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
• 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)
• 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:

• Septic shock
• Hypotension
• Cardiovascular system collapse
• Toxic shock syndrome
• Death ensues

• Pain

  The patient’s pain was at a level of 10 and palpation for pulses was impossible due to this pain level. [podiatrytoday.com]

  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]

  neck stiffness, shortness of breath, abdominal pain, nausea, dysuria, diarrhea, and lower extremity edema. [webeye.ophth.uiowa.edu]

• 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]

  You can’t describe the way the pain is, and the fever I had was just unbelievable,” Madsen said. “But then, after they started the NeutroPhase and started killing all of the toxins in my arm, the fever subsided and went away. [foxnews.com]

  She was admitted to our hospital at 7 days of age because of fever, poor feeding, and a large erythematous, indurated area in the lumbar region. [pediatrics.aappublications.org]

  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]

• Gangrene

  Fournier’s gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier’s gangrene severity index. Arch Esp Urol (2009) 62 :532–40. Pubmed Abstract | Pubmed Full Text 29. [frontiersin.org]

  Gluteal gas gangrene with necrotizing fasciitis Gas gangrene Necrotic muscle with gas bubbles but minimal inflammation Leg lesion Necrotizing fasciitis and panniculitis (pneumococci) Pneumococcal sepsis Septic thrombus Associated vasculitis Advertisement [pathologyoutlines.com]

  Convert to ICD-10-CM : 728.86 converts directly to: 2015/16 ICD-10-CM M72.6 Necrotizing fasciitis Approximate Synonyms Necrotizing fasciitis due to infectious organism with gangrene Necrotizing fasciitis w gangrene due to infectious organism Necrotizing [icd9data.com]

  Physical findings Toxaemia (esp. late) area of erythema quickly spreads into normal skin without sharp demarcation dusky or purplish skin m ultiple identical patches of gangrenous skin - large area of skin gangren e. Bullae with putrid discharge. [slideshare.net]

  The patient was hospitalized for peristomal gangrene with necrotizing fasciitis. Emergency action was taken to resolve the parietal gangrene. [ncbi.nlm.nih.gov]

• Swelling

  A broad differential diagnosis in case of lower lip swelling is essential to avoid inappropriate treatment delay. [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]

  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]

  […] limits penetration by antibiotics; - desquamation followed by gangrene may be relentless; - clinical findings: - clinical signs of pain out of proportion to exam coupled with areas of anesthesia (from microvascular and nerve damage) - hyperyrexia, and chills [wheelessonline.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]

• Tachypnea

  Similarly, patients may present high fever, anxiety, altered mental status, leukocytosis, shock, and tachypnea, when shock is about to develop. [frontiersin.org]

  Tachypnea, hyperglycemia (with osmotic diuresis), and fever aggravate the hypovolemic state. 48 Tissue bacteria are isolated in about 76% of cases. 49 In our series, positive tissue cultures were found in 24 cases (62%). [jamanetwork.com]

• Vomiting

  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]

  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]

  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]

  A person may have fever, chills, fatigue and vomiting, all of which could be mistaken for other types of illnesses. The most important clue to look out for is if these symptoms occur after some type of skin injury. [newsweek.com]

• Hypotension

  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]

  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]

  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]

  […] 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]

  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]

  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]

  Fever and tachycardia were frequent but not uniformly present. The leukocyte count of the peripheral blood was usually elevated with a shift to the left. Thrombocytopenia was noted in half of the cases. Hypocalcemia was rarely reported. [pediatrics.aappublications.org]

• Foot Pain

  42 year old female with no past medical history presents with increasing foot pain over the past 5 days. [web.archive.org]

  Skip to content learn bedside ultrasound, one week at a time 42 year old female with no past medical history presents with increasing foot pain over the past 5 days. [ultrasoundoftheweek.com]

• Leg Pain

  Over the last two days, she has had progressive leg swelling of her entire right thigh. The pain is now so severe that she is having difficulty walking. [emdocs.net]

• 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]

  Later, the skin turns violet, often with the development of large fluid-filled blisters (bullae). The fluid from these blisters is brown, watery, and sometimes foul smelling. Areas of dead skin turn black (gangrene). [msdmanuals.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]

  No puncture wounds, omphalitis, or other skin rashes were noted. The skin lesion extended rapidly to both flanks and the affected skin became violaceous in color ( Fig 1 B). [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]

  There was extensive loss of skin and subcutaneous fat of the right inguinal region. Superficial skin ulceration reached the umbilicus. After initial resuscitation, she was catheterized with a Foley catheter and intravenous ceftriaxone was given. [emro.who.int]

  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]

  Painful skin ulcers with gangrenous margins may be a feature of mixed bacterial infections. 2 The presence of crepitus is variable. [aafp.org]

  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]

• Skin Discoloration

  discoloration (red-purple, dusky blue) Crepitance Skin bullae Systemic Toxicity: Fever Tachycardia Hypotension Altered mental status Systemic inflammatory response syndrome Fulminant shock and multiorgan failure Body sites most often affected by necrotizing [clinicaladvisor.com]

  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]

  The areas surrounding these lesions tend to be more erythematous as the advanced stage sets in with skin discoloration, duskiness, necrosis and at times, eschar tissue formation. [1], [2], [4] The cutaneous signs pointing toward NF in the early stages [onlinejets.org]

  The infection progresses over the course of one or a few days, despite antibiotic therapy, with gradual skin discoloration from initial erythema to areas of frank necrosis. Bullae containing hemorrhagic fluid develop at the affected areas. [infectiousdiseaseadvisor.com]

• Withdrawn

  TOC was permanently withdrawn. Literature review and discussion We identified three case reports of NF in RA patients receiving TOC 3–5 and three under TNF antagonists 6–8 ( Table 1 ). [reumatologiaclinica.org]

  Targeted antimicrobial therapy was applied during 28 days and was withdrawn upon the general stabilization of the patient’s clinical status and isolation of physiological flora from the incision. [woundsresearch.com]

  He developed multi-organ dysfunction and ultimately, after discussions with his family, care was withdrawn and he died peacefully. [psnet.ahrq.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]

  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]

  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]

  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]

  This is because the symptoms — fever, pain, swelling and tenderness at the affected site — may be non-specific or confused with a mild, superficial infection. [abc.net.au]

• 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]

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

  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]

• 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]

• Leukocytosis

  Fever and leukocytosis were more common in teenage patients. Monomicrobial necrotizing (type 2) fasciitis was much more common than polymicrobial (type 1) fasciitis. Next to Streptococci and Staphylococci, Pseudomonas aeruginosa was often isolated. [ncbi.nlm.nih.gov]

  A blood test usually shows that the number of white blood cells has increased (leukocytosis). The specific bacteria causing the infection are identified by laboratory analysis of blood or tissue samples (culture). [msdmanuals.com]

  Laboratory studies typically reveal signs of 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 [nursingcenter.com]

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.

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.

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]:

• Streptococci (group A, Streptococcus pyogenes)
• Methicillin resistant Staphylococcus aureus
• Clostridium perfringens
• Bacteroides fragilis
• Aeromonas hydrophila
• Vibrio vulnificus
• Pseudomonas

It may also be due to opportunistic fungal infections inclding:

• Candida
• Zygomycetes

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)

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.

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.

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.

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”.

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.

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.