Streptococcal necrotizing fasciitis and the dermatologist

The performance of clinical risk scores in the diagnosis of necrotising fasciitis

OBJECTIVE

Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems.

METHODS

This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality.

RESULTS

A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively).

CONCLUSION

The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.

Necrotizing Fasciitis: Expect the unexpected

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Necrotizing Fasciitis is a rapidly progressive and potentially lethal soft tissue infection, aggressive surgical debridement supplemented with culture sensitive antibiotics is essential.

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Skin and soft tissue infections due to non-typhoidal salmonella present as subcutaneous abscesses in the vicinity of the G.I tract or as a wound infection post-surgery on a contaminated organ.

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Salmonella Newport has recently been implicated in diarrheal illness in humans specially in those consuming minced beef in the US.

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Necrotizing Fasciitis due to Salmonella, has been reported with group B and C however no previous reports of human NF have been reported with this serovars.

Introduction

Necrotizing fasciitis is a rapidly progressive and potentially fatal soft tissue infection. A wide spectrum of aerobic and nonaerobic organisms has been implicated as the causative pathogen. Necrotizing Fasciitis due to Salmonella serovars have previously been implicated both with and without a prodromal diarrheal illness, but mono-microbial Salmonella NF is very rare.

Case presentation

We have discussed the case of a 67-year-old man who presented with necrotizing fasciitis of the perianal region in the emergency department of our hospital. He underwent serial debridement and a defunctioning colostomy, tissue and blood cultures revealed Salmonella Newport as the culprit microorganism. He received antibiotic therapy tailored to the organism and was discharged on recovery. He currently awaits a reversal of his colostomy.

Discussion

Necrotizing fasciitis infections are rapidly progressive and potentially lethal, a high index of suspicion and aggressive surgical debridement supplemented with culture sensitive antibiotics is essential. Salmonella Newport has recently been implicated in diarrheal illness, associated with consumption of minced beef in the US. To the best of our knowledge, no previous reports of NF have been published related to Salmonella newport. The unexpected growth of this organism from tissue cultures and the excellent response to treatment prompted us to highlight this case as the first report of its type in the medical literature.

Conclusion

Necrotizing soft tissue infections are associated with considerable morbidity and mortality, and delayed recognition and treatment can have severe implications. Necrotizing fasciitis due to Salmonella serovars has been reported with Group B and C however no previous reports of NF have been reported with this serovar.

Severe soft tissue infection masquerading as necrotising fasciitis in a 31-year-old woman with a background of right thigh arteriovenous malformation

A 31-year-old woman with a history of a right thigh arteriovenous malformation presented with an acute history of right thigh pain and swelling. This rapidly progressed to gross sepsis. She was intubated, requiring inotropic support and renal replacement therapy. She was considered disproportionately unwell, with the impression one of necrotising fasciitis (NF). She was taken to theatre for emergency exploration and debridement. There was no evidence of NF to note in theatre. Tissue samples cultured group C Streptococcus, with histopathological examination confirming group C Streptococcal soft tissue infection. Thereafter, she was treated with high-dose intravenous antibiotics, use of a negative pressure wound therapy system, and multiple returns to theatre for repeat debridement. Her condition gradually improved, and she was stepped down to a surgical ward 3 weeks after admission. Nine weeks after initial presentation, she underwent skin grafting for wound closure. She returned to work 7 months later.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer)

We report a case of under treated necrotizing fasciitis (NF) in a 65-year-old woman with diabetes misdiagnosed as Mycobacterium ulcerans infection. She came to the Institut Médical Evangélique (IME) with an extensive painful edematous ulcerated lesion on the dorsum of the right foot and ankle. The diagnosis of Buruli ulcer (BU) was based initially on clinical findings and place of residence (Songololo Territory, the largest known focus of BU in Bas-Congo province). Tissue specimens gave negative results for acid-fast bacilli (AFB), culture, and polymerase chain reaction (PCR) for M. ulcerans. Histopathologic analysis revealed marked necrosis of the lower dermis and subcutaneous tissue. No AFB was found. Later, scattered foci of intracellular gram-positive cocci typical of streptococci were seen. Clinicopathologic correlation of these findings strongly supported the diagnosis of NF. This patient shows the difficulties that may be encountered even in known endemic areas in recognizing BU cases purely on clinical findings.

Necrotizing fasciitis

Necrotizing fasciitis is an uncommon, rapidly spreading infection, affecting primarily the deep fascia, which may result in secondary necrosis of the subcutaneous tissue, fascia and muscle. We report a patient that had the cardinal features; namely, excruciatingly painful lesions, demonstration of gas in the tissue and an obnoxious foul odor, prominent erythema, induration, patchy necrosis, and loss of sensation in the left buttock and thigh. Its onset probably followed inadvertent trauma/injury of the left buttock. Corroborative microscopic pathology confirmed the diagnosis. Debridement and intensive supportive therapy comprising antibiotics, analgesics and fluids were given. The outcome of the therapy was gratifying.

Necrotizing fasciitis

Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft-tissue infection. The single most important variable influencing mortality is time to surgical débridement. Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.

Eikenella Corrodens Causing Necrotizing Fasciitis after an Elective Inguinal Hernia Repair in an Adult: A Case Report and Literature Review

We report an unusual case of necrotizing fasciitis in a 43-year-old man after elective inguinal hernia repair. The patient presented to the emergency department 9 days postoperatively with high fevers, tachycardia, and crepitus along his abdominal wall. He was treated with broad-spectrum antibiotics and underwent a diagnostic laparoscopy as well as a wide debridement of all necrotic tissue. Cultures grew out Eikenella corrodens, which, to our knowledge, has only been reported in one other case as a cause of necrotizing fasciitis. Patients can develop necrotizing fasciitis after elective, clean procedures and should be adequately resuscitated, undergo immediate surgical debridement, and receive antibiotics. Laparoscopy can be useful in determining if intraabdominal pathology is the cause of the infection and a wound vacuum-assisted device is a cost-effective way to decrease healing times.

Necrotizing fasciitis: reviewing the causes and treatment strategies

PURPOSE

To update the practitioner with causes, diagnosis, and treatment options for necrotizing fasciitis.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in better understanding the pathophysiology, diagnosis, and treatment of necrotizing fasciitis.

OBJECTIVES

After reading this article and taking this test, the reader should be able to: 1. Identify the risk factors and causes of necrotizing fasciitis (NF). 2. Describe the clinical presentation and diagnosis of NF. 3. Explain the treatment options for NF.

Necrotizing fasciitis: a deadly infection

Necrotizing fasciitis (NF) is a life-threatening condition, consisting of a soft-tissue infection with rapidly progressive, widespread fascial necrosis. NF may be caused by a wide variety of microbes. Indeed, NF may be an infection of one species of bacteria or may be polymicrobial. Prompt diagnosis and treatment are essential. Surgical debridement and antibiotic therapy are the primary treatment options.

Life-threatening necrotizing fasciitis

Necrotizing fasciitis is characterized by a rapidly progressing necrosis of subcutaneous fat and fascia, which can be life-threatening without prompt recognition, surgical intervention, and immediate antibiotic therapy. Necrotizing fasciitis has been subdivided into type 1, or polymicrobial necrotizing fasciitis, and type 2, or group A streptococcal necrotizing fasciitis. In addition, synonyms, such as streptococcal gangrene and "flesh-eating bacteria syndrome," have been used in the literature.

A guide to antibiotic resistance in bacterial skin infections

The emergence of bacterial resistance to commonly used antibiotics is not new. In this review we have tried to cover the ever increasing problems facing the treatment and containment of bacterial skin infections. We have tried to give an overview of the varied mechanisms by which bacteria gain and spread antimicrobial resistance, whilst dealing with the patterns of resistance exhibited by some of the commonly encountered organisms. Where there is evidence, we have formulated an approach on how to tackle antibiotic resistance. Where there is a lack of evidence we have formulated what we perceive to be appropriate guidelines.

Necrotising fasciitis

Necrotising fasciitis is a rare soft tissue infection, primarily involving the superficial fascia and resulting in extensive undermining of the surrounding tissues. The author of this article describes her experience when encountering this distressing condition.

Necrotizing fasciitis in a child: a rare complication of idiopathic nephrotic syndrome

In nephrotic syndrome there is an increased tendency for bacterial infections due to immunological changes secondary to proteinuria, treatment (including steroids), and other as yet unknown causes. However, necrotizing fasciitis (NF) is an uncommon complication of the disease and has rarely been reported in nephrotic children. We report a 14-month-old boy with nephrotic syndrome who developed sepsis and NF as a complication. He was treated successfully with intensive medical and surgical treatment.

Management of a patient with postoperative necrotizing fasciitis

This case study highlights the care of a diabetic woman who had previously undergone elective surgery for a hernia repair, and who later presented with necrotizing fasciitis. The need for a flexible approach to dressing choice is emphasized in terms of patient comfort and ease of management in the community.