br Discussion Several organ systems can be

Discussion Several organ systems can be affected by marathon running. Most problems that have been mentioned involve the musculoskeletal, gastrointestinal, cardiac, renal, and pulmonary systems, and also include electrolyte and fluid imbalance, but seldom soft-tissue infections. Because marathon has become a popular sport, many medical issues are discussed to prevent morbidity and mortality. Of marathon participants, 2–8% will seek medical attention during or immediately after completing the race. Some of the problems are self-limited and easily solved, but some are life threatening, such as severe dehydration, hyponatremia, heat stroke, acute renal failure, acute coronary syndrome, and ischemic colitis. Environmental factors are also proved to play an important role in causing the runners\' needs for medical service. However, soft-tissue infections in marathon races were seldom discussed in the past, and in fact no medical articles were found after our PubMed search using the keywords “marathon” and “soft tissue infection.” In our opinion, most marathon runners have ignored the skin wounds, regarding them as nothing special. Marathon runners, however, should protect the developing bullae from being broken and care the wound, if necessary, with occlusive dressing. Ultramarathon, an even more strenuous tropisetron combined with a critical environment, may cause multiple skin breaks more frequently, and thus increase the possibility of soft-tissue infections. Combined with a dehydration status and relative ischemia of muscles caused by extreme straining, the condition might progress quickly to disseminated NSTI. In this unusual case, the patient noticed only common, small blisters on her feet initially. However, she collapsed on the last day after completing the contest because of severe sepsis caused by the NSTI and compartment syndrome of her legs. She subsequently underwent major amputation to control the infection. If the NSTI had been detected earlier by the runner or first-line medical service providers from the ultramarathon association, this kind of tragedy would have been avoided in this extremely healthy marathon runner. A lack of medical aids in the long critical race may cause further deteriorations. Thus, the importance of soft-tissue care should also be emphasized to the ultramarathon runners and ultramarathon association. NSTI is notorious for its rapid progression, extensive destruction of tissue, systemic toxicity, and even loss of limbs. NSTIs are clinically manifested by fulminant destruction of tissue, signs of systematic toxicity, and a high rate of mortality. There are an estimated 3.5 cases/100,000 persons with a case-fatality rate of 24% for NSTIs. Clinical manifestations include systemic findings, such as fever, tachycardia, and hypotension, and typical local signs and symptoms such as tense edema outside the involved skin, disproportionate pain, blisters/bullae, crepitus, and subcutaneous gas. Early recognition of NSTIs is important. Wong et al proposed a scoring system, termed the LRINEC score, which uses a combination of abnormal laboratory variables to calculate the risk of NSTIs (Table 3). If the score is 6 or higher, the conditions are highly predictive of NF, with a positive predictive rate of about 98% and a negative predictive value of about 96%. The score of our patient upon arrival to the local hospital was 8, which was indicative of NSTI. If NSTI is recognized, urgent and aggressive management is mandatory. The keys are to explore and remove the necrotic infected tissue, to restore tissue perfusion by hemodynamic support, and to administer broad-spectrum antimicrobial therapy. A delay in surgical diagnosis and debridement increases the rates of severe morbidity and mortality. To salvage the septic shock status in our case, immediate amputation of the infected limbs was decided. The tragedy suffered by our patient will be a valuable lesson to all the marathon runners, and the ultramarathon association should pay due medical attention to soft-tissue infections. Therefore, it is necessary to remind the runners of maintaining adequate hydration and instruct them not to ignore their skin lesions.