1
|
Friederichs J, Gerl B, Schneidmüller D, Hungerer S. Severe necrotizing soft tissue infections-Is wound microbiology a prognostic factor for clinical outcome? Int Wound J 2023; 20:4235-4243. [PMID: 37646330 PMCID: PMC10681420 DOI: 10.1111/iwj.14325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023] Open
Abstract
Necrotizing soft tissue infections (NSTIs) represent similar pathophysiological features, but the clinical course might range from subacute to a rapidly progressive, fulminant sepsis. Initial wound microbiology is the base for the Guiliano classification. The timeline of microbiological colonization has not been described during the clinical course. The role of the different microbiological pathogens on the outcome and mortality is unclear. One hundred eighty patients were included with septic inflammation response syndrome on admission. Initial wound microbiology and the changes in wound microbiology were analysed during the clinical course and correlated with outcome and risk indicators. Overall mortality was 35%. Higher age, a high Charlson Comorbidity Index or ASA score and truncal infections were highly prognostic for a lethal outcome. Microbiological findings revealed significant differences in the persistence of bacteria during the course of disease. Streptococci were only detectable within the first 5 days, whereas other bacteria persisted over a longer period of time. Initial microbiological findings correlated with better prognosis when no causative agent was identified and for gram-negative rods. Varying survival rates were observed for different Streptococci, Staphylococci, Enterococci and other bacteria. The highest odds ratio for a lethal outcome was observed for Enterococci and fungi. Microbiological colonization changes during the clinical course of NSTIs and some microbiologic pathogens are predictive for worsening the outcome and survival. Streptococcus pyogenes is only detectable in the very early phase of NSTI and after 6 days not anymore detectable. Later Enterococci and fungi showed the highest odds ratios for a lethal outcome. Enterococci bacteria and fungi have yet not been considered of clinical relevance in NSTI or even as indicator for worsening the outcome.
Collapse
Affiliation(s)
- Jan Friederichs
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - Benedikt Gerl
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - D. Schneidmüller
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - Sven Hungerer
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
- Institute for BiomechanicsParacelsus Medical UniversitySalzburgAustria
| |
Collapse
|
2
|
Matsuki J, Ishigami A, Tanaka M, Hata S, Ishida Y, Nosaka M, Kuninaka Y, Yamamoto H, Shimada E, Hashizume Y, Takayasu T, Kimura A, Furukawa F, Kondo T. A case of necrotizing fasciitis following intra-articular injections - Iatrogenic or spontaneous? Leg Med (Tokyo) 2021; 54:101989. [PMID: 34798589 DOI: 10.1016/j.legalmed.2021.101989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/25/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
Here, we report a case of necrotizing fasciitis following intra-articular injection of hyaluronic acid. A 73-year-old female received intra-articular injections of hyaluronic acid due to arthralgia at the left shoulder and knee, and was found dead in her living room at one day. At the forensic autopsy, injection marks with bullae and erythema were found at the left shoulder and knee and liquefactive necrosis of muscle tissues was observed in the left but not right extremities. Histopathological examinations of the left upper arm and thigh revealed severe rhabdomyolysis with lots of bacterial clusters. Bacteriological examinations detected group A Streptococcus from intracardiac blood and affected muscle tissues. Postmortem biochemical analysis of blood showed escalated blood urea nitrogen (133.8 mg/dL), creatinine (4.57 mg/dL) and C-reactive protein (45.0 mg/dL). The cause of her death was diagnosed as streptococcal toxic shock syndrome (STSS). Moreover, it was suggested that the injection was inappropriately conducted and served as a portal of bacterial entry.
Collapse
Affiliation(s)
- Jumpei Matsuki
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Akiko Ishigami
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Motonari Tanaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Satoshi Hata
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yuko Ishida
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Mizuho Nosaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yumi Kuninaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Hiroki Yamamoto
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Emi Shimada
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yumiko Hashizume
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Tatsunori Takayasu
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Akihiko Kimura
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Fukumi Furukawa
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Toshikazu Kondo
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan.
| |
Collapse
|
3
|
Falkner F, Thomas B, Hundeshagen G, Wittenberg G, Bliesener B, Bigdeli AK, Kneser U. One-stage double free flap arteriovenous loop reconstruction of a massive abdominothoracic defect following necrotizing fasciitis: A case report. Microsurgery 2020; 40:911-915. [PMID: 33085145 DOI: 10.1002/micr.30673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/27/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
We report the case of a 67-year old male with necrotizing fasciitis after injection of the glenohumeral joint. After extensive debridement a massive defect from the left hip joint to the left upper arm, exposing ribs, scapula, axillary vessels and brachial plexus (45 × 40 cm) was present. Reconstruction was performed with a conjoined right myocutaneous tensor fasciae lata/vastus lateralis flap and a left myocutaneous vastus lateralis flap in combination with an arteriovenous loop originating from the axillary vessels using the greater saphenous vein. Revisional surgeries were necessary including ribs resection and flap re-advancements. Due to multiorganic failure invasive ventilation, renal replacement- and extensive transfusion therapy was required. After 241 days the patient was discharged for rehabilitation. At the 12 months follow-up wounds were sufficiently closed without the need for further intervention. This case illustrates that immediate diagnosis followed by an aggressive multidisciplinary treatment approach is crucial for the patient survival.
Collapse
Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Wittenberg
- Department of Anesthesia, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Anesthesia, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
4
|
Floether L, Bucher M, Benndorf R, Burgdorff AM. Necrotizing fasciitis caused by the treatment of chronic non-specific back pain. BMC Anesthesiol 2020; 20:245. [PMID: 32979925 PMCID: PMC7519487 DOI: 10.1186/s12871-020-01161-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/15/2020] [Indexed: 12/02/2022] Open
Abstract
Background Chronic back pain is a multifactorial disease that occurs particularly in adults and has many negative effects on the quality of daily life. Therapeutic strategies are often multimodal and designed for a long-term therapy period. In some cases, one option is joint infiltration or intrathecal injection with local anaesthetics. An adverse effect of this intervention may be necrotic fasciitis, a disease with high mortality and few therapeutic options. Case presentation This case shows a 53-year-old female patient who developed necrotic fasciitis after infiltrations of the sacroiliac joint and after epidural-sacral and intrathecal injections. Conclusion Thanks to early and aggressive surgical intervention, antibiotic treatment and hyperbaric oxygenation, she survived this serious complication and was able to return to life.
Collapse
Affiliation(s)
- Lilit Floether
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany.
| | - Michael Bucher
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Ralf Benndorf
- Department of Clinical Pharmacy and Pharmacotherapy, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Anna-Maria Burgdorff
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| |
Collapse
|
5
|
[Necrotizing fascitis in a patient infected by trocanteritis: Use of the LRINEC scale in early detection]. Semergen 2020; 47:e17-e18. [PMID: 32778362 DOI: 10.1016/j.semerg.2020.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/14/2020] [Indexed: 11/22/2022]
|
6
|
Inoue M, Kako E, Kinugasa R, Sano F, Iguchi H, Sobue K. Necrotizing fasciitis following primary peritonitis caused by Streptococcus pyogenes with covS mutation in a healthy woman: a case report. JA Clin Rep 2019; 5:29. [PMID: 32025929 PMCID: PMC6966751 DOI: 10.1186/s40981-019-0249-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background Primary peritonitis due to Streptococcus pyogenes (S. pyogenes) is uncommon in patients without comorbid conditions such as immunosuppression, nephritic disease, or liver cirrhosis. Furthermore, it does not cause another infection at the same time in a healthy person. However, several S. pyogenes mutants have been reported, and some of them exhibit strong virulence. Mutation of the control of virulence (cov) S gene of Streptococcus enhances bacterium survival by repressing negative regulators of virulence, which causes bacterial invasion of aseptic tissues, such as the parenteral space. We report a case of primary peritonitis and subsequent necrotizing fasciitis by the same S. pyogenes species with mutated covS in a previously healthy woman. Case presentation We present the case of a 55-year-old woman admitted to the hospital due to abdominal pain and nausea. She was treated for peritonitis. A few days later, she became hypotensive and tachycardic and was transferred to the intensive care unit (ICU) for the treatment of septic shock with primary peritonitis. On the second day of her ICU stay, both of her forearms developed swelling and redness around the peripheral injection site. The patient had developed necrotizing fasciitis. Since her skin symptoms spread rapidly, urgent debridement was performed. Her condition improved with antibiotic treatment and multiple episodes of debridement. S. pyogenes was detected in cultures of the patient’s blood, ascites, and skin. The identified strain was emm89 genotype and had a genetic mutation of covS. Conclusions S. pyogenes with covS mutation may spread from a portal, such as the upper respiratory tract or digestive system, to all organs immediately, causing septic shock. Infection with S. pyogenes with mutated genes should be considered in the differential diagnosis of gastrointestinal symptoms, even in a previously healthy patient.
Collapse
Affiliation(s)
- Masashi Inoue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Rie Kinugasa
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Fumiaki Sano
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hironobu Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| |
Collapse
|
7
|
Garcia-Carretero R, Gonzalez-Moreno M, Rodriguez-Maya B, Isaba-Ares E. Gas-forming gluteal abscess after intramuscular self-injections due to Clostridium perfringens. BMJ Case Rep 2019; 12:12/2/bcr-2018-228408. [PMID: 30755431 DOI: 10.1136/bcr-2018-228408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Marta Gonzalez-Moreno
- Department of Internal Medicine, Hospital Universitario de Mostoles, Mostoles, Spain
| | - Belen Rodriguez-Maya
- Department of Internal Medicine, Hospital Universitario de Mostoles, Mostoles, Spain
| | - Elena Isaba-Ares
- Department of Internal Medicine, Hospital Universitario de Mostoles, Mostoles, Spain
| |
Collapse
|
8
|
Necrotizing Soft Tissue Fasciitis after Intramuscular Injection. Case Rep Surg 2018; 2018:3945497. [PMID: 29854541 PMCID: PMC5964413 DOI: 10.1155/2018/3945497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/10/2018] [Indexed: 11/24/2022] Open
Abstract
Necrotizing soft tissue fasciitis (NSTIs) or necrotizing fasciitis is an infrequent and serious infection. Herein, we describe the clinical course of a female patient who received a diagnosis of NSTIs after gluteus intramuscular injection. We also report the results of our review of published papers from 1997 to 2017. Since now, 19 cases of NSTIs following intramuscular injections have been described. We focus on the correlation between intramuscular injection and NSTIs onset, especially in immunosuppressed patients treated with corticosteroids, suffering from chronic diseases or drug addicted. Intramuscular injections can provoke severe tissue trauma, representing local portal of infection, even if correctly administrated. Otherwise, it is important not to inject drug in subcutaneous, which is a less vascularized area and therefore more susceptible to infections. Likewise, a proper injecting technique and aspiration prior to injection seem to be valid measure to prevent intra-arterial or para-arterial drug injection with the consequent massive inflammatory reaction. Necrosis at the infection site appears to be independent of the drug, and it is a strong additional risk factor for NSTIs.
Collapse
|