Question 1 of 10

    Necrotizing Fasciitis

    Necrotizing fasciitis left leg[1]

    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.

    This disease is promted by the following process: infectious.

    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:

    Skin
    Blister
    • You have dark blisters near your wound that drain black fluid.[drugs.com]
    • Blisters can also form.[newsweek.com]
    • Some people get ulcers, blisters, or black spots on the skin.[cdc.gov]
    • […] of necrosis Abrupt, diffuse, fortitude, amputate the virulent Swollen, febrile, decayed, overwhelmed in misery The stench so vile, so foul, immanent and grotesque Immune system declines, toxemia channels through the veins Toxic shock - vitality drops Blistered[genius.com]
    • Over the next 24 to 48 hours the rash darkens, and blisters begin to form.[britannica.com]
    Skin Lesion
    • Blisters, bumps, black dots, or other skin lesions might appear.[healthline.com]
    • The family did not notice other skin lesions or trauma.[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]
    • Bullae and ecchymotic skin lesions also point to the condition (and are not normally found with cellulitis). [ 2 ] A high index of suspicion is necessary and suspected cases should be referred immediately.[patient.info]
    Skin Ulcer
    • 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]
    • 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]
  • more...
  • urogenital
  • more...
  • cardiovascular
    Tachycardia
    • 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]
    • […] erythematous, tender, swollen skin becomes smooth, shiny and tensely swollen - darkens, patchy, blisters and bullae - gangrene a wooden-hard feel of the subcutaneous tissue oedema beyond the margin of erythema crepitus (gas gangrene) Systemic fever, tachycardia[lifeinthefastlane.com]
    • Necrotising fasciitis should be suspected in any patient with a soft-tissue infection accompanied by prominent pain and/or anaesthesia over the infected area, or signs and symptoms of systemic toxicity such as fever or hypothermia, tachycardia, tachypnoea[bestpractice.bmj.com]
    • Affected patients are toxic upon presentation, and often manifest tachycardia, hypotension, and pain out of proportion to clinical findings at the site of infection.[clinicaladvisor.com]
    • Fever and tachycardia were frequent but not uniformly present.[pediatrics.aappublications.org]
  • more...
  • musculoskeletal
  • more...
  • respiratoric
    Tachypnea
    • Similarly, patients may present high fever, anxiety, altered mental status, leukocytosis, shock, and tachypnea, when shock is about to develop.[frontiersin.org]
  • more...
  • neurologic
    Confusion
    • Later symptoms can include: Fever Chills Fatigue (tiredness) Vomiting These confusing symptoms may delay a person from seeking medical attention.[cdc.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]
    • […] swelling will usually feel firm to the touch diarrhoea and vomiting dark blotches on the skin that turn into fluid-filled blisters If left untreated, the infection can spread through the body quickly and cause symptoms such as dizziness , weakness and confusion[nhs.uk]
    • "It's difficult to diagnose necrotizing fasciitis, because in the early stages, the signs and symptoms tend to be very wide, very general, very easily confused with minor diseases and minor conditions," said study researcher Dr.[huffingtonpost.com]
    • The patient may also experience: confusion dehydration diarrhea and vomiting skin swells and changes color, turning violet areas of tissue turn black and start to die intense pain until the necrosis or gangrene kills the nerve endings After 4-5 days ,[medicalnewstoday.com]
    Altered Mental Status
    • Average 3.0 of 22 Ratings Question COMMENTS (10) (OBQ04.264) A 56-year-old diabetic male presents to the emergency department by ambulance after developing high-grade fevers, malaise, and altered mental status.[orthobullets.com]
    • Patients are acutely ill, with high fever, tachycardia, altered mental status ranging from confusion to obtundation, and hypotension.[merckmanuals.com]
    • mental status Systemic inflammatory response syndrome Fulminant shock and multiorgan failure Body sites most often affected by necrotizing fasciitis: Lower extremities Perineum and genitourinary region (Fournier's gangrene) Upper extremities Abdomen[clinicaladvisor.com]
    • Similarly, patients may present high fever, anxiety, altered mental status, leukocytosis, shock, and tachypnea, when shock is about to develop.[frontiersin.org]
    • Patients must be operated on emergently if they present with altered mental status, hypotension, left shift or metabolic acidosis. 47 Early surgical intervention is life-saving and must be performed as early as possible, since a delay in treatment beyond[eyewiki.aao.org]
  • more...
  • Entire body system
    Fever
    • These are: Fever with shock and light-headedness Fever with a sunburn rash Fever with a cough and difficulty breathing Fever with cellulitis that can progress to necrotizing fasciitis or myositis The classic warning signals are unusually severe pain at[healthcentral.com]
    • Historically, group A streptococci have been responsible for deadly outbreaks of scarlet fever , rheumatic fever , and toxic shock syndrome .[britannica.com]
    • : Group A strep (the most common) Klebsiella Clostridium E. coli Staphylococcus aureus Aeromonas hydrophila other bacterial species Symptoms Symptoms of necrotizing fasciitis include (but are not limited to): rapid onset of severe pain and swelling, fever[health.state.mn.us]
    • My fever went down, but then I took another turn for the worse.”[foxnews.com]
    • Flu -like symptoms such as diarrhea , nausea , fever, dizziness , weakness , and general malaise.[webmd.com]
    Swelling
    • You have a fever and a new wound with redness, swelling, or pain.[drugs.com]
    • The patient complained of pain, swelling, and a 6 4-cm complex mass of blood-filled bullae on her abdominal panniculus, 7 cm from her well-healed incision.[anesthesiology.pubs.asahq.org]
    • There may be edema , or swelling, and crackling under the skin.[medicalnewstoday.com]
    • Acute swelling of the limbs: magnetic resonance pictorial review of fascial and muscle signal changes.[en.wikibooks.org]
    • Early symptoms can include: a small but painful cut or scratch on the skin intense pain that's out of proportion to any damage to the skin a high temperature (fever) and other flu-like symptoms After a few hours to days, you may develop: swelling and[nhs.uk]
    Severe Pain
    • One alerting sign is unusually severe pain - far greater than normal for a cut or wound - and painful lymph nodes.[healthcentral.com]
    • pain and swelling, fever, and redness at the site of the injury.[health.state.mn.us]
    • Snapshot A 45-year-old woman presents to the emergency department for severe pain of her left foot.[medbullets.com]
    • The early symptoms are also similar to common post-surgical complaints, such as: severe pain inflammation fever nausea Diagnosis is often based on advanced symptoms, such as the presence of gas bubbles under the skin.[webmd.com]
    • pain Other symptoms may include: Fever Chills Sweating Nausea Weakness Lightheadedness or dizziness Risk factors This type of infection, although rare, can happen to anyone at any time.[sepsis.org]
    High Fever
    • Typically patients have high fevers and elevated white-blood-cell counts.[ucdenver.edu]
    • Immediate side effects include high fever, nausea, diarrhea and chills.[people.com]
    • Patients are acutely ill, with high fever, tachycardia, altered mental status ranging from confusion to obtundation, and hypotension.[merckmanuals.com]
    • It's not so much the chills, the high fever, nausea and stomach upset that many survivors of necrotizing fasciitis remember most.[ajc.com]
    • Systemic manifestations of NF are high fever, hypotension, prostration, and multi-organ failure (i.e., sepsis and septic shock).[psnet.ahrq.gov]
    Anemia
    • The infection can spread up to 2.5 cm/h, with minimal change in the overlying skin. 1 Erythema, swelling, and severe pain are generally seen at presentation. 1 Bullae and soft tissue gas ( fig. ) are late signs. 1 Anemia, hyponatremia, hypoglycemia, and[anesthesiology.pubs.asahq.org]
    • […] infection (leukocytosis with a predominance of neutrophils), muscle damage (elevated creatine phosphokinase levels), hepatic or renal insufficiency or failure (elevated liver enzyme, blood urea nitrogen, and creatinine levels), electrolyte imbalances, and anemia[nursingcenter.com]
    • Laboratory studies in patients with necrotizing fasciitis may reveal metabolic acidosis, leukocytosis, anemia, thrombocytopenia, coagulopathy, hyponatremia, or renal or liver dysfunction.[emdocs.net]
    Localized Edema
    • Via infection, local inflammatory processes produce increased amounts of purulence, local edema, and eventually necrosis in the deep tissues, leading to pain out of proportion to clinical findings, edema, and eventually skin discoloration and surface[clinicaladvisor.com]
    • After surgical debridement, the use of the VAC system helps wound healing by absorbing excess exudates; reducing localized edema, and finally drawing wound edges together .[frontiersin.org]
    Dog Bite
    • In the episode Three Stories , the farmer patient was exposed to the bacteria through a dog bite.[house.wikia.com]
  • more...
  • Course
  • more...
  • 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

    Laboratory

    Serum
    Abnormal Renal Function
    • Blood tests - may show leukocytosis, acidosis, altered coagulation profile, hypoalbuminaemia and abnormal renal function. [ 5 ] ( NB : an inflammatory response may be absent in patients who are immunosuppressed or with liver disease.)[patient.info]
    • As in severe sepsis, abnormal renal function, hypoalbuminaemia, hyponatraemia, abnormal liver function, metabolic acidosis, and high serum lactate concentrations may occur.[academic.oup.com]
  • more...
  • Microbiology
    Vibrio Vulnificus
    • Fortunately, Vibrio vulnificus infection is relatively uncommon, but the incidence seems to be increasing.[medicinenet.com]
    • […] be necessary; - references: - Necrotizing Soft-tissue Infections and Sepsis Caused by Vibrio vulnificus Compared with Those Caused by Aeromonas Species . - Infections caused by halophilic marine Vibrio bacteria . - streptococci pyogenes infections: -[wheelessonline.com]
    • . - I Brook, EH Frazier - Journal of clinical microbiology, 1995 - Am Soc Microbiol Autopsy cases of fulminant‐type bacterial infection with necrotizing fasciitis: Group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection - T[symptoma.com]
    • The most recent case that made national headlines involved a man who died four days after becoming infected with the ocean-dwelling microbe Vibrio vulnificus .[acsh.org]
    • Necrotising fasciitis caused by Vibrio vulnificus in the lower limb following exposure to seafood on the hand.[emdocs.net]
    Gram-Positive Coccus
    • 11/21/2017 Patient Comments & Reviews The eMedicineHealth doctors ask about Necrotizing Fasciitis: 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[emedicinehealth.com]
  • more...
  • 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.

    Complications

    Fever
    • These are: Fever with shock and light-headedness Fever with a sunburn rash Fever with a cough and difficulty breathing Fever with cellulitis that can progress to necrotizing fasciitis or myositis The classic warning signals are unusually severe pain at[healthcentral.com]
    • Historically, group A streptococci have been responsible for deadly outbreaks of scarlet fever , rheumatic fever , and toxic shock syndrome .[britannica.com]
    • : Group A strep (the most common) Klebsiella Clostridium E. coli Staphylococcus aureus Aeromonas hydrophila other bacterial species Symptoms Symptoms of necrotizing fasciitis include (but are not limited to): rapid onset of severe pain and swelling, fever[health.state.mn.us]
    • My fever went down, but then I took another turn for the worse.”[foxnews.com]
    • Flu -like symptoms such as diarrhea , nausea , fever, dizziness , weakness , and general malaise.[webmd.com]
    Shock
    • (a life-threatening reaction) If toxic shock occurs, the organs begin to shut down, and death may soon follow.[everydayhealth.com]
    • 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]
    • About 50% of patients with necrotizing fasciitis have clinical features overlapping those of streptococcal toxic shock syndrome, a disease of shock and multiorgan failure associated with the release of streptococcal pyrogenic exotoxins and evolving from[nursingcenter.com]
    • Historically, group A streptococci have been responsible for deadly outbreaks of scarlet fever , rheumatic fever , and toxic shock syndrome .[britannica.com]
    • It is also responsible for skin infections, as well as rare, severe illnesses, such as toxic shock syndrome.[medicalnewstoday.com]
    Necrotizing Fasciitis
    • Necrotizing Fasciitis Alternative Names: Necrotizing fasciitis; Fasciitis necrotizing; Flesh eating bacteria; Soft tissue gangrene.[disabled-world.com]
    • , 2005 - SciELO Brasil Cervical necrotizing fasciitis of odontogenic origin - Y Rapoport, MZ Himelfarb, D Zikk, J Bloom - Oral surgery, oral medicine, , 1991 - Elsevier Aerobic and anaerobic microbiology of necrotizing fasciitis in children - I Brook[symptoma.com]
    Cellulitis
    • , Necrotising fasciitis , Necrotizing cellulitis , Necrotising myositis , Necrotizing fasciitis (disorder) , Necrotizing fasciitis Dutch necrotiserende fasciïtis NAO , necrotiserende cellulitis , fasciïtis necrotiserend , necrotiserende fasciïtis , Fasciitis[fpnotebook.com]
    • Included 145 patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to Changi General Hospital.[mdcalc.com]
    • Lymphangitis is rarely seen (unlike cellulitis).[patient.info]
    • She is admitted for IV antibiotics to treat cellulitis.[emdocs.net]
    • Stone HH, Martin JD: Synergistic necrotizing cellulitis.[link.springer.com]
    Skin Infection
    • Much more severe that it is normal for similar size skin infections.[prod.hopkins-abxguide.org]
    • Good Wound Care Is Important Common sense and good wound care are the best ways to prevent a bacterial skin infection.[cdc.gov]
    • According to the Centers for Disease Control and Prevention, necrotizing fasciitis is a serious bacterial skin infection that spreads quickly and kills the body’s soft tissue.[merriam-webster.com]
    • According to the Centers for Disease Control and Prevention , necrotizing fasciitis is a serious bacterial skin infection that spreads quickly and kills the body’s soft tissue.[usatoday.com]
    • Sometimes nicknamed "flesh-eating bacteria," necrotizing fasciitis is a serious, yet rare, bacterial skin infection that spreads quickly.[everydayhealth.com]
    Anemia
    • The infection can spread up to 2.5 cm/h, with minimal change in the overlying skin. 1 Erythema, swelling, and severe pain are generally seen at presentation. 1 Bullae and soft tissue gas ( fig. ) are late signs. 1 Anemia, hyponatremia, hypoglycemia, and[anesthesiology.pubs.asahq.org]
    • […] infection (leukocytosis with a predominance of neutrophils), muscle damage (elevated creatine phosphokinase levels), hepatic or renal insufficiency or failure (elevated liver enzyme, blood urea nitrogen, and creatinine levels), electrolyte imbalances, and anemia[nursingcenter.com]
    • Laboratory studies in patients with necrotizing fasciitis may reveal metabolic acidosis, leukocytosis, anemia, thrombocytopenia, coagulopathy, hyponatremia, or renal or liver dysfunction.[emdocs.net]
    Hypoxia
    • Local hypoxia with systemic illnes s ( immunosuppression or DM  compromise of the fascial blood supply ) Schwartz’s principles of surgery, 9 th ed.[slideshare.net]
    • Most produce toxins that inhibit the immune response, damage or kill tissue, produce tissue hypoxia, specifically dissolve connective tissue, or do all of the above.[medicinenet.com]
    • In most cases, the anaerobic bacteria proliferate in an environment of local tissue hypoxia.[podiatrytoday.com]
    • Medications Necrotizing fasciitis is treated with antibiotics usually administered intravenously, however, until surgical debridement has occurred tissue hypoxia limits the efficacy of intravenous antibiotics. [3] A high dose antibiotic regimen is critical[physio-pedia.com]
    • Various bacterial enzymes and toxins lead to vascular occlusion and result in tissue hypoxia and ultimately - tissue necrosis.[disabled-world.com]
    Gas Gangrene
    • All That Is Gas Is Not Gas Gangrene: Mechanical Spread of Gas in the Soft Tissues. [wheelessonline.com]
    • […] aerobes and anaerobes, such as coliforms, klebsiella, streptococci, staphylococci, clostridia, bacteroids, and corynbacteria CAUSTIVE ORGANISMS Monomicrobial pathogens: Streptococci (especially Streptococcus pyogenes – Group A) Clostridium perfringens (gas[lifeinthefastlane.com]
    • D.D - - - DM - - Obvious portal of entry - - - Gas in tissue Systemic Toxicity Local Pain Diffuse Pain Fever Myositis viral/ parasitic Pyomyositis Gas Gangrene Type 2 Type 1 Clinical Findings 18.[slideshare.net]
    • These bacteria are not as common causes of NF, but have been known to cause NF and gas gangrene.[rarediseases.org]
    • gangrene Treatment Management approach prompt surgical debridement is the mainstay of treatment along with antibiotic treatment Medical intravenous empiric antibiotics indication a treatment component of necrotizing fasciitis directed against likely[medbullets.com]
    Acquired Immunodeficiency Syndrome
    • Musculoskeletal complications of the patient with acquired immunodeficiency syndrome (AIDS): CT evaluation.[eyewiki.aao.org]
    Compartment Syndrome
    • Himelfarb, D Zikk, J Bloom - Oral surgery, oral medicine, , 1991 - Elsevier Aerobic and anaerobic microbiology of necrotizing fasciitis in children - I Brook - Pediatric dermatology, 2008 - Wiley Online Library Bacteraemic necrotizing fasciitis with compartment[symptoma.com]
    • Fever is not a usual finding with compartment syndrome.[clinicaladvisor.com]
    • Limb ischaemia , compartment syndrome .[patient.info]
    • syndrome Myositis Muscle necrosis Please rate topic.[medbullets.com]
    • syndrome (traumatic) ( T79.A- ) complications of pregnancy, childbirth and the puerperium ( O00-O9A ) congenital malformations, deformations, and chromosomal abnormalities ( Q00-Q99 ) endocrine, nutritional and metabolic diseases ( E00 - E88 ) injury[icd10data.com]
    Septic Shock
    • Even with aggressive management, septic shock, neurologic deterioration, and eventual death occur at an alarmingly high rate.[nursingcenter.com]
    • Sepsis and septic shock can result from an infection anywhere in the body, such as pneumonia , influenza , or urinary tract infections .[sepsis.org]
    • Days 4-5 approximately: Hypotension and septic shock develop.[patient.info]
    • She was in septic shock and multi-organ system failure. [youcaring.com]
    • Septic shock induced by group A streptococcal infection: clinical and therapeutic aspects.[emdocs.net]
    Toxic Shock Syndrome
    • Historically, group A streptococci have been responsible for deadly outbreaks of scarlet fever , rheumatic fever , and toxic shock syndrome .[britannica.com]
    • Streptococcal toxic shock syndrome may develop.[merckmanuals.com]
    • The overall mortality rate is 25%-30% more than 70% of cases are associated with toxic shock syndrome [ 3 ].[omicsonline.org]
    • shock syndrome may complicate this latter form Location While it can affect any part of the body, the extremities, the perineum, and the truncal areas are the most commonly involved 4 .[radiopaedia.org]
    • GAS is associated with toxic shock syndrome and with life-threatening skin and soft-tissue infections, most notably necrotizing fasciitis, each of which is associated with an incredibly high morbidity and mortality.[emedicinehealth.com]
    Varicella
    • - DM Zerr, ER Alexander, JS Duchin, LA Koutsky - Pediatrics, 1999 - Am Acad Pediatrics Necrotising fasciitis - S Hasham, P Matteucci, PRW Stanley, NB Hart - Bmj, 2005 - bmj.com Children hospitalized for varicella: a prevaccine review - CL Peterson, L[symptoma.com]
    • A case - control study of necrotizing fasciitis during primary varicella .[slideshare.net]
    • Ultrasound Ultrasound may be more useful in children 3-4 (with a rising incidence after primary varicella infection 11 ). [radiopaedia.org]
    • For children, varicella infection during the two weeks prior to their GAS infection was a significant risk factor for developing necrotizing fasciitis.[austincc.edu]
    • Underlying conditions including alcohol abuse, intravenous drug abuse, chronic liver or renal disease, diabetes, malignancy, immunosuppression and possibly, tuberculosis. [ 6 ] NF in children may follow varicella zoster infection. [ 7 ] Note that NF can[patient.info]

    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:

    • Type I (polymicrobial, more than one type of bacteria are involved, may be aerobic or anaerobic)
    • Type II (monomicrobial, Group A streptococcal infection, occasionally, staphylococci are involved)
    • Type III (monomicrobial, gram negative bacteria are involved).
    • Type IV (fungal infection)

    Causes

    Hypoxia
    • Local hypoxia with systemic illnes s ( immunosuppression or DM  compromise of the fascial blood supply ) Schwartz’s principles of surgery, 9 th ed.[slideshare.net]
    • Most produce toxins that inhibit the immune response, damage or kill tissue, produce tissue hypoxia, specifically dissolve connective tissue, or do all of the above.[medicinenet.com]
    • In most cases, the anaerobic bacteria proliferate in an environment of local tissue hypoxia.[podiatrytoday.com]
    • Medications Necrotizing fasciitis is treated with antibiotics usually administered intravenously, however, until surgical debridement has occurred tissue hypoxia limits the efficacy of intravenous antibiotics. [3] A high dose antibiotic regimen is critical[physio-pedia.com]
    • Various bacterial enzymes and toxins lead to vascular occlusion and result in tissue hypoxia and ultimately - tissue necrosis.[disabled-world.com]
    Acquired Immunodeficiency Syndrome
    • Musculoskeletal complications of the patient with acquired immunodeficiency syndrome (AIDS): CT evaluation.[eyewiki.aao.org]
    Beta-Hemolytic Streptococcus
    • . - I Brook, EH Frazier - Journal of clinical microbiology, 1995 - Am Soc Microbiol Autopsy cases of fulminant‐type bacterial infection with necrotizing fasciitis: Group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection - T[symptoma.com]
    • Last Reviewed 11/21/2017 Patient Comments & Reviews The eMedicineHealth doctors ask about Necrotizing Fasciitis: Cause of Necrotizing Fasciitis Group A Strep Streptococcus pyogenes , also known as group A beta-hemolytic Streptococcus, or group A strep[emedicinehealth.com]
    • Microbiological type Pathogens Site of infection Co-morbidities Type I (polymicrobial) Obligate and facultative anaerobes Trunk and perineum Diabetes mellitus Type II (monomicrobial) Beta-hemolytic streptococcus A Limbs Type III Clostridium species Limbs[lifeinthefastlane.com]
    • Type II infections are monomicrobial, most commonly caused by group A beta-hemolytic Streptococcus alone or with aureus [2].[emdocs.net]
    • Historically, group A–beta-hemolytic streptococcus has been identified as the major cause of this infection.[psnet.ahrq.gov]
    Suppurative Inflammation
    • Most areas of the tissue showed coagulative necrosis with focal suppurative inflammation.[nature.com]
    Gram-Positive Coccus
    • 11/21/2017 Patient Comments & Reviews The eMedicineHealth doctors ask about Necrotizing Fasciitis: 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[emedicinehealth.com]
    Anaerobic Bacteria
    • The most common pathogen is group A Streptococcus, but polymicrobial infection with Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is not uncommon.[orthobullets.com]
    • Type I is usually caused by mixed aerobic or anaerobic bacteria, such as group A streptococcus, Bacteroides fragilis, Staphylococcus aureus, species of Clostridium, Pseudomonas aeruginosa, Enterobacteriaceae, and others. 2 It's seen in postoperative patients[nursingcenter.com]
    • Surgery / Trauma  tissue hypoxia  PMNL dysfunction  good environment for f acultative aerob es  more oxidation  proliferat ion of anaerobic bacteria  angiothrombotic microbial invasion  liquefactive necrosis Microbiology: - G roup A h a emolytic[slideshare.net]
    • Co-infection from anaerobic bacteria is possible, as well.[clinicaladvisor.com]
    • The majority of instances of necrotizing fasciitis are, 'polymicrobial,' and involve both aerobic and anaerobic bacteria.[disabled-world.com]

    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.

    Other symptoms

    Staphylococcal Infection
    • Type 2 - Group A streptococcus (GAS) : occurs in any age group and in otherwise healthy people; occasionally accompanied by staphylococcal infection.[patient.info]
    • Type 2 NF consists of infections with group A Streptococcus ( Streptococcus pyogenes ) with or without a coexisting Staphylococcal infection 7 .[eyewiki.aao.org]
    • […] retrospective study by Hsiao et al found that Aeromonas infection, Vibrio infection, cancer, hypotension, and band form WBC count greater than 10% were independent positive predictors of mortality in patients with necrotizing fasciitis, while streptococcal and staphylococcal[emedicine.medscape.com]

    Self-assessment

    Ask Question


    5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.

    References

    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.

    • Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - Elsevier
    • Group B streptococcal necrotizing fasciitis and streptococcal toxic shock-like syndrome in adults - MA Gardam, DE Low, R Saginur - Archives of internal , 1998 - Am Med Assoc
    • Autopsy cases of fulminant‐type bacterial infection with necrotizing fasciitis: Group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection - T Tajiri, G Tate, H Akita, N Ohike - Pathology , 2008 - Wiley Online Library
    • Necrotising fasciitis - S Hasham, P Matteucci, PRW Stanley, NB Hart - Bmj, 2005 - bmj.com
    • Cervicofacial necrotizing fasciitis: Report of three cases and literature review - RJ Balcerak, JM Sisto, RC Bosack - Journal of Oral and Maxillofacial , 1988 - Elsevier
    • Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases - L Whitesides, C Cotto-Cumba, RAM Myers - Journal of oral and , 2000 - Elsevier
    • Epidemiological, bacteriological and complicating features of erysipelas - C Jorup-rönström - Scandinavian journal of infectious , 1986 - informahealthcare.com
    • Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - Elsevier
    • Children hospitalized for varicella: a prevaccine review - CL Peterson, L Mascola, SM Chao, JM Lieberman - The Journal of , 1996 - Elsevier
    • Cervical necrotizing fasciitis due to bacterial tonsillitis - B Zilberstein, R Cleva, RS Testa, U Sene, R Eshkenazy - Clinics, 2005 - SciELO Brasil
    • Bacteraemic necrotizing fasciitis with compartment syndrome caused by non-O1 Vibrio cholerae - CH Chang-Chien - Journal of plastic, reconstructive & aesthetic surgery, 2006 - Elsevier
    • Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases - W Tung-Yiu, H Jehn-Shyun, C Ching-Hung - Journal of oral and , 2000 - Elsevier
    • Autopsy cases of fulminant‐type bacterial infection with necrotizing fasciitis: Group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection - T Tajiri, G Tate, H Akita, N Ohike - Pathology , 2008 - Wiley Online Library
    • Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus - DM Aronoff, KC Bloch - Medicine, 2003 - journals.lww.com
    • Cervical necrotizing fasciitis of odontogenic origin - Y Rapoport, MZ Himelfarb, D Zikk, J Bloom - Oral surgery, oral medicine, , 1991 - Elsevier
    • Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients - AM Kosloske, AH Cushing, TA Borden - Journal of pediatric , 1981 - Elsevier
    • Case of necrotizing fasciitis caused by coagulase-negative staphylococcus: utility of magnetic resonance imaging for the preoperative diagnosis of necrotizing fasciitis - T Sato, K Hagiwara, H Matsuno, Y Chiyokura - Journal of infection and , 2005 - Springer
    • Aeromonas bacteremia: review of 59 episodes - WC Ko, YC Chuang - Clinical Infectious Diseases, 1995 - cid.oxfordjournals.org
    • Bacteraemic necrotizing fasciitis with compartment syndrome caused by non-O1 Vibrio cholerae - CH Chang-Chien - Journal of plastic, reconstructive & aesthetic surgery, 2006 - Elsevier
    • Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome? - DL Stevens - Clinical infectious diseases, 1995 - cid.oxfordjournals.org
    • Salmonella group C necrotizing fasciitis: a case report and review of the literature - T Khawcharoenporn, A Apisarnthanarak - and infectious disease, 2006 - Elsevier
    • Determinants of mortality for necrotizing soft-tissue infections. - CR McHenry, JJ Piotrowski, D Petrinic - Annals of , 1995 - ncbi.nlm.nih.gov
    • Cervical necrotizing fasciitis as a complication of tonsillectomy - JE Sonne, SB Kim, DK Frank - Otolaryngology--Head and Neck , 2001 - oto.sagepub.com
    • Aerobic and anaerobic microbiology of necrotizing fasciitis in children - I Brook - Pediatric dermatology, 2008 - Wiley Online Library
    • Infektionen durch grampositive Bakterien - H Schäfer - Infektionskrankheiten der Haut: Grundlagen, , 2010 - books.google.com
    • Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases - W Tung-Yiu, H Jehn-Shyun, C Ching-Hung - Journal of oral and , 2000 - Elsevier
    • A woman with a painful and swollen hand - MP Hendriks, M van Deuren - Neth J Med, 2009 - njmonline.nl
    • Determinants of mortality for necrotizing soft-tissue infections. - CR McHenry, JJ Piotrowski, D Petrinic - Annals of , 1995 - ncbi.nlm.nih.gov
    • A case-control study of necrotizing fasciitis during primary varicella - DM Zerr, ER Alexander, JS Duchin, LA Koutsky - Pediatrics, 1999 - Am Acad Pediatrics
    • Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - Elsevier
    • Bacterial skin and soft tissue infections: review of the epidemiology, microbiology, aetiopathogenesis and treatment - L Tognetti, C Martinelli, S Berti - Journal of the , 2012 - Wiley Online Library
    • Clinical and microbiological features of necrotizing fasciitis. - I Brook, EH Frazier - Journal of clinical microbiology, 1995 - Am Soc Microbiol

    Media References

    1. Necrotizing fasciitis left leg, CC BY 2.0

    Languages

    Self-assessment