A 76-year-old woman with heart failure history, with no other relevant condition presented to the emergency department for evaluation of 6 hours of pain in right upper limb associated with small serous vesicles, without systemic symptoms. On physical examination, serous content vesicles with erythematous base, edema and intense pain on palpation were identified. No systemic inflammatory response or hemodynamic instability were reported. Antibiotic coverage was started, however, during the first 6 hours it progressed rapidly (Figure 1) with the presence of fever and ecchymosis, suspecting necrotizing fasciitis. Surgical debridement was performed. Leukocytosis, positive c-reactive protein and negative blood cultures were reported. Despite prompt treatment 48 hours later the patient dies. Necrotizing fasciitis is a deep tissue infection and it’s a surgical emergency, where early diagnosis and treatment are essential. (1, 2) Diabetes, cirrhosis and trauma are well known risk factors. (3) Findings like disproportionate pain, bullae or ecchymosis, tense edema, subcutaneous emphysema, systemic toxicity and rapid progression should rise suspicious about this entity. (4) The definitive diagnosis can only be made by surgical exploration and should not be delayed by diagnostic studies. (1) Despite early treatment mortality rises upon 30% mainly associated with dissemination, comorbidities, extreme ages and delay in treatment. (2)