Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience

BACKGROUND

Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we attempted to determine the diagnostic and prognostic value of the LRINEC score.

METHODS

A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively.

RESULTS

The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84%, respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared to 2.4, respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations.

CONCLUSION

In isolation, we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, because of its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.

Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, severe soft tissue infection, characterized by rapid and extensive necrosis of the skin, subcutaneous tissue, and superficial and deep fascia. It is frequently misdiagnosed as other infectious diseases, leading to inappropriate treatment and potentially serious consequences. It may be complicated by septic shock and multiple organ failure with a fatal outcome.

PATIENT CONCERNS

A 73-year-old woman presented with continuous itching, skin lesions, pain, and swelling of the outer side of her left leg. The patient was diagnosed with septic shock and multiorgan failure caused by left leg NF.

DIAGNOSIS

Septic shock and multiorgan failure caused by left leg NF.

INTERVENTIONS

Two surgeries were performed on the patient's leg, which effectively treated her septic shock and multiple organ dysfunction.

OUTCOMES

The patient was followed up three times after her discharge. She had a good recovery, was generally well with no significant sequelae, and returned to her regular life.

CONCLUSION

NF is an acute severe illness with high mortality. It is easily misdiagnosed, leading to delayed or erroneous treatment and serious (or potentially fatal) outcomes. Rapid and accurate diagnosis of NF is essential for patient recovery. In difficult cases, multidisciplinary consultations may be helpful. The management of NF includes early and thorough surgical debridement, antibiotics, and symptomatic treatment.

Necrotizing Fasciitis of the Upper Extremity - A Review

Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.

A Rare Case of Acute Infectious Purpura Fulminans Caused by Klebsiella Pneumoniae and Human Herpesvirus Type 5

Background

Purpura fulminans (PF), a rare, life-threatening disorder, is a hematological emergency in which there is skin necrosis, disseminated intravascular coagulation (DIC), and protein C deficiency. In PF, the skin necrosis and DIC are secondary to protein C deficiency. This may progress rapidly to multiorgan failure caused by the thrombotic occlusion of small- and medium-sized blood vessels.

Case Report

This article presents the case of a 22-year-old male with fever as well as necrotic and purpuric skin lesions. The ultrasound and computed tomography scans revealed infections in the skin wounds as well as venous microthrombosis and thrombosis in multiple intracranial and pulmonary vessels. The laboratory tests showed signs of sepsis, thrombocytopenia, an abnormal decrease in protein C and antithrombin III, DIC, multiple organ and system failures, gastric varices, and gastrointestinal hemorrhage. The blood, sputum, and secretions under the skin lesions were cultured and were positive for Klebsiella pneumoniae. The results of the high-throughput genetic testing of the pathogenic microorganism DNA were consistent. In addition, human herpesvirus type 5 was detected. The histopathological examination of the skin lesions revealed pathological features consistent with PF. After successful treatment by the departments of Dermatology, Emergency Critical Care Medicine, and the Intensive Care Unit, the patient was discharged after 67 days of hospitalization.

Conclusion

Adults with acquired protein C and/or S deficiency states, including certain bacterial and viral infections, who drink alcohol and take varieties of non-steroidal anti-inflammatory analgesics at the same time, may develop acute infectious PF. Clinicians should be aware of this for early diagnosis and treatment.

Necrotizing Soft Tissue Infections of the Perineum

Necrotizing soft tissue infections of the perineum are rapidly progressing infections associated with significant morbidity and mortality. Prompt diagnosis and management with early surgical debridement is necessary to improve survival from this deadly disease. Repeat debridements are not uncommon. Important adjuncts to surgery include broad-spectrum antibiotics and management in an intensive care unit, as patients frequently develop multisystem organ failure. Once the acute phase is managed, fecal diversion with either an ostomy or fecal management catheter can be considered to decrease soiling of the wound and facilitate healing. Long-term management requires meticulous wound care, often with the assistance of negative pressure wound therapy. Patients may ultimately require skin grafts or tissue flaps for soft tissue coverage following extensive surgical debridements.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

Comparison of LRINEC Scoring System with Finger Test and Histopathological Examination for Necrotizing Fasciitis

Background  Necrotizing fasciitis (NF) is a life-threatening condition requiring urgent attention. It is clinically difficult to diagnose, linked to severe systemic toxicity, and has poor prognosis. In 2001, Andreasen and coworkers described the "Finger test" for the diagnosis of NF. Subsequent studies have suggested early recognition and management of NF. In this study, we compare the LRINEC-Laboratory Risk Indicator for Necrotizing Fasciitis-scoring system with the "Finger test" and histopathological examination for diagnosis of NF. Results  In our study, LRINEC scoring system and Finger test are statistically significant in the diagnosis of NF. Males are more frequently affected, and the most common organism causing NF is Staphylococcus . Histopathology remained the gold standard for diagnosis of NF, while LRINEC score and Finger test were good diagnostic tools for early diagnosis, with sensitivities of 83.33 and 86.11%, respectively. Conclusion  LRINEC laboratory-based scoring system is easy and reliable diagnostic tool though histopathology remains the gold standard. There is statistically significant correlation between histopathology and laboratory criteria. LRINEC test is independently better than bedside Finger test alone or combined LRINEC and bedside Finger test.

Necrotizing fasciitis of the chest wall: A clinical case report and literature review

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

Labio-facial Necrotizing Fasciitis in a Young Patient

ABSTRACT

Necrotizing fasciitis (NF) is an infection of the deeper tissues that results in progressive destruction of muscle fascia and overlying subcutaneous fat. It has a fast and destructive course. Moreover, it is related to immunosuppression and could be fatal. The aim of this study is to report a clinical case of a young patient, without immunosuppression, who developed NF evolution due to an erroneous diagnosis of abscess at the beginning of the disease. Patient was submitted to broad-spectrum antibiotic therapy and aggressive surgical treatment. Adequate treatment led to a satisfactory evolution in a short period of time. Early recognition and adequate treatment are essential for a favorable prognosis.

Pediatric necrotizing soft tissue infection after elective surgery: A case report and literature review

INTRODUCTION

Necrotizing soft tissue infections (NSTIs) are rare but often lethal. Early diagnosis and aggressive surgical debridement are essential to achieve the best possible outcome.

CASE PRESENTATION

A 12-year old boy was diagnosed with a necrotizing soft tissue infection following elective revision surgery for functional impairment resulting from scar tissue of the neck. Fever and inflammation of the surgical wound manifested 24-36 hours postoperatively. Antibiotic therapy with amoxicillin-clavulanic acid was initiated, but the patient was unresponsive. Ultrasonography, a wound culture and surgical exploration confirmed the diagnosis. The culture was positive for a Streptococcus pyogenes infection and antibiotic treatment was switched to penicillin and clindamycin. Following the diagnosis, surgical debridement was performed subcutaneously, and only necrotic tissue was removed to preserve as much skin tissue as possible. After eradication of the infection, vacuum-assisted closure of the wound was used to close the subcutaneous space. The patient was discharged after 40 days.

CONCLUSION

In this patient, we treated a necrotizing soft tissue infection with antibiotics, skin sparing surgeries and negative pressure wound therapy (NPWT). We used ultrasonography as imaging technique to help with the diagnosis. The extensiveness of surgical debridement was rather limited. We focused on opening all affected fascial layers. The surgical debridement was subcutaneous, and only necrotic tissue was removed. Because of the location in the neck, we tried to avoid an aggressive skin debridement to preserve as much skin tissue as possible. Negative pressure wound therapy is not frequently used in this context but it contributed to an enhanced wound healing. Ultrasonography for diagnosing NSTIs is useful, but the clinical findings and an explorative surgery will remain most important.

Validation of finger test for necrotising soft tissue infection

Background:

Necrotising soft tissue infection (NSTI) is rare but fatal. Andreasen proposed finger test as an early diagnostic tool to differentiate NSTI from other soft tissue infections. We aim to evaluate the accuracy and reproducibility of the test for the diagnosis of NSTI.

Methods:

Patients who were admitted to our department from 2012 to 2016 with suspicion of NSTI and finger test done were retrospectively reviewed. Finger test was done and interpreted as described by Andreasen. Definitive diagnosis of NSTI was confirmed with surgical and pathological findings.

Results:

Among the 35 patients included in the study, NSTI was confirmed in 10 cases. Finger test had a sensitivity of 100%, a specificity of 80%, positive predictive value of 66.7%, negative predictive value of 100% and an overall accuracy of 85.7%. There was no difference in demographics or comorbidities between NSTI and non-NSTI groups. Surgeons involved had 76.7% agreement and moderate reproducibility (kappa = 0.48) on the diagnostic criteria of finger test.

Conclusion:

A negative finger test was reliable to exclude NSTI and a positive test suggested further surgical exploration. Yet, clinical judgement was still of paramount importance to treat NSTI promptly.

Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study

BACKGROUND

Necrotizing soft tissue infection (NSTI) of the upper extremities is a rare, but potentially life-threatening infection in patients with type 2 diabetes mellitus (T2DM). We analyzed the clinical characteristics and the outcome of NSTI of upper extremities in these patients.

METHODS

This was a retrospective study analyzing the clinical characteristics and the outcomes of 33 T2DM patients with NSTI of upper extremities, who were treated in the department of hand surgery between January 2011 and December 2017.

RESULTS

Predisposing factors for NSTI were recognized in 16 (48.5%) patients. Eleven (33.3)% patients had septic shock while ten (30.3%) had acute renal insufficiency at the time of presentation, of which six required dialysis. The mean glycosylated hemoglobin was 9.6(±2.6)% and the random plasma glucose at admission was 271(±96) mg/dl. Monomicrobial infection was seen in 16(49%) patients and polymicrobial infection in 9(27%) patients. Gram-positive causation was found in 25(66%) patients. Twelve (36.4%) patients required amputation, six (18.2%) of which were major. Death occurred in more than one-fifth (21.2%) of the patients during treatment.

CONCLUSION

Necrotizing soft tissue infection of the upper extremities in T2DM is associated with increased risk of severe infection, amputation and mortality.

Necrotizing Infections of the Hand and Wrist: Diagnosis and Treatment Options

Necrotizing infections of the hand and wrist are important clinical entities because of their rapidly progressive and potentially lethal nature. These infections encompass a spectrum of diseases with overlapping signs and symptoms, which can be subtle and nonspecific. If the brief prodromal period of these infections goes unrecognized, a local area of devitalized tissue can evolve into fulminant infection, multiorgan failure, and potentially death. Early recognition and treatment including administration of broad-spectrum antibiotics and surgical débridement are paramount to improving patient outcomes.

Purpura Fulminans: a Rare but Fierce Presentation of Pneumococcal Sepsis

Infectious purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) due to diffuse intravascular thrombosis and haemorrhagic infarction of the skin. PF can present in infancy/childhood or adulthood and usually presents as ecchymotic skin lesions, fever and hypotension. It is most commonly a consequence of sepsis related to Neisseria meningitidis, Streptococcus pneumoniae or Haemophilus influenzae. Despite aggressive management of sepsis with intravenous fluids, antibiotics, and conventional and nonconventional therapies, the condition still carries a mortality rate of 43%^[1]. Streptococcus pneumoniae mostly presents with community-acquired pneumonia. We present a case of PF secondary to DIC related to Pneumococcal sepsis in an otherwise healthy and immunocompetent patient.

Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis

Background

Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults.

Methods

This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded.

Results

Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms.

Conclusion

This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.

Necrotizing fasciitis induced by Vibrio vulnificus in patients without marine contact in Hong Kong

Necrotizing fasciitis caused by Vibrio species is a life-threatening soft tissue infection with rapid progression and high mortality. The classic history of Vibrio species–induced necrotizing fasciitis is the infection of wounds by direct invasion or contact with contaminated seawater or raw seafood, especially in immunocompromised patients.

We present two cases of Vibrio vulnificus necrotizing fasciitis in the upper limb without any wounds or seawater contact and with good past medical history. Both underwent timely surgical debridement and resulted with good functional outcome. Although rare, as clinicians, we need to have a high index of suspicion for the possibility of V. vulnificus necrotizing fasciitis despite no risk factors and give timely and appropriate treatment and, more importantly, patient survival.

Cervical necrotising fasciitis: a rare complication of infectious mononucleosis

Cervical necrotising fasciitis (NF) is an aggressive polymicrobial infection of the subcutaneous tissues in the head and neck. We present a case of a healthy 19-year-old man who developed cervical and upper mediastinal NF after an initial presentation of infectious mononucleosis (IM). He was treated with broad-spectrum antibiotics in addition to incision and drainage of an anterior neck and upper mediastinal abscess. He progressed favourably after ten days of hospitalisation and was discharged home on intravenous antibiotics. This is a unique case of cervical NF as a sequelae of IM in a previously healthy paediatric patient.

Necrotizing fasciitis of the finger

A 62 year old woman with a medical history of hypertension presented to her local general practice with moderate pain in the right ring finger which worsened over a few hours after onset. Her condition progressed swiftly into sepsis and required hospital admission in the intensive care unit. Over the course of 24 h the patient was diagnosed with necrotizing fasciitis in the finger but unfortunately despite treatment with antimicrobials and surgical debridement the patient’s finger could not be saved and she had amputation of her finger.

Post-traumatic occipital psoriatic plaque complicated by extensive necrotizing fasciitis of the head and neck: a case report and literature review

Necrotizing fasciitis (NF) is a severe infection involving the superficial fascial layers, subcutaneous cellular tissue, and possibly skin. It usually has a fulminant evolution, rapidly leading to death in the absence of early diagnosis and aggressive surgical treatment. We herein report a rare case of NF secondary to a traumatized occipital psoriatic plaque in an alcoholic 47-year-old woman and compare this case with the published literature. The NF extended to the entire scalp, right face, and posterior and lateral cervical region. Despite the initially guarded prognosis, the patient’s survival emphasizes the importance of aggressive surgical treatment with wide excision of all necrotic structures without any aesthetic compromise.

Frozen sections are unreliable for the diagnosis of necrotizing soft tissue infections

Necrotizing soft tissue infections are rare but are associated with high rates of morbidity and mortality. The use of bedside or intraoperative frozen sections has been reported to be associated with faster diagnosis and better outcomes; however, to date no large studies have been published to determine the sensitivity and specificity of frozen sections in this setting. Twenty years of cases suspicious for necrotizing soft tissue infection at a large academic referral center were reviewed, blinded to the final clinical diagnosis (gold standard). Cases were assessed for the number of neutrophils, extent of necrosis, presence of thrombi, bacteria, karyorrhexis, and fibrin, and concordance with permanent sections. A total of 166 cases suspicious for necrotizing soft tissue infection had frozen section slides available for review. Sixty-three cases were clinically determined to be positive and 103 negative. Neutrophils, necrosis, thrombi, bacteria, karyorrhexis, and fibrin were present in both positive and negative cases; however, no histological feature or combination of features was found to be both sensitive and specific for necrotizing soft tissue infection. The combined presence of necrosis and frequent neutrophils was 73% sensitive and 68% specific, with a 58% positive predictive value and 80% negative predictive value. The additional observation of bacteria decreased sensitivity to 32%, whereas raising specificity to 91%, with 69% positive predictive value and 68% negative predictive value. Thirty-two cases (19%) contained findings identified on permanent sections (eg, bacteria) not observed on frozen section slides, highlighting the risk of false negatives owing to technical limitations or sampling errors. Frozen sections in necrotizing soft tissue infections and negative cases may show similar histological findings. Combined with the risk of false negatives, these results suggest that frozen sections are likely to be of limited clinical utility due to lack of sensitivity and specificity, and risk for delayed diagnosis and treatment.

Acute Kidney Injury in a Case of Purpura Fulminans Developing Secondary to Antithrombin 3 Deficiency

Purpura fulminans associated with antithrombin 3 (AT 3) deficiency is very rare in adults and neonates. It can be categorized into three principal forms - neonatal, idiopathic and acute infectious. Purpura fulminans has been reported to cause cardiac, pulmonary and renal damage in rare cases. We describe an adult case of purpura fulminans developing in association with AT 3 deficiency without infection following a surgical procedure, and acute kidney injury (AKI) developing secondary to rhabdomyolysis and disseminated intravascular coagulation (DIC). To the best of our knowledge there have been no previous cases of purpura fulminans and AKI developing in association with acquired AT 3 deficiency without infection after surgery.

Successful management of a 24-year-old pregnant woman with necrotising fasciitis of the forearm

A 24-year-old woman who was 24 weeks pregnant presented to the emergency department with septic shock and an elbow wound that had become infected. She sustained an injury to the tip of the right elbow on a light switch 4 days prior. In the space of 1 day, she developed a necrotising soft tissue infection, which was rapidly spread to the forearm with florid sepsis. Her initial serum C reactive protein was 392 mg/L, and white cell count was 32×10⁹/L. The patient was treated promptly with aggressive surgical debridement and broad-spectrum antibiotics. An early multidisciplinary approach including orthopaedic surgeons, anaesthetics, intensive care, obstetrics, microbiologists and paediatrics was taken. Ultimately, both mother and child had an excellent outcome, the former of whom only had minimal soft tissue resection and primary wound closure. Emphasis is made on first treating the mother as the patient and priority.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.

Reconstruction of Near-Total Loss of the Upper and Lower Lips due to Purpura Fulminans with Local Tissue and a Dual-Skin Paddled Anterolateral Thigh Flap

It is difficult to totally reconstruct the lip, achieving good functional and aesthetic results. There have been few reports of reconstructing complete lip defects. Moreover, upper and lower lip necrosis by purpura fulminans has not been reported. We present a case of a 60-year-old male purpura fulminans patient with upper and lower lip necrosis. Fortunately, our patient had retained his oral commissure function. We reconstructed this defect with an orbicularis oris muscle-skin-mucosal pedicled flap derived from the region between the nasolabial folds for upper lip; a similar bipedicled flap for the lower lip and the donor site was closed with a dual-skin paddled anterolateral thigh flap. Postoperative results were satisfactory, that is, no lip tightness or aperture restriction was seen, and symmetry had been achieved. The new lips exhibited complete sensory recovery. Drooling was minimal during rest and feeding. We could select a method that combined the advantages of local and free flaps. We consider our method for this defect is superior to those described in previous studies, in that the restoration of lip sensation and oral sphincter function can be achieved to some extent in 1 stage while preserving the oral commissure function.

Learning from Clinical Experience with Necrotizing Fasciitis: Treatment and Management

GENERAL PURPOSE

To provide information about necrotizing fasciitis (NF), how to recognize it, and evidence-based treatment.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, you should be able to: ABSTRACT: Necrotizing fasciitis is a threatening, rapidly progressive, infectious disease of the soft tissue. In this article, based on 3 cases, the authors aim to summarize the clinical experience of patients with necrotizing fasciitis and the current concepts of the treatment and management of this disease.

Necrotizing Fasciitis of the Cheek: A Case Report

The term necrotizing fasciitis (NF) was first used by Wilson in 1952, who described this rare, however, progressive infection that primarily affects the fascia and subcutaneous tissues. Necrotizing fasciitis may affect any part of the body; however, it usually appears on the extremities. The most common microorganisms isolated in NF areStaphylococcus aureus, groupA Streptococci, andEscherichia Coli.

We are presenting the case of a sixty-seven-year old woman, who was admitted for the perforation of painful edema of the left cheek. Clinical examination of the anterior two-thirds of the left cheek revealed a defect of the full thickness of the skin, 3×4 cm in size. During the patient’s hospitalization she was treated by parenterally administered broad-spectrum antibiotics, necrotomy, fasciotomy of the cheek and the extraction of the remaining roots in the 3rdand 4thquadrant.

Necrotic fasciitis is a rare, rapidly progressive infection of soft tissues, which, if untimely diagnosed and treated, may be life-threatening. The prognosis of treatment depends on the early recognition of the disease. It is treated with aggressive surgical debridement followed by antibiotic therapy.

Necrotizing fasciitis-A catastrophic complication following routine tibia fracture surgery: A case report and literature review

RATIONALE

Necrotizing fasciitis (NF) is defined as a rare, life-threatening, rapidly spreading soft tissue infection resulting from a polymicrobial origin, with a predominance of anaerobic organisms that presents with necrosis of the muscle, fascia, and surrounding soft tissue.

PATIENT CONCERNS AND DIAGNOSES

A 64-year-old male who sustained tibia fracture caused by falling from a height underwent a tibia surgery with minimally invasive plate osteosynthesis technique in another institution. Postoperatively, the patient had development of a very uncommon NF at the site of the tibia procedure. When the patient was transferred to our unit, he rapidly processed to toxic shock and coagulopathy.

INTERVENTIONS AND OUTCOMES

Although the patient underwent antibiotics treatment in the emergency room and was transferred to the operating room for surgery promptly, the patient's condition deteriorated rapidly and he died of septic shock and multiple organ failure unfortunately.

LESSONS

Our study aims to highlight the risk of NF in the elderly with diabetes during the perioperative period even if the injury is a simple closed fracture. Physicians must be vigilant to early inflammatory signs and pain in immunosuppressed patients.

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 of the extremities: implementation of new management technologies

INTRODUCTION

Necrotising fasciitis (NF) is potentially life-threatening soft-tissue infection. Early diagnosis and aggressive surgical debridement are critical to decrease mortality and morbidity. The impacts of new management technologies such as hydro-bisturi-assisted debridement (HAD) and negative pressure wound therapy (NPWT) are not yet clear with respect to treatment of NF. The objective of this study was to describe laboratory (including LRINEC score), clinical and microbiological factors, treatment methods and outcomes related to managing necrotising fasciitis, focusing on the implementation of new treatment methods in our centre.

METHODS

From June 2010 to June 2014, adult patients diagnosed with necrotising fasciitis affecting an upper or lower limb that were admitted to our hospital, a referral tertiary care centre, were eligible to participate in this study. Demographic data, clinical features, location of infection, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score on the day of admission, microbiology and laboratory results, use of HAD, wound management using NPWT, and patient outcomes were retrospectively analysed. A univariate risk factor analysis was performed, in an attempt to define prognostic factors for mortality.

RESULTS

A total of 20 patients satisfied the inclusion criteria. Type II NF (Group A ß-haemolytic streptococci) was found in 8 cases (40%). The average LRINEC score on the day of admission was 6. The lower extremity was affected in 60% of the cases. All patients were treated operatively, with 2.5 interventions on average. Hydro-bisturi was used in the first debridement in 40% of the cases (8 out 20). In 75% of the studied cases, Negative Pressure Wound Therapy (NPWT) was the technique selected for surgical wound management. The global mortality rate was 30%. On univariate analysis, the only factors significantly associated with mortality were high levels of creatinin (p=0.033) and low blood glucose levels (p=0.012). Finally, four amputations were observed in this series.

CONCLUSION

We confirm that necrotising fasciitis (NF) of the extremities, despite new advancements in treatment and critical care management, is still a potentially life-threatening soft-tissue infection (30% mortality). New, advanced wound management modalities have been heavily used in management of necrotising fasciitis, but these have not had significant impacts on morbidity and mortality rates.

Necrotizing Fasciitis of the First Ray Caused by Group a Streptococcus

Necrotizing fasciitis of the hand is a rare clinical entity, frequently with devastating functional consequences. A case of necrotizing fasciitis of the thumb and thenar eminence caused by Group A Streptococcus is reported and the management of this condition in the upper limb discussed.

A rare case of Fournier's Gangrene

We report a rare case that highlights acute pancreatitis as the protagonist of Fournier’s Gangrene. This patient was treated with a radical debridement of his perineum at presentation and subsequently reconstructed with split thickness skin grafting. This is an unusual aetiology of necrotizing fasciitis with only one other case reported in the literature. This serves to emphasize to physicians that acute pancreatitis is a potential source when investigating and treating patients with Fournier’s Gangrene.

Necrotizing Fasciitis and The Diabetic Foot

Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.

Necrotizing fasciitis of the chest in a neonate in southern Nigeria

We discuss the successful saving of a male neonate with necrotizing fasciitis of the chest following a hot fomentation of the umbilicus with exposure of the ribs and the pleural space on the right side. He recovered 5 weeks after admission. We stressed the need to recognize necrotizing fasciitis extending from the upper anterior abdominal wall to the chest following hot fomentation of the umbilicus. The need for multidisciplinary cooperation for excellent outcome is very important, that is, neonatologist, medical microbiologist, and plastic and chest surgeons.

World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections

Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.

Current concepts in the management of necrotizing fasciitis

Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.

View from the front lines: an emergency medicine perspective on clostridial infections in injection drug users

Injection drug use (IDU), specifically non-intravenous "skin-popping" of heroin, seems to provide optimal conditions for Clostridial infection and toxin production. IDU is therefore a major risk factor for wound botulism and Clostridial necrotizing soft tissue infections (NSTI) and continues to be linked to cases of tetanus. Case clusters of all 3 diseases have occurred among IDUs in Western U.S. and Europe. Medical personnel who care for the IDU population must be thoroughly familiar with the clinical presentation and management of these diseases. Wound botulism presents with bulbar symptoms and signs that are easily overlooked; rapid acquisition and administration of antitoxin can prevent neuromuscular respiratory failure. In addition to Clostridium perfringens, IDU-related NSTIs can be caused by Clostridium sordellii and Clostridium novyi, which may share a distinct clinical presentation. Early definitive NSTI management, which decreases mortality, requires a low index of suspicion on the part of emergency physicians and low threshold for surgical exploration and debridement on the part of the surgeon. Tetanus should be preventable in the IDU population through careful attention to vaccination status.

Necrotising fasciitis due to an infected sebaceous cyst

The current case presents a patient who was admitted to our hospital with the diagnosis of cellulitis of the right groin. In the following days, the patient's condition deteriorated and developed a septic shock. Exploration in the operating room showed a necrotising fasciitis of the adductor muscles, with an infected sebaceous cyst in the inguinal crest as port d'entrée. After extensive surgical debridement, antibiotic therapy, haemodynamic and respiratory support, the patient recovered. Necrotising fasciitis is a rare but very lethal condition, which necessitates aggressive surgical therapy and antibiotic support. The current case report is the first report to show a necrotising fasciitis due to an infected sebaceous cyst.

Prognostic factor of mortality and its clinical implications in patients with necrotizing fasciitis caused by Vibrio vulnificus

In Taiwan, the aquatic environment and endemic hepatitis contribute to the high susceptibility of Vibrio vulnificus infection. A multidisciplinary treatment protocol for necrotizing fasciitis caused by V. vulnificus was developed in our institute, namely, ceftriaxone or ceftazidime combined with doxycycline or minocycline followed by an emergency fasciotomy and intensive care unit admission. We retrospectively reviewed 100 cases to evaluate the effectiveness of our treatment protocol and identify independent predictors of mortality to improve clinical outcomes. Cases of culture-confirmed V. vulnificus infection between January 1996 and December 2011 were reviewed. Necrotizing fasciitis was surgically diagnosed if these criteria were met: necrotic fascia, "dishwater discharge", and loss of resistance while doing finger dissection along the fascia plane. One hundred cases met these criteria and were included for analysis. Eighteen patients died (18 % mortality). Unknown injury events, presence of multiple skin lesions, leukocytes < 10,000 cells/mm(3), platelets < 100,000/mm(3), serum creatinine ≥1.3 mg/dL, serum albumin < 2.5 mg/dL, and delayed treatment beyond 3 days post-injury or symptom onset were associated with significantly higher mortality. Multivariate analysis showed that treatment delayed beyond 3 days is an independent factor indicating a poor prognosis (OR 10.75, 95 % CI 1.02-113.39, p = 0.048). Early diagnosis and prompt treatment within 3 days post-injury or symptom onset should be the goal for treating patients with necrotizing fasciitis caused by V. vulnificus. Additional investigations to rescue patients with a prolonged disease course of necrotizing fasciitis (≥3 days) may be important.

Early diagnosis of necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis.

METHODS

A systematic literature search of PubMed was undertaken using the keywords 'necrotising fasciitis', 'necrotising skin infection', 'diagnosis' and 'outcome'. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included.

RESULTS

Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44.5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80.8 per cent), pain (79.0 per cent) and erythema (70.7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24.8 per cent of patients).

CONCLUSION

A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case.

"Synchronous" multifocal necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is an infection of the soft tissue, and is fatal if not promptly and aggressively treated. Although it is rare, it is not exceptional; nevertheless, its presentation may be misleading and may delay the diagnosis. We highlight the possible synchronous development of NF in multiple noncontiguous areas.

CASE REPORT

A 44-year-old diabetic man with no history of trauma complained of nonspecific lower back pain, which he treated with analgesics and oral antibiotics. Erythema at the left arm appeared, and the general condition worsened. The patient was admitted to the Emergency Department, and NF was diagnosed at the right gluteus and left arm.

CONCLUSION

"Synchronous" multifocality is not an expected presentation of NF, and it complicates the diagnosis and delays treatment, with a potentially negative impact on outcome.