Necrotizing fasciitis

Periorbital necrotizing fasciitis -- a review

Necrotizing fasciitis (NF) is a severe infection characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. Periorbital NF is uncommon because of the excellent blood supply to that area; nevertheless, it can sometimes result in death. The aim of this study is to present a systematic review and analyse the factors associated with death. We carried out a systematic literature review of all cases of periorbital NF published in the English language over the past 20 years and present the predisposing conditions, triggering factors, organisms causing NF, presence or absence of toxic shock and the prognosis. The significance of various risk factors leading to death was analysed. We traced a total of 94 patients with periorbital NF from 61 reports. There were no triggering incidents in 25 cases (26.6%). In 48 cases (51.1%), the organism responsible for NF was Group A beta haemolytic Streptococcus. Toxic shock occurred in 29 (30.9%) cases, and loss of vision in 13 (13.8%). Surgical debridement was carried out in 80 (85.1%) cases. There were eight cases (8.5%) of death. This seems to be less than previously reported figures. Toxic shock syndrome (p < 0.001), type 1 infections (p = 0.018), facial involvement (p = 0.032) and blindness because of periorbital NF (p = 0.035) were significantly associated with mortality. Mortality caused by NF arising from the periorbital area seems to be on the decline. However, it is important to recognize it early and institute treatment to avoid toxic shock that leads to death. Type 1 infections, although rare in periorbital area, are not associated with immunocompromised status and nevertheless carry a significant risk of mortality. Major morbidity is loss of vision followed by soft-tissue defects affecting function and cosmesis.

Group A streptococcal necrotizing fasciitis in the emergency department

BACKGROUND

Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients.

OBJECTIVE

An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED.

METHODS

Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group.

RESULTS

During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002-0.16; p < 0.001).

CONCLUSIONS

A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis.

Necrotising fasciitis of odontogenic origin

Necrotising fasciitis (NF) is a rare infection of the fascial planes, which is less common in head and neck, because of the rarity and higher vascularity in the region. We report a case of necrotising fasciitis in a 43-year-old man, arising from a dental infection treated successfully by early diagnosis, prompt surgical management, antibiotic therapy and adjunctive hyperbaric oxygen (HBO) therapy. The diagnosis of descending NF must always be considered in a patient who presents with a history of oropharyngeal infection with evidence of neck swelling, chest pain, and dyspnea or respiratory distress. Aggressive surgical debridement of all involved tissue along with intravenous antibiotic therapy should be initiated before aerobic and anaerobic cultures are obtained. HBO may also be of some benefit in the treatment of this potentially fatal infection.

[Hyperbaric oxygenation for necrotizing soft tissue infections: pro]

Necrotizing soft tissue infections are a complex pathological spectrum of symptoms and result in a significantly increased risk of mortality depending on the degree of dissemination as well as the underlying bacterial infection. Hyperbaric oxygen therapy (HBOT) can significantly improve the effectiveness of a multidisciplinary treatment concept consisting of surgical debridement, critical care and antibiotic treatment. HBOT itself assists solid wound healing by bactericidal and bacteriostatic effects and by increasing the oxygen supply up to the cellular level resulting in an optimization of oxygen-dependent metabolic processes. The efficacy of treatment in a centre of cooperating specialized departments can therefore be increased by utilizing HBOT as adjunct treatment. Nevertheless, if a HBOT facility is available, excluding HBOT is equivalent to omission of an effective therapy option to the disadvantage of patients.

Necrotizing Fasciitis of the Cervical Region following Extravasation Injury

Necrotizing fasciitis is a rapidly progressive soft tissue infection that can cause local tissue destruction, necrosis, and life threatening severe sepsis. Necrotizing fasciitis in the head and neck region caused by an extravasation injury is rare. This paper reports a patient with necrotizing fasciitis of the cervical region caused by an extravasation injury which required an early surgical debridement.

An elderly patient presenting with hip pain following a fall: an unusual presentation of necrotising fasciitis

Necrotising fasciitis (NF) is a rapidly progressive soft tissue infection involving necrosis of subcutaneous tissues. Early surgical intervention reduces mortality, but initial clinical findings are often non-specific and can delay the diagnosis. An 80-year-old patient, presented to our emergency department with pain in her left hip and mild bruising following a fall. An x-ray, requested to investigate a possible hip fracture, in fact demonstrated air in the subcutaneous tissues. She rapidly deteriorated and soon developed blood-filled blisters, crepitus and fixed staining of the skin. She underwent urgent debridement of involved tissues in theatre confirming the diagnosis of NF. The presence of subcutaneous emphysema on plain radiograph as in this case, is extremely specific to the diagnosis of NF. Although other imaging modalities can aid diagnosis these remain as an adjunct rather than a definitive diagnostic tool and should not delay surgical intervention based on clinical findings.

Polymicrobial abdominal wall necrotizing fasciitis after cesarean section

We report a case of a previously healthy woman after an uneventful caesarean section who developed polymicrobial necrotizing fasciitis. She was given a non-steroidal anti-inflamatory drug (NSAID) after her delivery. Her post-delivery course was complicated by septic shock, and required multiple debridements before abdominal reconstruction. This case describes the increased risk of necrotizing fasciitis with NSAID use. Unusual were the organisms causing the polymicrobial necrotizing fasciitis: Staphylococcus aureus, Enterobacter agglomerans, Acinetobacter baumannii, and two strains of Enterobacter cloacae.

Necrotizing Fasciitis Associated with Staphylococcus lugdunensis

Necrotizing fasciitis is a life-threatening soft tissue infection that results in rapid local tissue destruction. Type 1 necrotizing fasciitis is characterized by polymicrobial, synergistic infections that are caused by non-Group A streptococci, aerobic and anaerobic organisms. Type 2 necrotizing fasciitis involves Group A Streptococcus (GAS) with or without a coexisting staphylococcal infection. Here we provide the first report of necrotizing fasciitis jointly associated with the microbes Group B Streptococcus and Staphylococcus lugdunensis. S. lugdunensis is a commensal human skin bacterium known to cause often painful and prolonged skin and soft tissue infections. To our knowledge, however, this is the first case of Staph. lugdunensis-associated necrotizing fasciitis to be reported in the literature.

[Necrotising fasciitis in a patient with common variable immunodeficiency]

Necrotizing fasciitis is a severe infection that leads to necrosis of the tissues and systemic involvement, with a rapid progress and a fatal outcome. Although this condition is rare, it must be suspected and rapidly treated, as the prognosis depends on this. The treatment is based on immediate surgery, wide spectrum antibiotic treatment, and support measures in a critical care unit. We present the case of a patient who was admitted to Recovery room after surgical debridement due to suspicion of fasciitis. The patient also had a common variable immunodeficiency or hypogammaglobulinaemia, characterised by a B lymphocyte deficiency, as well as on treatment with methotrexate for Crohn's disease. Both produced an immune deficiency. After 11 days of treatment there was a clinical, analytical and haemodynamic improvement, and she was discharged.

Infections in patients with diabetes mellitus: A review of pathogenesis

In general, infectious diseases are more frequent and/or serious in patients with diabetes mellitus, which potentially increases their morbimortality. The greater frequency of infections in diabetic patients is caused by the hyperglycemic environment that favors immune dysfunction (e.g., damage to the neutrophil function, depression of the antioxidant system, and humoral immunity), micro- and macro-angiopathies, neuropathy, decrease in the antibacterial activity of urine, gastrointestinal and urinary dysmotility, and greater number of medical interventions in these patients. The infections affect all organs and systems. Some of these problems are seen mostly in diabetic people, such as foot infections, malignant external otitis, rhinocerebral mucormycosis, and gangrenous cholecystitis. In addition to the increased morbidity, infectious processes may be the first manifestation of diabetes mellitus or the precipitating factors for complications inherent to the disease, such as diabetic ketoacidosis and hypoglycemia. Immunization with anti-pneumococcal and influenza vaccines is recommended to reduce hospitalizations, deaths, and medical expenses.

Drug induced neutropaenia--a trigger for necrotising fasciitis?

The authors present a case of necrotising fasciitis of the peristomal area, in a patient who had undergone a previous ileostomy for ulcerative colitis. This was associated with neutropaenia, secondary to carbimazole, which had been commenced a few weeks previously for thyrotoxicosis. The authors therefore, stress the importance of monitoring patients closely for possible side effects and complications, while they are on immunosuppressive medication.

Necrotizing fasciitis of the chest wall caused by infected dentigerous cyst: a case report

Necrotizing fasciitis of the chest wall is a fairly uncommon condition. Early diagnosis and treatment is the two main factors responsible for the prognosis. Odontogenic cause of the necrotizing fasciitis of the chest wall is a rare phenomenon. It can be easily missed during the initial examination. Mortality still remains high in necrotizing fasciitis despite the use of modern powerful antibiotics and advances in the care of critically ill patients. The disease manifestation can range from a fulminant presentation to a subtle and insidious development. In this paper we are presenting a case of necrotizing fasciitis of chest wall caused by infected dentigerous cyst.

Fournier's gangrene in a patient receiving treatment for idiopathic thrombocytopenic purpura

We report the case of a 68-year-old man who was diagnosed with Fournier's gangrene (FG), which developed during immunosuppresive treatment for idiopathic thrombocytopenic purpura (ITP). The patient was administered steroids for ITP but on the 36th day, he developed FG and septic shock. We initiated antibiotic treatment and drained a periproctal abscess immediately. On day 53, extensive drainage to progressive FG and a splenectomy was performed, following which both FG and thrombocytopenia improved. This is the first case of FG has developing in a ITP patient. It appears that high-dose immunoglobulin therapy and splenectomy should be considered earlier especially for a patient complicated with FG.

Necrotizing fasciitis of the breast: a case managed without mastectomy

OBJECTIVE

To report a rare presentation of necrotizing fasciitis (NF) in the breast and its management.

CLINICAL PRESENTATION AND INTERVENTION

A 61-year-old non-diabetic lady presented with a painful swollen right breast and yellowish discharge associated with fever for the last few days. Based on clinical examination and haematological parameters, a provisional diagnosis of breast abscess was made that later proved to be a case of NF. She was managed conservatively with repeated debridement followed by split-skin grafting with preservation of the breast.

CONCLUSION

This case showed that NF of the breast can present as a simple breast abscess which was managed conservatively.