 |
|
|
|
|
|
|
|
|
 |
 |
 |
 |
 |
 |
 |
 |
|
Background
This is a rare and rapidly progressive infeaction of the superficial fascia and subcutaneous tissue. Several bacteria are known to cause this disease and frequently, cultures may reveal a mixed flora. Recently, this disease has the popular name, dubbed by the media, as flesh-eating bacteria disease.
OUTLINE
EPIDEMIOLOGY CHARACTERIZATION SYNONYMS Gangrenous erysipelas
Hospital gangrene
Acute cutaneous gangrene
Nonclostridial crepitant cellulitis
Streptococcal gangrene
Synergistic necrotizing cellulitis
Meleney cellulitisINCIDENCE Rare
DISEASE ASSOCIATIONS CHARACTERIZATION VARICELLA
Group A streptococcal necrotizing fasciitis complicating primary varicella: a series of fourteen patients.
Brogan TV, Nizet V, Waldhausen JH, Rubens CE, Clarke WR.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital and Medical Center, University of Washington, School of Medicine, Seattle 98105, USA.
Pediatr Infect Dis J 1995 Jul;14(7):588-94 Abstract quote We retrospectively reviewed the clinical course of group A Streptococcus necrotizing fasciitis complicating primary varicella in children admitted to Children's Hospital and Medical Center, Seattle, WA, during a 18-month period.
The potential benefit of various therapeutic interventions was examined. Fourteen children ages 6 months to 10 years were treated for group A Streptococcus necrotizing fasciitis as a complication of primary varicella. Eight patients experienced a delay in initial diagnosis as a result of nonspecific, early clinical findings of necrotizing fasciitis. Each patient underwent surgical exploration with fasciotomies and debridement. Initial antibiotic therapy was broad spectrum and included clindamycin. Hyperbaric oxygen therapy for as many as 6 treatments was used as adjunctively therapy in 12 patients, with subjective benefit in 6 patients. All 14 patients were discharged home with good function and no long term sequelae.
This potentially fatal bacterial infection of the deep fascial layers requires early recognition by primary care physicians and an intensive, multidisciplinary therapeutic approach, including thorough surgical debridement and appropriate antibiotic therapy.
A case-control study of necrotizing fasciitis during primary varicella.Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE.
Department of Pediatrics, Children's Hospital and Regional Medical Center/University of Washington, Seattle 98105-0371, USA.
Pediatrics 1999 Apr;103(4 Pt 1):783-90 Abstract quote OBJECTIVE: An increase in the incidence of necrotizing fasciitis (NF) occurring in previously healthy children with primary varicella was noted in the Washington State area between December 1993 and June 1995. Our objective was to investigate ibuprofen use and other risk factors for NF in the setting of primary varicella.
METHODS: Case-control study. Demographic information, clinical parameters, and potential risk factors for NF were compared for cases and controls. Cases of NF were analyzed to identify potential determinants of NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome. Multivariate logistic regression was used to evaluate the association between ibuprofen use and NF. A case was defined as a child with NF hospitalized within 3 weeks of primary varicella (n = 19). Controls were children hospitalized with a soft tissue infection other than NF within 3 weeks of primary varicella (n = 29). Odds ratios (ORs) of ibuprofen, as well as other potential risk factors were evaluated. In addition, demographic and clinical data as well as other potential risk factors were compared between cases and controls.
RESULTS: After controlling for gender, age, and group A streptococcus isolation, cases were more likely than controls to have used ibuprofen before hospitalization (OR, 11. 5; 95% confidence interval, 1.4 to 96.9). In most children, ibuprofen was initiated after the onset of symptoms of secondary infection. Children with NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome were more likely than children with uncomplicated NF to have used ibuprofen (OR, 16.0; 95% confidence interval, 1.0 to 825.0). Children with complicated NF also had a higher mean maximum temperature (40.9 degrees C vs 39.3 degrees C), and a longer mean duration of secondary symptoms (1.7 days vs 0.6 days) before admission than children with uncomplicated NF.
CONCLUSION: Ibuprofen use was associated with NF in the setting of primary varicella. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of NF and its complications during varicella.
STREPTOCOCCUS GROUP A
Fulminant group A streptococcal necrotizing fasciitis: clinical and pathologic findings in 7 patients.Dahl PR, Perniciaro C, Holmkvist KA, O'Connor MI, Gibson LE.
Department of Dermatology, Mayo Clinic, Rochester, USA.
J Am Acad Dermatol 2002 Oct;47(4):489-92 Abstract quote BACKGROUND: Necrotizing fasciitis is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Examination of deep incisional biopsy specimens can provide prompt diagnosis and improve survival. We describe 7 patients with necrotizing fasciitis caused by group A Streptococcus species.
OBJECTIVE: Our purpose was to describe the unique dermatopathology and clinical features in 7 patients with necrotizing fasciitis caused by group A Streptococcus.
METHODS: We conducted a retrospective review.
RESULTS: The average age of the patients was 47 years. Fasciitis occurred on an extremity in all cases. All 5 patients with streptococcal toxic shock syndrome died of their disease. The histopathologic findings from early fascial disease revealed superficial epidermal necrosis, edema, and hemorrhage with few inflammatory cells, whereas clinically advanced, necrotic skin lesions revealed diffuse necrosis, thrombosis, neutrophilia, and numerous gram-positive diplococci.
CONCLUSIONS: Patients with clinical features of necrotizing fasciitis should have a deep incisional biopsy specimen obtained from the central area of ecchymotic, necrotic plaques to confirm the diagnosis. Immediate surgical intervention is necessary to reduce the morbidity and mortality rates associated with necrotizing fasciitis.
PATHOGENESIS CHARACTERIZATION POLYMICROBIAL
Necrotizing soft-tissue infections.Fontes RA Jr, Ogilvie CM, Miclau T.
Department of Orthopedic Surgery, San Francisco General Hospital, CA 94110, USA
J Am Acad Orthop Surg 2000 May-Jun;8(3):151-8 Abstract quote Necrotizing fasciitis is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen, or perineum. Necrotizing fasciitis typically begins with trauma; however, the inciting event may be as seemingly innocuous as a simple contusion, minor burn, or insect bite.
Differentiating necrotizing infections from common soft-tissue infections, such as cellulitis and impetigo, is both challenging and critically important. A high degree of suspicion may be the most important aid in early diagnosis. Prompt diagnosis is imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death. Although group A Streptococcus is the most common bacterial isolate, a polymicrobial infection with a variety of Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is more common. Orthopaedic surgeons are often the first physicians to evaluate patients with such infections and therefore need to be familiar with this potentially devastating disease and its management.
Prompt diagnosis, immediate administration of broad-spectrum antibiotic coverage, and emergent aggressive surgical debridement of all compromised tissues are critical to reduce the morbidity and mortality of these rapidly progressing infections.
LABORATORY/RADIOLOGIC/
OTHER TESTSCHARACTERIZATION RADIOLOGIC
Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management.Becker M, Zbaren P, Hermans R, Becker CD, Marchal F, Kurt AM, Marre S, Rufenacht DA, Terrier F.
Department of Radiology, University Hospital of Geneva, Switzerland.
Radiology 1997 Feb;202(2):471-6 Abstract quote PURPOSE: To determine the characteristic diagnostic features of necrotizing fasciitis and to evaluate the role of computed tomography (CT) in its management.
MATERIALS AND METHODS: Fourteen patients with surgically proved necrotizing fasciitis of the extracranial head and neck were examined with contrast material-enhanced CT. Clinical, radiologic, surgical, pathologic, and anatomic findings at admission and after initial treatment were analyzed retrospectively.
RESULTS: Constant CT features of necrotizing fasciitis were diffuse thickening and infiltration of the cutis and subcutis (cellulitis); diffuse enhancement and/or thickening of the superficial and deep cervical fasciae (fasciitis); enhancement and thickening of the platysma, sternocleidomastoid muscle, or strap muscles (myositis); and fluid collections in multiple neck compartments. Inconstant CT features included gas collections, mediastinitis, and pleural or pericardial effusions. All patients underwent extensive surgical debridement. Follow-up CT scans in 11 patients revealed clinically unsuspected progression of the inflammatory process in previously unaffected areas, a finding that warranted additional surgery in nine patients. Twelve patients survived, and two patients died of septic shock and aspiration pneumonia despite intensive surgical and medical treatment.
CONCLUSION: Early recognition of necrotizing fasciitis with CT enables appropriate surgical treatment. CT may also be a useful guide in further patient treatment after initial surgical debridement.
Necrotizing fasciitis: CT characteristics.Wysoki MG, Santora TA, Shah RM, Friedman AC.
Department of Radiologic Sciences, Allegheny University Hospital, Philadelphia, PA 19129, USA.
Radiology 1997 Jun;203(3):859-63 Abstract quote PURPOSE: To establish computed tomographic (CT) criteria for the diagnosis of necrotizing fasciitis.
MATERIALS AND METHODS: Twenty CT scans in 20 patients with pathologically proved necrotizing fasciitis were reviewed retrospectively for fascial thickening, fat infiltration, focal fluid collection, soft-tissue gas, muscle involvement, and intra-abdominal extension; the findings were correlated with clinical factors, including associated illnesses, disease site, treatment, and outcome.
RESULTS: Average patient age was 57.8 years; there were 13 men and seven women. Four patients (20%) died. Asymmetric fascial thickening and fat stranding were seen in 16 patients (80%). Gas tracking along fascial planes was present in 11 patients (55%), and abscesses were found in seven patients (35%). Infection sites were scrotum (n = 6), a lower extremity (n = 4), perineum (n = 4), neck (n = 2), back (n = 2), arm (n = 1), and abdomen (n = 1). Underlying illness (n = 17) was diabetes in 10 patients (50%), alcoholism in three (15%), chronic renal failure in two (10%), and drug abuse in two (10%).
CONCLUSION: CT criteria of asymmetric fascial thickening and gas are valuable in assessing suspected necrotizing fasciitis. CT also can provide information on coexistent deep collections.
LABORATORY MARKERS Value of standard laboratory tests for the early recognition of group A beta-hemolytic streptococcal necrotizing fasciitis.
Simonart T, Simonart JM, Derdelinckx I, De Dobbeleer G, Verleysen A, Verraes S, de Maubeuge J, Van Vooren JP, Naeyaert JM, de la Brassine M, Peetermans WE, Heenen M
Clin Infect Dis 2001 Jan;32(1):E9-12 Abstract quote The laboratory data for 17 patients with group A beta-hemolytic streptococcal necrotizing fasciitis (GAS NF) were compared with data for 145 patients hospitalized for cellulitis during the same period.
Admission values of C-reactive protein and creatine kinase were higher for patients in the group with GAS NF than for patients in the group with cellulitis (P<.001), suggesting that standard laboratory tests may be useful for the early differential diagnosis of GAS NF and cellulitis.
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION GENERAL VARIANTS HEAD AND NECK
Necrotizing fasciitis of the head and neck: an analysis of 47 cases.Lin C, Yeh FL, Lin JT, Ma H, Hwang CH, Shen BH, Fang RH.
Division of Plastic and Reconstructive Surgery, Veterans General Hospital-Taipei and the National Yang-Ming University, Taiwan, People's Republic of China.
Plast Reconstr Surg 2001 Jun;107(7):1684-93 Abstract quote Necrotizing fasciitis is an overwhelming infection common to the perineum, abdominal wall, and extremities. It is a surgical emergency related to a high mortality rate that is more often seen in elderly and immunocompromised patients. Necrotizing fasciitis occurs uncommonly in the head and neck region.
Over a 12-year period, 47 cases of necrotizing fasciitis of the head and neck region were collected at this hospital. The demographics, predisposing factors, clinical presentation and courses, management, complications, and outcomes were analyzed. The cases were divided into two groups: survivors and nonsurvivors. Statistical comparisons were made of the parameters age, gender, smoking or drinking habit, underlying medical problems, laboratory data, and treatments used. Forty-two patients (89.4 percent) had associated systemic disease; most of these patients had diabetes (72.3 percent). The clinical manifestations are nonspecific but are often typical for diagnosis. The necessity of computed tomographic scans is not conclusive in this study. Presentation of septic shock (p = 0.004) and association with underlying malignancy (p = 0.03) were the only statistically significant factors that led to a poor prognosis.
The cornerstones of proper management include early diagnosis, aggressive surgical debridement, broad-spectrum antibiotics, and intensive supportive care.
Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases.Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, Hung-An C.
Department of Dentistry, National Cheng Kung University Hospital, Tainan, Taiwan ROC.
J Oral Maxillofac Surg 2000 Dec;58(12):1347-52 Abstract quote PURPOSE: Although most cases of cervical necrotizing fasciitis (CNF) are odontogenic in origin, reports of this disease in the dental literature are sparse. The purpose of this study was to review the cases treated on our service, and to analyze the features of this disease and the responses to management, to supplement the understanding of this relatively rare and life-threatening disease.
PATIENTS AND METHODS: All cases of infection admitted to the OMS service in a period of 10.5 years were studied retrospectively. The diagnosis of CNF was established by the findings on surgical exploration and histologic examination. The patients' age, sex, medical status, causes of the infection, bacteriology, computed tomography scan findings, surgical interventions, complications, survival, and other clinical parameters were reviewed.
RESULTS: A total of 422 cases of infection were admitted, and 11 cases of cervical necrotizing fasciitis were found. The incidence of CNF was 2.6% among the infections hospitalized on the OMS service. There were 7 male and 4 female patients. Eight patients were older than 60 years of age. Seven patients had immunocompromising conditions, including diabetes mellitus in 4, concurrent administration of steroid in 2, uremia in 1, and a thymus carcinoma in 1. All patients showed parapharyngeal space involvement; four also showed retropharyngeal space involvement. Gas was found in the computed tomography scan in 6 patients, extending to cranial base in 3 of them. Anaerobes were isolated in 73% of the infections, whereas Streptococcus species were uniformly present. All patients received 1 or more debridements. Major complications occurred in 4 patients, including mediastinitis in 4, septic shock in 2, lung empyema in 1, pleural effusion in 2, and pericardial effusion in 1. All major complications developed in the immunocompromised patients, leading to 2 deaths.
CONCLUSION: The mortality rate in this study was 18%. Early surgical debridement, intensive medical care, and a multidisciplinary approach are advocated in the management of CNF.
PEDIATRIC
Necrotizing fasciitis in childhood.Murphy JJ, Granger R, Blair GK, Miller GG, Fraser GC, Magee JF.
Department of Surgery, British Columbia's Children's Hospital, Vancouver.
J Pediatr Surg 1995 Aug;30(8):1131-4 Abstract quote Necrotizing fasciitis is a rare entity in the pediatric population. Five cases of this soft tissue infection were treated at the authors' institution between January and December 1993. Three of the children were profoundly neutropenic secondary to chemotherapy. All five were treated with aggressive surgical debridement, frequent dressing changes, broad-spectrum antibiotics, and nutritional support. In addition, the patients with neutropenia received a combination of granulocyte-colony stimulating factor and granulocyte transfusions. One child died of overwhelming sepsis and bone marrow graft failure. The others eventually made a complete recovery.
Necrotizing fasciitis may be becoming a more common problem in children. Aggressive chemotherapeutic regimens and more frequent use of bone marrow transplantation could be a factor in this. Early diagnosis and aggressive surgical therapy is critical. However, mortality may be significant, especially in patients with neutropenia. Leukocyte response to the infection may be a prognostic marker.
Pseudomonas and enteric gram-negative organisms are seen frequently in immunocompromised children with necrotizing fasciitis. Antimicrobial selection should supply adequate coverage of these organisms.
Necrotizing fasciitis in children: prompt recognition and aggressive therapy improve survival.Moss RL, Musemeche CA, Kosloske AM.
University of New Mexico, School of Medicine, Department of Surgery, Albuquerque 87131-5341, USA.
J Pediatr Surg 1996 Aug;31(8):1142-6 Abstract quote Necrotizing fasciitis (NF) is a bacterial infection of the soft tissues with a fulminant course and a high mortality rate.
The authors performed a review to define the diagnosis, bacteriology, and management of NF in the pediatric population. This report of 20 cases treated over 18 years represents the largest reported pediatric experience. These infections were attributable to secondary infection of varicella lesions (5), omphalitis (4), extremity lesions (4), perineal infections (3), head and neck lesions (2), inguinal herniorrhapy (1), and breast abscess (1). Nineteen of the 20 children were healthy, without chronic disease or immunosuppression. All patients presented with an altered sensorium and signs of systemic toxicity. Fever (40%), tachycardia (70%), and abnormal white blood cell count (50%) were not uniformly present. There was marked tissue edema in all patients, with a characteristic peau d'orange appearance in 18. Seven infections were caused by streptococcus; the remainder were polymicrobial, involving multiple aerobes and anaerobes. Initial gram stain was of limited utility; in 14 of 19 cases the result was negative or showed only one of many organisms present. Fifteen patients survived and five died. All survivors underwent aggressive surgical debridement within 3 hours of admission. The survivors required of a mean of 3.8 operations. Fascial excision of up to 35% of total body surface area was required. One patient required amputation, two had colostomies, and six required extensive skin grafting for reconstruction. All five patients who died had delayed initial management.
Conclusion: NF is a serious cause of death in previously healthy children. The diagnosis should be considered in the presence of any soft tissue infection presenting with signs of toxicity and marked wound edema, even in the absence of fever or abnormal white blood cell count. Immediate surgical debridement and coverage with penicillin, an aminoglycoside, and metronidazole are essential. Subsequent changes in antibiotics should be based on culture data because gram stain results are not reliable. More than one operation is required in almost all cases.
Staphylococcal necrotizing fasciitis in the mammary region in childhood: a report of five cases.Bodemer C, Panhans A, Chretien-Marquet B, Cloup M, Pellerin D, de Prost Y.
Department of Dermatology, Hopital Necker Enfants-Malades, Paris, France.
J Pediatr 1997 Sep;131(3):466-9 Abstract quote OBJECTIVE: Necrotizing fasciitis is a highly lethal soft tissue infection rarely reported in childhood. The initiating site is usually a local trauma or a surgical wound. We observed five cases of necrotizing fasciitis the initiating site for which was the mammary region and discuss their management.
STUDY DESIGN: We describe these five patients and review the clinical characteristics of their presentation.
RESULTS: Staphylococcal necrotizing fasciitis was observed in the mammary region in all five cases. Four children were newborn infants with a mammitis preceding the onset of necrotizing fasciitis. Surgical debridement was done only after the fourth day from onset of illness. All children were discharged in good condition after 1 month. Two have been followed until puberty, with destruction of the mammary gland in one case and good development in the other one.
CONCLUSION: Mammitis may be the initiating event for necrotizing fasciitis in neonates. Necrotizing fasciitis is a life-threatening disease; patients require early intensive care, parenteral antibiotic therapy, and surgical debridement. In a few instances surgery can be carefully delayed until the necrotic area is more delineated if the condition is diagnosed early during disease evolution and appropriate treatment is instituted in intensive care units.
Necrotizing fasciitis in infancy: an uncommon setting and a prognostic disadvantage.Abbott RE, Marcus JR, Few JW, Farkas AM, Jona J.
The Department of General Surgery (Pediatrics) Northwestern University Medical School, Evanston Hospital, IL, USA.
J Pediatr Surg 1999 Sep;34(9):1432-4 Abstract quote Necrotizing fasciitis is a potentially fatal, progressive soft tissue infection that typically occurs in adults, and only rarely occurs in infants. Although adults in whom necrotizing fasciitis develops are commonly diabetic, malnourished, or otherwise immunocompromised, infants in whom the disease develops are typically healthy and without clear predisposing factors.
Herein, however, the authors report the case of an infant with compromised immunity secondary to the manifestations and treatment of panhypopituitarism, in whom postoperative necrotizing fasciitis developed after bilateral inguinal herniorrhaphy. The diagnosis, pathological mechanism, and treatment of necrotizing fasciitis are reviewed and the distinguishing features in infants are highlighted. The combination of a low incidence and very high mortality rate associated with necrotizing fasciitis in this subgroup strengthens the need for hypercritical suspicion.
Early diagnosis and the prompt initiation of surgical treatment are the most essential means to improve on the prognosis for necrotizing fasciitis in infants.
Necrotizing fasciitis: report of 39 pediatric cases.Fustes-Morales A, Gutierrez-Castrellon P, Duran-Mckinster C, Orozco-Covarrubias L, Tamayo-Sanchez L, Ruiz-Maldonado R.
Department of Pediatric Dermatology, National Institute of Pediatrics, Mexico City, Mexico.
Arch Dermatol 2002 Jul;138(7):893-9 Abstract quote BACKGROUND: Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection. General features and risk factors for fatal outcome in children are not well known.
OBJECTIVE: To characterize the features of NF in children and the risk factors for fatal outcome.
DESIGN: Retrospective, comparative, observational, and longitudinal trial.
SETTING: Dermatology department of a tertiary care pediatric hospital.
PATIENTS: All patients with clinical and/or histopathological diagnosis of NF seen from January 1, 1971, through December 31, 2000.
MAIN OUTCOME VARIABLES: Incidence, age, sex, number and location of lesions, preexisting conditions, initiating factors, clinical and laboratory features, diagnosis at admission, treatment, evolution, sequelae, and risk factors for fatal outcome.
RESULTS: We examined 39 patients with NF (0.018% of all hospitalized patients). Twenty-one patients (54%) were boys. Mean age was 4.4 years. Single lesions were seen in 30 (77%) of patients, with 21(54%) in extremities. The most frequent preexisting condition was malnutrition in 14 patients (36%). The most frequent initiating factor was varicella in 13 patients (33%). Diagnosis of NF at admission was made in 11 patients (28%). Bacterial isolations in 24 patients (62%) were polymicrobial in 17 (71%). Pseudomonas aeruginosa was the most frequently isolated bacteria; gram-negative isolates, the most frequently associated bacteria. Complications were present in 33 patients (85%), mortality in 7 (18%), and sequelae in 29 (91%) of 32 surviving patients. The significant risk factor related to a fatal outcome was immunosuppression.
CONCLUSIONS: Necrotizing fasciitis in children is frequently misdiagnosed, and several features differ from those of NF in adults. Immunosuppression was the main factor related to death. Early surgical debridement and antibiotics were the most important therapeutic measures.
VULVAR
Postpartum and vulvar necrotizing fasciitis. Early clinical diagnosis and histopathologic correlation.Schorge JO, Granter SR, Lerner LH, Feldman S.
Department of Obstetrics, Gynecology, Brigham and Women's Hospital, Boston, Massachusetts 02115. USA.
J Reprod Med 1998 Jul;43(7):586-90 Abstract quote OBJECTIVE: To review the clinical course and correlate histopathologic findings of obstetrics and gynecology patients with necrotizing fasciitis
STUDY DESIGN: Seven-teen patients with postpartum or vulvar necrotizing fasciitis were identified from 1981 to 1996. Medical records were retrospectively reviewed. Information was available for all patients until death or discharge from the hospital. Histopathologic material on 15 patients was available for review.
RESULTS: Five postpartum patients were diagnosed and surgically debrided one to nine days after cesarean delivery, with no mortality. Twelve patients with vulvar necrotizing fasciitis were diagnosed and surgically debrided <1-10 days after presentation to a physician, with three deaths (25%). On histopathologic review, all cases had prominent lobular and septal panniculitis. Thirteen cases had histologic evidence of fasciitis.
CONCLUSION: Early diagnosis and aggressive surgical debridement in patients with postpartum and vulvar necrotizing fasciitis may improve the outcome. Histopathologic findings are remarkably consistent and may help to confirm the diagnosis.
HISTOLOGICAL TYPES CHARACTERIZATION GENERAL Extensive necrosis of soft tissue
SPECIAL STAINS/IMMUNOPEROXIDASE/
OTHERCHARACTERIZATION SPECIAL STAINS Gram stain
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES GENERAL
A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection.Wall DB, Klein SR, Black S, de Virgilio C.
Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
J Am Coll Surg 2000 Sep;191(3):227-31 Abstract quote BACKGROUND: Necrotizing fasciitis (NF) has been associated with certain "hard" clinical signs (hypotension, crepitance, skin necrosis, bullae, and gas on x-ray), but these may not always be present. Using results of a previous study, we developed a simple model to serve as an adjunctive tool in diagnosing NF (admission WBC > 15.4 x 10(9)/L or serum sodium [Na] < 135 mmol/L) and determined its ability to distinguish between patients with NF and nonnecrotizing soft tissue infection (non-NF).
STUDY DESIGN: A retrospective review was conducted of consecutive NF (n=31) and non-NF patients (n= 328) treated at a single institution during an 11-month period. Comparison of admission vital signs, physical examination findings, radiology results, and number of patients meeting model criteria was performed.
RESULTS: Ninety percent of NF patients and 24% of non-NF patients met model criteria (p < 0.0001). The model had a sensitivity of 90%, a specificity of 76%, a positive predictive value of 26%, and a negative predictive value of 99% for diagnosing NF. Nineteen (61%) NF patients had no "hard" signs of NF; the model correctly classified 18 (95%) of these patients.
CONCLUSIONS: Admission WBC greater than 15.4 x 10(9)/L and serum Na less than 135mmol/L are useful parameters that may help to distinguish NF from non-NF infection, particularly when classic "hard" signs of NF are absent.
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSTIC FACTORS
Clinical manifestations, microbiology and prognosis of 42 patients with necrotizing fasciitis.Hung CC, Chang SC, Lin SF, Fang CT, Chen YC, Hsieh WC.
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.
J Formos Med Assoc 1996 Dec;95(12):917-22 Abstract quote Forty-two cases of necrotizing fasciitis (NF) surgically confirmed between January 1991 and October 1995 were retrospectively reviewed.
This was done in order to describe the underlying diseases, clinical presentations, etiology and outcome of NF and to assess the prognostic value of a simplified severity scoring system. The system scores changes in consciousness status, body temperature, blood pressure and ventilation to determine the likely outcome of NF. Twenty-five men and 17 women with a median age of 51 years (range, 17-87 yr) were included. Diabetes mellitus (57.1%) was the most common underlying disease. The mean duration of symptoms before admission was 8 days (median, 7 d; range, 1-30 d). The extremities (66.7%) were most commonly involved. Initial clinical presentations within 48 hours of admission included skin erythema and swelling at the affected site (97.6%), pyrexia (61.9%), hypotension (33.3%), altered consciousness (28.6%), bullous lesions (26.2%) and crepitus (9.5%).
The mean number of isolated pathogens was 1.8 (range, 0-6). Eight patients had mixed aerobic and anaerobic infections. The attributable case fatality rate was 23.8%. Higher severity score (> or = 4 points), hypotension, altered consciousness, respiratory failure requiring ventilator support, elevation of alanine aminotransferase levels > twofold, serum creatinine > 177 mumol/L, thrombocytopenia (< 100 x 10(9)/L), and worsening symptoms and signs within 48 hours of admission were associated with higher fatality rates (p < 0.05).
Clinical experience with 20 cases of group A streptococcus necrotizing fasciitis and myonecrosis: 1995 to 1997.Haywood CT, McGeer A, Low DE.
Department of Plastic Surgery at the Toronto Hospital, Ontario, Canada.
Plast Reconstr Surg 1999 May;103(6):1567-73 Abstract quote During the last decade, there has been a dramatic resurgence of necrotizing fasciitis caused by group A streptococcal disease with mortality rates from 43 to 58 percent.
The objective of this study was to review recent clinical experience regarding the diagnosis and management of streptococcal necrotizing fasciitis, including the use of high-dose intravenous immunoglobulin. From April of 1995 to December of 1997, 20 consecutive adult patients meeting clinical and/or histopathologic criteria for streptococcal necrotizing fasciitis were identified in the Toronto area. Of those, 16 (80 percent) were treated with > or = 1 mg/kg of intravenous immunoglobulin. Fourteen men and 6 women ranging in age from 33 to 89 were identified (median age 55.5 years). Sixteen patients (80 percent) with necrotizing fasciitis survived. Ten patients had necrotizing fasciitis alone, none of whom died. Eight patients were identified with myonecrosis and necrotizing fasciitis, three of whom died.
The case fatality rate of all patients who received intravenous immunoglobulin was 19 percent (3 of 16) and was not statistically significantly different (p = 1.0) from the case fatality rate of 25 percent (1 of 4) in those patients who did not receive intravenous immunoglobulin. A total of seven patients (35 percent) were diagnosed as having a cause for their signs and symptoms other than necrotizing fasciitis when they initially presented to a physician; one of these patients died. There was no correlation with the M type or the streptococcal pyrogenic exotoxin genotype and outcome.
Necrotizing fasciitis: a 10-year retrospective study of cases in a single university hospital in Oman.Rangaswamy M.
Department of Surgery, P.O. Box: 38, Sultan Qaboos University Hospital, Postal Code: 123, Muscat, Oman.
Acta Trop 2001 Oct 22;80(2):169-75 Abstract quote OBJECTIVE: (1) To study the clinical profile of all cases of necrotizing fasciitis (NF) diagnosed in a university hospital in Oman. (2) To evolve a strategy for early diagnosis.
PATIENTS AND METHODS: The inpatient records of the Sultan Qaboos University hospital from 1990-99 were searched for the words "fasciitis", "necrosis" or "gangrene" and cases of NF (defined as a soft tissue infection characterized by widespread necrosis of the subcutaneous tissues confirmed at surgery or pathology or both) were selected and analyzed. Cases with necrosis due to other obvious causes were excluded.
RESULTS: Of the seven cases of NF (hospital incidence-8.4/10(5)), there were three post-operative, three spontaneous and one post-traumatic. Sites involved: upper limb (1), lower limb (2), abdomen (2), gluteal (1), and breasts (1). The median age was 50 years (range 21-85) and the male:female ratio was 4:3. All patients had local pain out of proportion to the signs and six had fever. Hypotension, liver or kidney dysfunction or coagulopathy were seen in four and a drop in haemoglobin was seen in six. In none was NF even considered by the referring or admitting physician, diagnosis being delayed by 2-10 days. In four cases a diagnostic incision under local anesthesia revealed the correct diagnosis. At surgery, extensive fascial and fat necrosis were seen in all, but only two had myonecrosis. The commonest isolate was beta-hemolytic group D streptococcus (4/7). Blood and tissue were positive for beta-hemolytic group A streptococci in one fatal case. Mean hospital stay was 54.5 days (11-134), mean surgical procedures were 2.3 per case, two required ICU admission with one death.
CONCLUSION: NF is a rare but serious bacterial disease that is often incorrectly diagnosed. Unexplained severe local pain, deep tenderness without impressive local signs, fall in haemoglobin, organ system dysfunction and constitutional upsets were regular features. A high index of suspicion and immediate direct inspection of the fascia facilitates an early diagnosis.
Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients.Childers BJ, Potyondy LD, Nachreiner R, Rogers FR, Childers ER, Oberg KC, Hendricks DL, Hardesty RA.
Department of Surgery, Loma Linda University School of Medicine, Loma Linda Medical School, California 92350, USA.
Am Surg 2002 Feb;68(2):109-16 Abstract quote This review was prompted by continued public and professional interest of necrotizing fasciitis as well as worldwide increases in the incidence of streptococcal invasive infections.
Our objective was to outline the clinical course of necrotizing fasciitis and delineate factors relating to mortality among 163 diagnosed patients. Over 14 years patients diagnosed with necrotizing fasciitis were reviewed for patient history, comorbid conditions, and progression of clinical course. A logistic regression model was used to identify factors increasing mortality risk among necrotizing fasciitis patients. Nearly 17 per cent of the patients showed no identifiable antecedent trauma. Seventy-one per cent of tissue culture-positive patients (145) had multibacterial infections. Although no streptococcal species were recovered from one-third of these culture-positive patients there was an increase in mortality noted with beta-Streptococcus infections.
Ninety-six per cent of the patient deaths were correlated with variables organized into the following categories: 1) patient history (intravenous drug use and age <1 or >60 years), 2) comorbid conditions (cancer, renal disease, and congestive heart failure), 3) characteristics of clinical course (trunk involvement, positive blood cultures, peripheral vascular disease, and positive cultures for beta-streptococcus or anaerobic bacteria), and 4) quantitative timeline of clinical course (time: injury to diagnosis, diagnosis to treatment). Mortality is correlated to patient history, comorbid conditions, and progression of clinical course.
Necrotizing fasciitis can occur idiopathically and is generally a polymicrobial infection that sometimes occurs in the absence of streptococci. Clearly the mortality and morbidity associated with necrotizing fasciitis can be decreased with clinical awareness, early diagnosis, adequate surgical debridement, and intensive supportive care.
TREATMENT PENICILLIN RESISTANT
Necrotizing fasciitis due to penicillin-resistant Streptococcus pneumoniae: case report and review of the literature.Ballon-Landa GR, Gherardi G, Beall B, Krosner S, Nizet V.
Department of Medicine, Scripps Mercy Hospital, San Diego, CA, USA.
J Infect 2001 May;42(4):272-7 Abstract quote Necrotizing fasciitis (NF) is a life-threatening infection involving rapid necrosis of subcutaneous and fascial tissues. Streptococcus pneumoniae (SPN) soft tissue infection is exceedingly uncommon, reported primarily in patients with immunosuppression or other underlying conditions.
We report a case of NF and septic shock in a healthy 32-year-old man, whose only predisposing factor was antecedent blunt trauma. Pathological examination and culture of the extensive tissue debridement were positive only for SPN. The serotype 9V isolate was penicillin (PCN)-resistant (MIC=2.0), and closely-related by pulse field gel electrophoresis and multilocus fingerprinting to clone France 9V-3, an important genetic reservoir for increasing PCN-resistance worldwide.
This unique case has implications for our pathogenic under-standing and empiric management of NF.
Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Weedon D. Weedon's Skin Pathology. Churchill Livingstone. 1997.
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.
Last Updated 10/25/2002
Send
mail to psdermpath@earthlink.net with
questions or comments about this web site.
Copyright © 2002
The Doctor's Doctor