1.5 mg / dl ) , and normal blood sugar . his glycated hemoglobin was normal , and tests for anti - nucleosome antibody and anti - dsdna were negative . the patient was referred to tertiary care center on next day ( day 3 ) where the 2 cm incision was made in the skin down to the deep fascia after local anesthetic agent infiltration . lack of bleeding along with dishwater - colored fluid was noticed seeping from the wound . on gentle probing with index finger , pseudomonas aeruginosa was cultured from an on table tissue biopsy done on 4 day during debridement and gas gangrene was negative ruling out another differential . therefore , it was switched over by meropenem , teicoplanin , and clindamycin . despite early diagnosis and treatment with multiple antibiotics in an intensive care unit , nf still continued to expand above the stump and debridement was done 3 times after amputation on day 9 , 12 , and 15 . finally , the patient died on 20 day of initial presentation due to septic shock and acute renal failure . diabetes , renal impairment , immunocompromised condition and rheumatic conditions including systemic lupus erythematosus , systemic sclerosis , polymyositis , dermatomyositis , rheumatoid arthritis , and ankylosing spondylitis are known to predispose , but nf has only rarely been reported in association with plaster only [ 5 , 6 ] . p. aeruginosa is also a rare cause of nf unlike streptococcus pyogenes or other polymicrobial infections . plaster - associated pseudomonas infection as an outbreak has been reported by houang et al .   in 1981 , in lancet . to our knowledge and as per medline search using the mesh terms  nf  and  plaster or cast ,  only one such case of nf associated with plaster was published by netzer and fuchs   in 2009 , in ajcc , and review of comparison between the two cases has been done as below in table 1 . comparison of our case with the only reported case of plaster induced nerotizing fasciitis sle : systemic lupus erythematous in our case , although patient was not immunecompromised but his elder age is also not in favors of competent immunity . the only cover of a soft roll ( soft care 6  ) was used as padding and no use of stockey net or other wrap was done . thermogenic effect of gypsum and inadequate wrap predispose the swollen skin to a damaged barrier . the freshly filled tap water in a plastic bucket was used for plaster , and its culture for pseudomonas came positive in 1 out of 3 samples taken directly from the terrace water tank source . plaster material of slab used in the patient was discarded could not be retrieved for culture . we have also compared our case with recently reported cases nf in table 2 and also reviewed two case series of nf table 3 . comparison of our case with the recently reported cases necrotizing fasciitis comparison of recent case series on necrotizing fasciitis our case along with one another reviewed published report , serve as a reminder that nf may indeed occur after plaster . a high index of suspicion is advised to orthopedicians after plaster to deal with such rare life - threatening complication . few measures are recommended by author for prevention of such case after failing to save the patient s life despite early diagnosis and radical management . plasters made up with sterile water in an autoclaved stainless steel bowl should be used . important early clues are pain , tenderness , itching and systemic illness out of proportion to the localized physical signs , and skin lesions like bullae and ecchymosis . a high index of suspicion is necessary , and suspected cases should be referred immediately for prompt surgical debridement . this case highlights such a life - threatening rare complication of plaster and author recommends proper precleaning of limb , use of sterile water , and adequate wrap for gypsum plasters .
introduction : plasters have been frequently associated with known complications such as infection , and compartment syndrome or deep vein thrombosis . however , life - threatening complication of necrotizing fasciitis ( nf ) has not been frequently attributed to plaster.case report : we had a case of a 62-year male developing a lethal nf triggered by a below knee plaster for undisplaced fracture medial malleolus after twisting injury . 
 he had no history suggestive of diabetes , renal impairment , and predisposing allergic factors or any comorbidity . despite early diagnosis and aggressive management with above knee amputation 
 , death occurs due to septic shock on the 20th day . 
 a similar case of reported lethal nf triggered by plaster has also been reviewed in this report.conclusion:this case highlights a life - threatening rare complication of plaster and author recommends thorough clinical history taking , precleaning of limb , use of sterile water and use of adequate wrap around skin for gypsum plasters as prevention apart from high index of suspicion for early diagnosis , and rapid management .