Intramusculer injection is an usefull and easy way to adminstrate varios drugs in daily practice ( 1 ). These injections has also some undesired effects such as soft tissue damage, pain in injection area, cellulitis, subcutanous abscesses and necrotizing fasciitis. Tissue necrosis typically becomes a few days after injection ( 2 ). Necrotizing fasciitis is a high mortal infection described that rapidly spreading with necrosis of fascia and subcutaneous fat. Thera are a few case reports in literature necrotizing fasciitis following intramusculer injection ( 3 , 5 ). Rhabdomyolysis is a sydrome characterized by muscle necrosis and the release of intracelluler muscle constituents into systemic circulation. Creatine kinase levels typically elevated, muscle pain and myoglobunuria may be present.It ranges from asemptomatic muscle enzymes elevations to acute kidney injury ( 6 ). There are a few reports in literature that rhabdomyolysis following dıclofenac adminstration (2, 7). We report herein a fatal case of progressive necrotizing fasciitis and rhabdomyolysis cause of acute kidney injury after intramusculer diclofenac injection, to the best of ourknowledge, both acute kidney injury due to rhabdomyolysis and necrotizing fasciitis after intramuskuler diclofenac injection are reported for the first time in this case.

A 37-year-old man was accepted to our emergency services fatigue, nause, vomiting, pain and swelling in his right leg. He received intramusculer injection of diclofenac in his right leg 2 days ago. There was no chronic disease or continuous drug use in past medical history. On admission his vital signs as follows: blood pressure 90/60mm/Hg, heart rate 96 beats /min, body temprature 37°C, respirotary rate 18 breaths/min. Phsical examination was remarkable for severe right leg tenderness, swelling and pain.Laboratory analysis showed white blood cell count: 46000/mm ³ platelet count: 42000/mm ³ serum creatinine: 5.05 mmol/L serum creatinin kinase: 3815 U/L. Urinalysis revealed myglobunuria.

The patient was resuscitated with intravenous fluids. Urine output decreased and in short time his body temprature rising to 39 ^o C. We initiated empiric intravenously meropenem and daptomycin antibiotherapy after taked samples for blood and ürine cultures. Superficial ultrasonography and computed tomography scan revealed air bubbles and microabscesses among muscles of thigh. Patient general condition had rapidly deteriorated. At this circumstances he had gone hemodialysis 2 hours. Then surgical debridman had done immediately, samples send for tissue culture, he entubeted and followed up in intensive care unit. Patient need hemodylasis in all follow-up. Blood culture and urine culture was negative but tissue culture grew streptococcus viridans. After surgical debridman, patient general condition went on critical. He was in septic shock and surgical team decided to amputete his leg. Although surgery was attempted the patient was extremeyl poor general condition and he went into respirotary arrest and died after 5 days following intramusculer injection.

Necrotizing fasciitis is a highly mortal infection of superficial fascia. Many etiologies cause necrotizing fasciitis and several possible sources are iatrogenic. Intramusculer injection is one of the rare etiologie of necrotizing fasciitis.The skin necrosis pathogenesis is lack but end artery damage is a reasonable explaining. Majority of necrotizing fasciitis causes polymicrobial but main bacterial group is A beta-hemolytic streptoccocus ( 1 , 3 ).

In a retrospective study revealed necrotizing fasciitis due to intramusculer injection has poorly prognosis, high amputation rates and high mortality. Also age, sex, extent of infection, diabetes, elevated serum creatinine and lactate levels are effective in prognosis (4, 5, 7).

In diagnosis x-ray, ultrasonography, ct-scan and mri have been used. In our case we used usg and ct-scan to diagnosis.Usg showed tissue edema and ct-scan showed air bubbles and microabscesses in tissue.

Rhabdomyolysis is characterized clinically by myalgias, red to brown urine due to myoglobinuria, and elevated serum muscle enzymes. Although clinical symtoms varies widely, the characteristic triad of complaints in rhabdomyolysis is muscle pain, weakness, and dark urine.In our case patient has eleveted creatinin kinase, thigh pain, elevated serum creatinin and myoglobunuira in urine. In past there are some cases rhabdomyolisis due to ıntramusculer injection ( 1 , 2 ). In a case report of injection drug user massive tissue necrosis rhabdmoyolsis and septic shock without fever had been reported ( 3 ). In our case patient had fever and tissue necrosis, differently In past there are some cases necrotizing fasciitis and rhabdomyolisis after intramusculer injection. In our case differently from past, both necrotizing fasciitis and acute kidney injury due to rhabdomyolisis occured concurently.

With this case report we point to a rare complication of intramusculer injections. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft tissue infection. Most important variable influencing mortality is time to surgical debridement. Clinician should suspect and be aware of severty in these cases. Early diagnosis and surgical intervention can be life-saving.