Question

    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:

    Entire body system
    Fever
    • People initially have signs of inflammation, fever and a fast heart rate.[en.wikipedia.org]
    • During the first 2 days, the following clinical features are present: Localized, severe, persistent pain Swelling Erythema No defined margins of the region of skin that is involved, resembling cellulitis Malaise Fever Chills and sweating Nausea and vomiting[symptoma.com]
    Severe Pain
    • Symptoms include red or purple skin in the affected area, severe pain, fever, and vomiting.[en.wikipedia.org]
    Swelling
    • During the first 2 days, the following clinical features are present: Localized, severe, persistent pain Swelling Erythema No defined margins of the region of skin that is involved, resembling cellulitis Malaise Fever Chills and sweating Nausea and vomiting[symptoma.com]
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  • neurologic
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  • Skin
    Blister
    • Skin color may progress to violet, and blisters may form, with subsequent necrosis (death) of the subcutaneous tissues.[en.wikipedia.org]
    • […] involved, resembling cellulitis Malaise Fever Chills and sweating Nausea and vomiting Dizziness Tachycardia No lymph node involvement Over the next 2 to 3 days, the clinical features include: Edema Formation of hemorrhagic bullae (fluid filled thin walled blisters[symptoma.com]
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  • respiratoric
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  • musculoskeletal
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  • cardiovascular
    Tachycardia
    • […] days, the following clinical features are present: Localized, severe, persistent pain Swelling Erythema No defined margins of the region of skin that is involved, resembling cellulitis Malaise Fever Chills and sweating Nausea and vomiting Dizziness Tachycardia[symptoma.com]
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  • 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
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  • Microbiology
    Vibrio Vulnificus
    • . - 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]
    • Vibrio vulnificus, a bacterium found in saltwater, is a rare cause.[en.wikipedia.org]
    • The disease is caused by certain bacteria including the following: Streptococci (group A, Streptococcus pyogenes) Methicillin resistant Staphylococcus aureus Clostridium perfringens Bacteroides fragilis Aeromonas hydrophila Vibrio vulnificus Pseudomonas[symptoma.com]
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  • 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

    Cellulitis
    • Diagnoses of severe cellulitis or abscess should also be considered due to similar presentations. 10% of patients with necrotizing fasciitis in the original study still had a LRINEC score 6.[en.wikipedia.org]
    • […] prevaccine review - CL Peterson, L Mascola, SM Chao, JM Lieberman - The Journal of , 1996 - 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 Cellulitis[symptoma.com]
    • During the first 2 days, the following clinical features are present: Localized, severe, persistent pain Swelling Erythema No defined margins of the region of skin that is involved, resembling cellulitis Malaise Fever Chills and sweating Nausea and vomiting[symptoma.com]
    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]
    Hypoxia
    • 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.[symptoma.com]
    Necrotizing Fasciitis
    • Necrotizing fasciitis affects 0.4 to 1 person per 100,000 per year.[en.wikipedia.org]
    • The morbidity and mortality rates associated with necrotizing fasciitis are high.[symptoma.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]
    Septic Shock
    • Gangrene Intense pain that disappears soon due to destruction of pain nerve endings After another 2 days, the following grave complications are seen: Septic shock Hypotension Cardiovascular system collapse Toxic shock syndrome Death ensues The following[symptoma.com]
    Shock
    • The bacteria enter the blood stream eventually, causing sepsis and shock.[symptoma.com]
    • 2000 - Elsevier Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - Elsevier Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock[symptoma.com]
    • Toxic shock syndrome Gangrene Noma (disease) Fournier's gangrene, another name for necrotizing fasciitis of the groin region Necrotizing fasciitis at DMOZ LRINEC Score Online[en.wikipedia.org]
    Skin Infection
    • Early diagnosis is difficult as the disease often looks early on like a simple superficial skin infection.[en.wikipedia.org]
    Toxic Shock Syndrome
    • Gangrene Intense pain that disappears soon due to destruction of pain nerve endings After another 2 days, the following grave complications are seen: Septic shock Hypotension Cardiovascular system collapse Toxic shock syndrome Death ensues The following[symptoma.com]
    • Toxic shock syndrome Gangrene Noma (disease) Fournier's gangrene, another name for necrotizing fasciitis of the groin region Necrotizing fasciitis at DMOZ LRINEC Score Online[en.wikipedia.org]
    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]
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  • 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)

    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.

    Self-assessment

    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
    • Determinants of mortality for necrotizing soft-tissue infections. - CR McHenry, JJ Piotrowski, D Petrinic - Annals of , 1995 - ncbi.nlm.nih.gov
    • 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
    • Salmonella group C necrotizing fasciitis: a case report and review of the literature - T Khawcharoenporn, A Apisarnthanarak - and infectious disease, 2006 - 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
    • Clinical and microbiological features of necrotizing fasciitis. - 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 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: a case report and review of 12 cases - L Whitesides, C Cotto-Cumba, RAM Myers - Journal of oral and , 2000 - Elsevier
    • Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - 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
    • Infektionen durch grampositive Bakterien - H Schäfer - Infektionskrankheiten der Haut: Grundlagen, , 2010 - books.google.com
    • Epidemiological, bacteriological and complicating features of erysipelas - C Jorup-rönström - Scandinavian journal of infectious , 1986 - informahealthcare.com
    • 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
    • Cervicofacial necrotizing fasciitis: Report of three cases and literature review - RJ Balcerak, JM Sisto, RC Bosack - Journal of Oral and Maxillofacial , 1988 - Elsevier
    • 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 as a complication of tonsillectomy - JE Sonne, SB Kim, DK Frank - Otolaryngology--Head and Neck , 2001 - oto.sagepub.com
    • Cervical necrotizing fasciitis due to bacterial tonsillitis - B Zilberstein, R Cleva, RS Testa, U Sene, R Eshkenazy - Clinics, 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 - Pediatric dermatology, 2008 - Wiley Online Library
    • Bacteraemic necrotizing fasciitis with compartment syndrome caused by non-O1 Vibrio cholerae - CH Chang-Chien - Journal of plastic, reconstructive & aesthetic surgery, 2006 - Elsevier
    • Aeromonas bacteremia: review of 59 episodes - WC Ko, YC Chuang - Clinical Infectious Diseases, 1995 - cid.oxfordjournals.org
    • 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
    • Bacteriology of necrotizing fasciitis - A Giuliano, F Lewis, K Hadley, FW Blaisdell - The American Journal of , 1977 - 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
    • 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
    • A case-control study of necrotizing fasciitis during primary 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 Mascola, SM Chao, JM Lieberman - The Journal of , 1996 - 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
    • Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients - AM Kosloske, AH Cushing, TA Borden - Journal of pediatric , 1981 - Elsevier

    Media References

    1. Necrotizing fasciitis left leg, CC BY 2.0

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