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Necrotizing Fasciitis

Necrotizing fasciitis is a rare, severe soft tissue infection typically by Group A streptococci, marked by necrosis of subcutaneous tissues with involvement of the fascia.


Presentation

During the first 2 days, the following clinical features are present:

Over the next 2 to 3 days, the clinical features include:

  • Edema
  • Formation of hemorrhagic bullae (fluid filled thin walled blisters)
  • Grey discoloration of the skin, indicating necrosis
  • Hardening of the subcutaneous tissues in the fascial planes
  • Crepitus due to production of gas in the tissues.
  • Gangrene
  • Intense pain that disappears soon due to destruction of pain nerve endings

After another 2 days, the following grave complications are seen:

Pain
  • We report a case of a previously healthy 68-year-old female who presented at our clinic with complaints of pain in her left calf since having experienced a very painful leg cramp 3 weeks prior.[ncbi.nlm.nih.gov]
  • After 10 years, elasticity of the skin and limb mobility are comparable to that in non-injured areas, and the patient is pain free.[ncbi.nlm.nih.gov]
  • A 39-year-old man who had received cadaveric renal transplantation (RT) 1 month previously presented with rash and pain on his left lower extremity.[ncbi.nlm.nih.gov]
  • Abstract Acute appendicitis is one of the most common causes of acute abdominal pain. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix.[ncbi.nlm.nih.gov]
  • Family physicians must have a high level of suspicion and low threshold for surgical referral when confronted with cases of pain, fever, and erythema.[ncbi.nlm.nih.gov]
Fever
  • A 37-year-old woman undergoing CAPD was admitted to the emergency room due to general weakness, fever, diarrhea, and abdominal pain.[ncbi.nlm.nih.gov]
  • In general, early symptoms were found to be fever, erythema, localized selling, and tenderness or pain. "Pain out of proportion" was not mentioned as a typical symptom. Fever and leukocytosis were more common in teenage patients.[ncbi.nlm.nih.gov]
  • Necrotizing fasciitis is a surgical emergency and should be considered by all emergency department acute care practitioners in cases of varicella in which fever is enduring and swelling or pain is disproportionate.[ncbi.nlm.nih.gov]
  • He presented with fever, dyspnea, and inflammatory signs bilaterally in the submandibular, submental, and superior thoracic regions as well as severe trismus.[ncbi.nlm.nih.gov]
  • Historically, group A streptococci have been responsible for deadly outbreaks of scarlet fever , rheumatic fever , and toxic shock syndrome .[britannica.com]
Swelling
  • A broad differential diagnosis in case of lower lip swelling is essential to avoid inappropriate treatment delay.[ncbi.nlm.nih.gov]
  • In this report, we present a case of CNF and descending mediastinitis from a non-odontogenic source in a patient presenting with neck swelling and odynophagia.[ncbi.nlm.nih.gov]
  • Periocular necrotizing fasciitis developed in a 12-month-old boy with swelling of both eyes and redness and a discharge from the left eye approximately 36 hours after blunt trauma.[ncbi.nlm.nih.gov]
  • Abstract We herein describe the case of a 27-day-old male infant who was brought to the emergency room for intermittent crying, and swelling of the left scrotum.[ncbi.nlm.nih.gov]
  • We present a 53-year-old diabetic woman who presented to the emergency room with several weeks of worsening breast and shoulder pain, swelling, and erythema.[ncbi.nlm.nih.gov]
Chills
  • He became sick two days earlier with malaise, chills and shivering. On admission he was hypotensive, anuric, with erythematous rash on his face, neck and chest, with acute renal failure and elevated creatine phosphokinase level.[ncbi.nlm.nih.gov]
  • Shortly thereafter she had chills and fever (temperature, 38.4 C [101.1 F]), and nafcillin therapy was begun.[nejm.org]
  • Necrotizing fasciitis is reported in half of patients with streptococcal toxic shock-like syndrome, or STSS. This illness is characterized by the presence of multiple symptoms: chills, fever or hypothermia and shock, confusion, vomiting, diarrhea, tachycardia[health.state.mn.us]
  • See a doctor right away if you have a fever, chills, or vomiting. Necrotizing fasciitis (neck-ro-tie-zing Fas-e-i-tis) is a serious bacterial skin infection that spreads quickly and kills the body’s soft tissue.[cdc.gov]
  • Blisters, ulcers, and black spots may be present on the skin and fever, the chills, being overly tired or throwing up are also symptoms of necrotizing fasciitis.[ctdermgroup.com]
Severe Pain
  • A 50-year-old homeless African-American man presented complaining of severe pain in his right lower extremity. A clinical workup was consistent with emphysematous pyomyositis and compartment syndrome; he received limb-saving surgical intervention.[ncbi.nlm.nih.gov]
  • One alerting sign is unusually severe pain - far greater than normal for a cut or wound - and painful lymph nodes.[healthcentral.com]
  • At the time of presentation, this diabetic patient was quite systemically ill (hypotensive with multi system organ failure) with severe pain at the site of infection.[meded.ucsd.edu]
  • Snapshot A 45-year-old woman presents to the emergency department for severe pain of her left foot. She states that this has never happened before. Her symptom is accompanied by fever and generalized myalgias.[medbullets.com]
  • pain and swelling, fever, and redness at the site of the injury.[health.state.mn.us]
Vomiting
  • Necrotizing fasciitis is reported in half of patients with streptococcal toxic shock-like syndrome, or STSS. This illness is characterized by the presence of multiple symptoms: chills, fever or hypothermia and shock, confusion, vomiting, diarrhea, tachycardia[health.state.mn.us]
  • See a doctor right away if you have a fever, chills, or vomiting. Necrotizing fasciitis (neck-ro-tie-zing Fas-e-i-tis) is a serious bacterial skin infection that spreads quickly and kills the body’s soft tissue.[cdc.gov]
  • Fever, chills, fatigue (tiredness), or vomiting may follow the initial wound or soreness. These confusing symptoms may delay a person from seeking medical attention. If you think you may have these symptoms after a wound, see a doctor right away.[web.archive.org]
  • Skin changes and pain can also be accompanied by fever, nausea, vomiting and diarrhoea. The infection can start in any part of the body but it most often affects the extremities.[prod.hopkins-abxguide.org]
  • Early on, you may notice: Discomfort near the injury Worsening of the pain that seems unusual for the type of injury Flu-like symptoms such as chills, vomiting, diarrhea, dehydration , general malaise, weakness, muscle pain, and fever Swollen, red, or[everydayhealth.com]
Hypotension
  • Cutaneous symptoms, oliguria, metabolic acidosis, acute renal failure, severe hypotension, and tachycardia occurred, and the patient was admitted to Intensive Care a few hours after initial admission.[ncbi.nlm.nih.gov]
  • On admission he was hypotensive, anuric, with erythematous rash on his face, neck and chest, with acute renal failure and elevated creatine phosphokinase level.[ncbi.nlm.nih.gov]
  • At the time of presentation, this diabetic patient was quite systemically ill (hypotensive with multi system organ failure) with severe pain at the site of infection.[meded.ucsd.edu]
  • ASSESSMENT Fever: can be hypothermic or hyperthermic Blood pressure: may be hypotensive; tissue destruction causes fluid volume loss Heart rate: tachycardia is present, especially in the presence of fever and hypotension Pain: initially a sudden onset[nurses.com]
  • […] fasciitis is reported in half of patients with streptococcal toxic shock-like syndrome, or STSS. This illness is characterized by the presence of multiple symptoms: chills, fever or hypothermia and shock, confusion, vomiting, diarrhea, tachycardia, hypotension[health.state.mn.us]
Tachycardia
  • Cutaneous symptoms, oliguria, metabolic acidosis, acute renal failure, severe hypotension, and tachycardia occurred, and the patient was admitted to Intensive Care a few hours after initial admission.[ncbi.nlm.nih.gov]
  • Necrotizing fasciitis is reported in half of patients with streptococcal toxic shock-like syndrome, or STSS. This illness is characterized by the presence of multiple symptoms: chills, fever or hypothermia and shock, confusion, vomiting, diarrhea, tachycardia[health.state.mn.us]
  • Systemic signs of necrotizing fasciitis, such as fever, tachycardia, and hypotension, are primarily due to the action of bacterial toxins. [14] [15] Referenced Articles[online.epocrates.com]
  • Although the following features can occur with cellulitis, they may instead suggest necrotizing fasciitis: Rapid progression Poor therapeutic response Blistering necrosis Cyanosis Extreme local tenderness High temperature Tachycardia Hypotension Altered[emedicine.com]
  • He initially complained of extreme thigh pain with erythema and swelling but rapidly developed bullae and worsening erythema over the affected area along with fever and tachycardia. A clinical photo is shown in Figure A.[orthobullets.com]
Blister
  • Don't delay first aid of even minor, non-infected wounds like blisters, scrapes, or any break in the skin.[web.archive.org]
  • Use soap and water to clean even small breaks in your skin, such as minor cuts or blisters. Cover the wounds with a sterile bandage. Wash your hands often with soap and water.[drugs.com]
  • It’s best not to wait to treat even minor scrapes, blisters or breaks in the skin with an antibacterial ointment and clean bandages. The chance of acquiring such an aggressive infection is rare, though some people are at higher risk.[newsweek.com]
  • Don’t delay first aid of even minor, non-infected wounds (like blisters, scrapes, or any break in the skin).[cdc.gov]
  • Blisters, ulcers, and black spots may be present on the skin and fever, the chills, being overly tired or throwing up are also symptoms of necrotizing fasciitis.[ctdermgroup.com]
Skin Lesion
  • BACKGROUND: Necrotizing fasciitis (NF) can appear after various penetrating or non-penetrating skin lesions. This is the first reported case in which NF occurred after a central venous line placement.[ncbi.nlm.nih.gov]
  • Blisters, bumps, black dots, or other skin lesions might appear. In the early stages of the infection, the pain will be much worse than it looks.[healthline.com]
  • The family did not notice other skin lesions or trauma. The patient did have a maximum temperature of 39.8 C 2 days before admission.[pediatrics.aappublications.org]
  • lesions are incised and drained or aspirated to obtain fluid for culture; - initial findings are localized pain and minimal swelling, often w/ no visible trauma or discoloration of the skin; - dermal induration and erythema eventually become evident;[wheelessonline.com]
Skin Ulcer
  • BACKGROUND: Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris.[ncbi.nlm.nih.gov]
  • Fever and chills Fatigue Progressive or later symptoms include the following: Progressive skin changes such as skin ulceration and bullae (thin-walled fluid-filled blisters ) formation Skin discoloration Necrotic scars (black scabs) Gas formation in the[medicinenet.com]
  • Superficial skin ulceration reached the umbilicus. After initial resuscitation, she was catheterized with a Foley catheter and intravenous ceftriaxone was given. Debridement of the wound was performed under general anaesthesia.[emro.who.int]
  • Other predisposing factors include trauma, fish-fin injury, chronic skin ulcer, burns, post operative wound infection, insect bite and colo-cutaneous fistula [ 24 – 27 ].[sjtrem.biomedcentral.com]
Angioedema
  • The patient had been diagnosed earlier as a case of angioedema by a physician and treated accordingly. She was mildly anemic, hyponatremic and hypokalemic.[ncbi.nlm.nih.gov]
Confusion
  • Symptoms Can Often Be Confusing The symptoms often start within hours after an injury and may seem like another illness or injury.[web.archive.org]
  • Necrotizing fasciitis is reported in half of patients with streptococcal toxic shock-like syndrome, or STSS. This illness is characterized by the presence of multiple symptoms: chills, fever or hypothermia and shock, confusion, vomiting, diarrhea, tachycardia[health.state.mn.us]
  • Later symptoms can include: Fever Chills Fatigue (tiredness) Vomiting These confusing symptoms may delay a person from seeking medical attention. If you have these symptoms after a wound, see a doctor right away.[cdc.gov]
  • This in part is due to the confusion … View Full Text Log in Log in using your username and password Log in through your institution Subscribe from 138 * Subscribe and get access to all BMJ articles, and much more.[bmj.com]
  • Flu like symptoms begin to occur, such as diarrhea, nausea, fever, confusion, dizziness, weakness, and general malaise; 5. Intense thirst occurs as the body becomes dehydrated; 6. The biggest symptom is all of these symptoms combined.[healthieryou.com]
Altered Mental Status
  • Patients are acutely ill, with high fever, tachycardia, altered mental status ranging from confusion to obtundation, and hypotension. Patients may be bacteremic or septic and may require aggressive hemodynamic support.[merckmanuals.com]

Workup

The following investigations are helpful in diagnosing necrotizing fasciitis.

  • Blood tests for white blood cell count, serum sodium levels, C-reactive protein and creatine kinase.
  • Blood urea nitrogen (BUN)
  • Arterial blood gas measurement
  • Bedside finger test: If the skin is open, the index finger can easily pass through the skin layers or if the skin is not broken, a scalpel can be used to perform this test.
  • Blood culture
  • Urinalysis
  • Wound swab culture
  • Tissue biopsy
  • Frozen tissue biopsy
  • Gram staining of the cultures

Imaging techniques for the investigation of necrotizing fasciitis include the following.

  • Soft tissue radiograph
  • Computerized tomography (CT) scan
  • Magnetic resonance imaging (MRI)
  • Ultrasound
  • Infrared spectroscopy for measuring the tissues oxygen saturation
Abnormal Renal Function
  • As in severe sepsis, abnormal renal function, hypoalbuminaemia, hyponatraemia, abnormal liver function, metabolic acidosis, and high serum lactate concentrations may occur.[academic.oup.com]
Vibrio Vulnificus
  • Vibrio vulnificus infection often occurs in warm regions, frequently leading to necrotizing fasciitis, sepsis, and death.[ncbi.nlm.nih.gov]
  • FLORIDA DEPT OF HEALTH - VIBRIO VULNIFICUS AWARENESS Vibrio vulnificus, a bacterium that is rampant in warm ocean waters and especially in raw shellfish like oysters and mussels, remains a huge concern for our southernmost states.[nnff.com]
  • Chronic kidney disease, including end-stage renal disease, has been identified as a possible risk factor for primary septicemia and wound infection by Vibrio vulnificus.[ncbi.nlm.nih.gov]
  • Fortunately, Vibrio vulnificus infection is relatively uncommon, but the incidence seems to be increasing. The U.S.[medicinenet.com]
  • Vibrio vulnificus , Aeromonas hydrophila , Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus, and MRSA can also cause it. [3] [4] [5] [7] Though very rare, mucormycosis has been reported as a cause in immunocompromised and immunocompetent[online.epocrates.com]
Gram-Positive Coccus
  • Cause of Necrotizing Fasciitis Group A Strep Streptococcus pyogenes , also known as group A beta-hemolytic Streptococcus, or group A strep (GAS) is a gram-positive coccus (spherical bacteria) that is ubiquitous, highly communicable, and spread primarily[emedicinehealth.com]
Beta-Hemolytic Streptococcus Group A
  • After amputation and aggressive debridement of soft tissue on the left side of the trunk, the patient completely recovered. beta-hemolytic streptococcus group A was isolated from the skin and tissue obtained during the surgery.[ncbi.nlm.nih.gov]

Treatment

The treatment of necrotizing fasciitis consists of the following.

  • Management of symptoms of shock (by the administration of intravenous fluids and provision of intensive care)
  • Intravenous wide-spectrum antibiotics are given. These include benzyl penicillin with clindamycin and gentamicin, or meropenem and clindamycin, or clindamycin, ciprofloxacin and metronidazole, or tetracycline and third-generation cephalosporins ( such as doxycycline, ceftazidime) or piperacillin/tazobactam.
  • Intravenous Immunoglobulins can also be given in these patients. [6]
  • Surgical debridement or in extreme cases, amputation of the affected part may also be required.
  • VAC (Vacuum Assisted Closure) is currently a popular option for the treatment of necrotizing fasciitis [7] [8].
  • Hyperbaric oxygen therapy has also shown good results in the management of necrotizing fasciitis [9] [10].
  • Skin grafts may be required for surgical or cosmetic benefit in these patients.

Prognosis

The morbidity and mortality rates associated with necrotizing fasciitis are high. If prompt treatment is not given, limb amputation will be required. A mortality rate of 20% to 75% has been found. Permanent disfigurement is the commonest complication of majority of the cases. Average life span of these patients has been found to be 38 to 44 years.

Etiology

Necrotizing fasciitis is common in cases of chronic infections (chronic liver disease, chronic renal disease) or in immunocompromised individuals, for example, in diabetics, HIV patients, those undergoing cancer chemotherapy or organ transplant patients. Bacteria enter the body through a break in the skin like cuts, abrasions, lacerations or surgical wounds.

The disease is caused by certain bacteria including the following [1] [2]:

It may also be due to opportunistic fungal infections inclding:

Based on etiology, necrotizing fasciitis is classified into following categories:

Epidemiology

The incidence of the disease is 1:10,000. It is more common in Asian and African countries. A male dominance with a 2-3:1 ratio has been recorded. The disease is rare in children.

The incidence is higher in immunocompromised patients, patients with neutropenia, individuals harboring open wounds, in the elderly, pregnant women and in obese people.

Sex distribution
Age distribution

Pathophysiology

The toxins (most commonly those released by group A beta hemolytic Streptococci (GABS) and Streptococcal pyrogenic exotoxins (SPEs) A, B, and C) released by the aerobic bacteria breakdown the skin and subcutaneous tissues, invading the deeper structures [3]. They cause the inhibition of immune response of the host and also cause tissue hypoxia, causing the gram negative bacteria to grow into the infected tissues [4]. Vascular occlusion and ischemia follow. The infected tissue eventually begins to die (necrosis) [5]. The bacteria enter the blood stream eventually, causing sepsis and shock.

Prevention

The following preventive measures are effective in reducing the occurrence of necrotizing fasciitis.

  • Proper tending of open cuts or wounds.
  • Washing hands regularly with soap and plenty of water.
  • Avoiding swimming or other such activities in case of a wound or infection till it heals.
  • Aseptic techniques should be used during surgeries to prevent infection of the wounds
  • Post-op care should be provided to the patients to avoid secondary MRSA infections.

Summary

Necrotizing fasciitis refers to the acute infection and necrosis of the fascia, the layer of connective tissue that surrounds most of the body tissues, like muscles, vessels and nerves. The infection is caused by certain bacteria that seem to “eat” the skin and subcutaneous structures of the body, resulting in a grotesque appearance, hence the name “flesh eating disease”.

Patient Information

Necrotizing fasciitis, commonly known as “flesh eating disease” is the disorder in which bacteria enter the body through open wounds. Individuals, in whom the immune defense mechanisms are low, are particularly susceptible to the disease. The bacteria “eat” the skin and the underlying tissues. The structures underneath are exposed.

If infection spreads to a large area and prompt medical care is not provided to the patient, amputation of the affected organ may be required. The patient may even die if not given adequate treatment. As bacteria enter through the breaks in the skin, it is vital to keep all sorts of wounds, cuts and abrasions clean. With proper care, the disease can be prevented.

References

Article

  1. Nakamura S, Nakayama K, Mikami H, Imai T. Multiple necrotizing fasciitis: its etiology and histopathological features. The Journal of dermatology. Dec 1987;14(6):604-608.
  2. Galosi A, Luttiken R, Enderer K. [Etiology and diagnosis of necrotizing fasciitis (author's transl)]. Zeitschrift fur Hautkrankheiten. Jan 15 1981;56(2):118-125.
  3. Fink A, DeLuca G. Necrotizing fasciitis: pathophysiology and treatment. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses. Feb 2002;11(1):33-36.
  4. Young MH, Aronoff DM, Engleberg NC. Necrotizing fasciitis: pathogenesis and treatment. Expert review of anti-infective therapy. Apr 2005;3(2):279-294.
  5. McGee EJ. Necrotizing fasciitis: review of pathophysiology, diagnosis, and treatment. Critical care nursing quarterly. Jan-Mar 2005;28(1):80-84.
  6. Cawley MJ, Briggs M, Haith LR, Jr., et al. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy. Sep 1999;19(9):1094-1098.
  7. Novelli G, Catanzaro S, Canzi G, Sozzi D, Bozzetti A. Vacuum assisted closure therapy in the management of cervico-facial necrotizing fasciitis: a case report and review of the literature. Minerva stomatologica. Apr 2014;63(4):135-144.
  8. de Geus HR, van der Klooster JM. Vacuum-assisted closure in the treatment of large skin defects due to necrotizing fasciitis. Intensive care medicine. Apr 2005;31(4):601.
  9. Hirn M. Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. A clinical and experimental study. The European journal of surgery. Supplement. : = Acta chirurgica. Supplement. 1993(570):1-36.
  10. Krasova Z, Matusek A, Chmelar D. [Hyperbaric oxygenation in the treatment of necrotizing fasciitis]. Vnitrni lekarstvi. Jul 1992;38(7):640-644.

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Last updated: 2019-07-11 20:55