Getting an infection from flesh-eating bacteria is already rare. In the U.S., it happens only 500 to 1,000 times per year. But getting two infections, called “synchronous” necrotizing fasciitis is even rarer. Recently, a diabetic man with synchronous infections became the 34th person in the past 50 years to fall victim and go into a coma, according to a team of surgeons, who reported on the case in the Journal of Emergency Medicine.

Doctors first learned about the 44-year-old diabetic man when he sought treatment for a fever and back pain, which he described as severe. But both over-the-counter and prescribed painkillers weren’t working. Doctors prescribed oral antibiotics when the man’s right buttock became inflamed, however, these didn’t help him either. Within hours his left arm began to redden and become inflamed as well, and his condition worsened.

“It’s difficult to diagnose necrotizing fasciitis, because in the early stages, the signs and symptoms tend to be very wide, very general, [and] very easily confused with minor diseases and minor conditions,” study author Dr. Ilaria Tocco Tussardi, of the Institute of Plastic Surgery at the University Hospital of Padova, Italy, told LiveScience (you can see a photo of the mans arm here).

With attempts to treat the man unsuccessful, the surgeons put the patient through a computed tomography (CT) scan and found that the connective tissue that covers the muscle was “thickened” in both of the affected areas. They also found gas bubbles inside the gluteus muscle. They opened the affected areas and ran their fingers through the tissue — if it cut through as easily as a knife, then the man had necrotizing fasciitis, Tocco Tussardi told LiveScience.

For the patient, there was no indication of a cut, scrape, or wound that would have initiated the onset of the infection. Doctors said that having diabetes could have weakened his immune system, causing it to spread through the bloodstream.

With the man in critical condition, and unable to breathe, the doctors performed three surgeries to remove the infection. The first one was to confirm the diagnosis and begin removing the infected tissue. But during the next two, they found that it had affected almost his entire arm, and decided that it would have to be amputated in order to stop any further damage.

Even with proper treatment, victims of necrotizing fasciitis have a 25 percent risk of dying. But for diabetics and other immunosuppressed patients, this risk increases dramatically. The patient had survived the operations, but septic shock had compromised his heart, circulatory system, and respiratory system. He fell into a coma and was eventually moved to a facility for permanent coma patients.

Signs of necrotizing fasciitis include fever, chills; skin changes, such as ulcerations and blisters; and redness, swelling, and abnormal pain in areas that were cut. Still, “the physician who is seeing a patient with signs that might be compatible with necrotizing fasciitis doesn’t usually think about it as a first diagnostic option,” Tocco Tussardi said.

Source: Tocco, Lancerotto L, Pontini A, et al. “Synchronous” Multifocal Necrotizing Fasciitis. Journal of Emergency Medicine. 2013.