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Williams Chen MC, Hoesley AJ, Griesmer K, Shufflebarger EF, Hadderton L, Pacheco ZS. Man with a swollen neck. J Am Coll Emerg Physicians Open 2024; 5:e13207. [PMID: 38938976 PMCID: PMC11199326 DOI: 10.1002/emp2.13207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/16/2024] [Indexed: 06/29/2024] Open
Affiliation(s)
| | - Adam J. Hoesley
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Katherine Griesmer
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Erin F. Shufflebarger
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Landry Hadderton
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Locklear T, Holland AB, Biswas S. Necrotizing Fasciitis Masquerading as Stroke: A Diagnostic Dilemma. Cureus 2024; 16:e60870. [PMID: 38910763 PMCID: PMC11192442 DOI: 10.7759/cureus.60870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
Necrotizing fasciitis (NF) poses a diagnostic challenge due to its rarity and similarity in presentation with other critical conditions. We report a case of a 79-year-old male who initially presented with altered mental status and stroke-like symptoms; he was ultimately diagnosed with abdominal wall NF spreading to the lower extremity. Despite a history of cecal mass perforation noted in prior imaging, the patient had been discharged from an outside emergency room on antibiotics, highlighting a missed opportunity for early intervention. Subsequent deterioration led to sepsis, organ failure, and ultimately, the detection of NF. Prompt recognition of subtle skin changes and laboratory abnormalities, along with a detailed physical examination, is essential for a timely and accurate diagnosis. Surgical debridement, coupled with broad-spectrum antibiotics, remains the cornerstone of treatment. Delays in surgical management significantly increase mortality, emphasizing the importance of prompt diagnosis and intervention. This case underscores the necessity for heightened awareness among healthcare providers to recognize NF promptly, especially when its clinical presentation overlaps with other critical conditions. Multidisciplinary collaboration and continued education are imperative to improve outcomes and prevent delays in the diagnosis and treatment of NF.
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3
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Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [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] [Indexed: 03/02/2024]
Abstract
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
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Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology; Department of Dermatology, Baylor University Medical Center; University of Texas at Southwestern; Texas A&M University School of Medicine, 1640 FM 544, Suite 100, TX 75056, USA.
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4
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Kircher HL, O'Dell JC, Chollet-Hinton L, Raheel A, Blaser WJ, McCoy CC, Winfield RD, Guidry CA. Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections. Am Surg 2024; 90:725-730. [PMID: 37878367 DOI: 10.1177/00031348231209528] [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] [Indexed: 10/26/2023]
Abstract
BACKGROUND Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours. METHODS We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests. RESULTS 77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure. CONCLUSION No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.
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Affiliation(s)
| | - Jacob C O'Dell
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Lynn Chollet-Hinton
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas, KS, USA
| | - Amani Raheel
- Department of Surgery, University of Missouri-Kansas City, Kansas, MO, USA
| | - Wolf J Blaser
- University of Kansas School of Medicine, Kansas, KS, USA
| | - Cameron C McCoy
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Robert D Winfield
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
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5
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Alzetani S, Harden S, Alzetani A. An unexpected case of thoracic necrotising fasciitis. BMJ Case Rep 2024; 17:e257946. [PMID: 38296508 PMCID: PMC10831425 DOI: 10.1136/bcr-2023-257946] [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] [Indexed: 02/05/2024] Open
Abstract
Necrotising fasciitis (NF) is a life-threatening bacterial infection characterised by rapid tissue destruction, which can have severe consequences if not recognised early and treated promptly. It is most commonly caused by group A streptococcus entering the body through breaks in the skin. This case report describes a patient who presented with systemic signs of infection, including right axillary pain, following a recent intramuscular injection. Clinical examination and radiological findings were consistent with NF, and surgical exploration confirmed the diagnosis of thoracic NF. The patient underwent extensive surgical debridement, intensive care management and subsequent reconstructive surgery. This report highlights the importance of early recognition of NF and that this condition is not limited to the limbs but may also affect the torso. It employs consideration of all portals of potential bacterial entry that may prompt a differential of NF through thorough history taking. This case encourages healthcare professionals to maintain awareness of skin infections as a potential though rare complication of procedures such as injections hence the continued value of aseptic techniques to minimise risk. Finally, it emphasises that prompt diagnosis, appropriate antibiotic therapy and immediate surgical intervention remain crucial in managing NF and improving patient outcomes.
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Affiliation(s)
- Sarah Alzetani
- Salisbury District Hospital NHS Foundation Trust, Salisbury, UK
| | - Stephen Harden
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Aiman Alzetani
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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6
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Guliyeva G, Huayllani MT, Sharma NT, Janis JE. Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5533. [PMID: 38250213 PMCID: PMC10798703 DOI: 10.1097/gox.0000000000005533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/03/2023] [Indexed: 01/23/2024]
Abstract
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.
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Affiliation(s)
- Gunel Guliyeva
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Maria T. Huayllani
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nishant T. Sharma
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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7
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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.
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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
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Huang TY, Kuo SF, Tsai YH, Chen JL, Peng KT, Huang YK, Hung CH, Li YY, Li HJ, Hsiao CT, Hsu WH. The Impact of Cefuroxime Susceptibility on Aeromonas Necrotizing Fasciitis Outcomes. Microorganisms 2023; 11:2776. [PMID: 38004787 PMCID: PMC10673460 DOI: 10.3390/microorganisms11112776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Despite aggressive antibiotic therapy and surgical debridement, Aeromonas necrotizing fasciitis (NF) can lead to high amputation and mortality rates. Our study compares the different antibiotic minimum inhibitory concentrations (MICs) via Epsilometer tests (E-tests) between non-survivors and survivors of Aeromonas NF of limbs. A prospective review of 16 patients with Aeromonas NF was conducted for 3.5 years in a tertiary coastal hospital. E-tests were conducted for 15 antimicrobial agents to determine the MIC value for Aeromonas species. These patients were divided into non-survival and survival groups. The clinical outcomes, demographics, comorbidities, presenting signs and symptoms, laboratory findings, and microbiological results between the two periods were compared. A total of four patients died, whereas 12 survived, resulting in a 25% mortality rate. A higher proportion of bloodstream infections (100% vs. 41.7%; p = 0.042), monomicrobial infections (100% vs. 33.3%; p = 0.021), shock (100% vs. 33.3%; p = 0.021), serous bullae (50% vs. 0%; p = 0.009), liver cirrhosis (100% vs. 25%; p = 0.009), chronic kidney disease (100% vs. 33.3%; p = 0.021), lower susceptibility to cefuroxime (25% vs. 83.3%; p = 0.028), and ineffective antibiotic prescriptions (75% vs. 16.7%; p = 0.029) was observed in non-survivors. Aeromonas NF is an extremely rare skin and soft-tissue infection that is associated with high mortality, bacteremia, antibiotic resistance, and polymicrobial infection. Therefore, antibiotic regimen selection is rendered very challenging. To improve clinical outcomes and irrational antimicrobial usage, experienced microbiologists can help physicians identify specific pathogens and test MIC.
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Affiliation(s)
- Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan; (T.-Y.H.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Microbiology Treatment and Research Center, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan;
| | - Shu-Fang Kuo
- Microbiology Treatment and Research Center, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan;
- Departments of Laboratory Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
- Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan
| | - Yao-Hung Tsai
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Orthopedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Jiun-Liang Chen
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Orthopedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Kuo-Ti Peng
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Orthopedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Yao-Kuang Huang
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Microbiology Treatment and Research Center, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan;
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Chien-Hui Hung
- Division of Infectious Diseases, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan; (T.-Y.H.); (C.-H.H.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Yen-Yao Li
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Orthopedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Hsing-Jung Li
- Department of Pediatrics, St. Martin De Porres Hospital, Chiayi City 60069, Taiwan;
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
| | - Wei-Hsiu Hsu
- College of Medicine, Chang Gung University, Taoyuan 33303, Taiwan; (Y.-H.T.); (J.-L.C.); (K.-T.P.); (Y.-K.H.); (Y.-Y.L.)
- Department of Orthopedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi City 61363, Taiwan
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Bitar ZI, Maadarani OS, Elzoueiry MM, Alfarhan A, Elhabibi ME. Necrotizing fasciitis following gastrostomy tube placement, detected by point-of-care ultrasound, case report. Int J Surg Case Rep 2023; 111:108889. [PMID: 37812958 PMCID: PMC10563042 DOI: 10.1016/j.ijscr.2023.108889] [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: 08/05/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Necrotizing fasciitis is a recognized rare complication of gastrostomy tube replacement, but if it occurs and is not discovered early, a lethal outcome is possible. CASE PRESENTATION We present a woman in her 80s who was known to have chronic atrial fibrillation with ischemic heart disease. She was fed through percutaneous endoscopic gastrostomy after brain injury. Erythema was observed around the stoma of the gastrostomy tube, which was later removed, and erythema extended to the left anterior abdomen. The patient was diagnosed with cellulitis. Point-of-care ultrasound examination suspected necrotizing fasciitis and, confirmed later by computerized tomography of the abdomen. The case was managed surgically. DISCUSSION Patients with a high clinical suspicion of necrotizing fasciitis should undergo early surgical debridement with antibiotic administration. Necrotizing fasciitis starts with a clinical picture indistinguishable from other skin infections, such as cellulitis, and imaging modalities are important for confirmation and early diagnosis. We present a case of necrotizing fasciitis after gastrostomy tube replacement for which point-of-care ultrasound played a pivotal role in confirming the diagnosis early. CONCLUSION Point-of-care ultrasound is a useful adjunct tool for clinical evaluation and assessment in diagnosing early critically ill patients with life-threatening necrotizing infections.
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Affiliation(s)
- Zouheir Ibrahim Bitar
- Critical Care Unit, Ahmadi Hospital, Kuwait Oil Company, POBOx 46468, Postal code 64015 Fahahil, Kuwait.
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Haykal S, Hadzimustafic N, Ghazarian D, Musgrave M. Three Ds for diagnosing necrotizing fasciitis by front-line clinicians. J Plast Reconstr Aesthet Surg 2023; 84:37-46. [PMID: 37320950 DOI: 10.1016/j.bjps.2023.05.020] [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: 08/23/2022] [Revised: 04/01/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages. OBJECTIVE To develop a diagnostic algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals. METHODS Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm. RESULTS The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the "3Ds" of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation. DISCUSSION The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.
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Affiliation(s)
- Siba Haykal
- Division of Plastic and Reconstructive Surgery, University Health Network, Toronto General Hospital, Department of Surgery, University of Toronto, Canada.
| | | | - Danny Ghazarian
- Department of Pathology, University Health Network, Toronto General Hospital, University of Toronto, Canada
| | - Melinda Musgrave
- Division of Plastic and Reconstructive Surgery, St. Michael's Hospital, Department of Surgery, University of Toronto, Canada
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11
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Daniels M, Perbix W, Oberländer H, Schiefer J, Fuchs PC, Seyhan H. The performance of clinical risk scores in the diagnosis of necrotising fasciitis. J Wound Care 2023; 32:284-290. [PMID: 37094928 DOI: 10.12968/jowc.2023.32.5.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
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.
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Affiliation(s)
- Marc Daniels
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Walter Perbix
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Henrik Oberländer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Jennifer Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Paul Christian Fuchs
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Harun Seyhan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
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12
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Falconi S, Wilhelm C, Loewen J, Soliman B. Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report. Cureus 2023; 15:e39635. [PMID: 37388614 PMCID: PMC10305508 DOI: 10.7759/cureus.39635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.
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Affiliation(s)
- Sirin Falconi
- Surgery, Texas Tech University Health Sciences Center School of Medicine, Lubbock, USA
| | - Christopher Wilhelm
- General Surgery, Texas Tech University Health Sciences Center School of Medicine, Amarillo, USA
| | - Jocelin Loewen
- General Surgery, Texas Tech University Health Sciences Center School of Medicine, Amarillo, USA
| | - Basem Soliman
- Department of Surgery, Texas Tech University Health Sciences Center, Amarillo, USA
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Canagasingham A, Okullo AT, He M, McCredie S. Fournier's gangrene with retroperitoneal extension in an immunocompetent patient. BMJ Case Rep 2023; 16:e250981. [PMID: 36759038 PMCID: PMC9923328 DOI: 10.1136/bcr-2022-250981] [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] [Indexed: 02/11/2023] Open
Abstract
A male patient in his 80s presented with the classic signs of Fournier's gangrene. At his initial debridement, an unusual florid involvement of the right cord was noted requiring a right inguinal orchidectomy in addition to extensive debridement. Although he subsequently stabilised in the intensive care unit, his inflammatory markers were noted to uptrend again requiring a relook procedure which revealed evidence of progressive necrosis in the right inguinal region. After further debridement, a CT scan of the abdomen and pelvis revealed intra-abdominal extension of the disease process with a retroperitoneal collection adjacent to the caecum-a rare complication of Fournier's gangrene. This required open surgical drainage for adequate disease control. He subsequently underwent split skin grafting prior to discharge to a rehabilitation facility.
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Affiliation(s)
- Ashan Canagasingham
- Department of General Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Alfin Taddeo Okullo
- Department of General Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Mike He
- Department of General Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Simon McCredie
- Department of Urology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
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14
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Gan RK, Sanchez Martinez A, Abu Hasan MAS, Castro Delgado R, Arcos González P. Point-of-care ultrasonography in diagnosing necrotizing fasciitis-a literature review. J Ultrasound 2023:10.1007/s40477-022-00761-5. [PMID: 36694072 DOI: 10.1007/s40477-022-00761-5] [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: 09/07/2022] [Accepted: 10/29/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a rapidly progressive necrosis of the fascial layer with a high mortality rate. It is a life-threatening medical emergency that requires urgent treatment. Lack of skin finding in NF made diagnosis difficult and required a high clinical index of suspicion. The use of ultrasound may guide clinicians in improving diagnostic speed and accuracy, thus leading to improved management decisions and patient outcomes. This literature search aims to review the use of point-of-care ultrasonography in diagnosing necrotizing fasciitis. METHOD We searched relevant electronic databases, including PUBMED, MEDLINE, and SCOPUS, and performed a systematic review. Keywords used were "necrotizing fasciitis" or "necrotising fasciitis" or "necrotizing soft tissue infections" and "point-of-care ultrasonography" "ultrasonography" or "ultrasound". No temporal limitation was set. An additional search was performed via google scholar, and the top 100 entry was screened. RESULTS Among 540 papers screened, only 21 were related to diagnosing necrotizing fasciitis using ultrasonography. The outcome includes three observational studies, 16 case reports, and two case series, covering the period from 1976 to 2022. CONCLUSION Although the use of ultrasonography in diagnosing NF was published in several papers with promising results, more studies are required to investigate its diagnostic accuracy and potential to reduce time delay before surgical intervention, morbidity, and mortality.
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Affiliation(s)
- Rick Kye Gan
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Antoni Sanchez Martinez
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Muhammad Abdus-Syakur Abu Hasan
- Emergency Medicine Department, Kulliyyah of Medicine, International Islamic University Malaysia (IIUM), Kuantan, Pahang, Malaysia
- Emergency and Trauma Department, Sultan Ahmad Shah Medical Center, IIUM, Kuantan, Pahang, Malaysia
| | - Rafael Castro Delgado
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
- SAMU-Asturias, Asturias, Spain
| | - Pedro Arcos González
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
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Bender ST, Ganz M, Mertens PR, Gross C. Bilateral non-contiguous necrotizing fasciitis of the lower extremities. Clin Case Rep 2023; 11:e6873. [PMID: 36698513 PMCID: PMC9851088 DOI: 10.1002/ccr3.6873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/16/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
Necrotizing fasciitis (NF) is an uncommon soft tissue infection. Multifocal-extremity NF is a rarity with high mortality rates. Herein we report a case of bilateral non-contiguous NF of the lower extremities due to Escherichia coli with a fatal outcome, stressing the necessity of rapid and aggressive intervention in suspected cases.
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Affiliation(s)
- Sascha T. Bender
- Clinic for Nephrology and Hypertension, Diabetes and EndocrinologyOtto‐von‐Guericke University MagdeburgMagdeburgGermany
| | - Maximilian Ganz
- Clinic for Nephrology and Hypertension, Diabetes and EndocrinologyOtto‐von‐Guericke University MagdeburgMagdeburgGermany
| | - Peter R. Mertens
- Clinic for Nephrology and Hypertension, Diabetes and EndocrinologyOtto‐von‐Guericke University MagdeburgMagdeburgGermany
| | - Christian Gross
- Clinic for Nephrology and Hypertension, Diabetes and EndocrinologyOtto‐von‐Guericke University MagdeburgMagdeburgGermany
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16
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Jain A, Meher R, Sharma R. MRSA Causing Necrotizing Fasciitis in 18-Month-Old Boy. EAR, NOSE & THROAT JOURNAL 2023; 102:NP3-NP4. [PMID: 33393814 DOI: 10.1177/0145561320986042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Necrotizing fasciitis is a rare and fulminant infection of the superficial fascia and subcutaneous cellular tissue. It is commonly polymicrobial, with the combination of aerobic and anaerobic bacteria, which contributes to the rapid progression and severity of the disease. The microbes commonly involved include group A streptococcus, Enterobacteriaceae, anaerobes, and Staphylococcus aureus. Over the past few years, skin and soft tissue infections, including necrotizing fasciitis, due to methicillin-resistant Staphylococcus aureus are increasing.
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Affiliation(s)
- Avani Jain
- ESIC Medical College and Hospital, Faridabad, India
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17
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Dalili A, Hamidi Alamdari D, Dalili A, Sarkardeh M, Rezapanah A, Tafazoli N. Autologous Platelet-Rich Plasma Injection and Platelet-Rich Fibrin Glue Insertion for the Treatment of Extensive Supralevator Anorectal Fistula: A Case Report. World J Plast Surg 2023; 12:58-62. [PMID: 37220581 PMCID: PMC10200087 DOI: 10.52547/wjps.12.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/02/2023] [Indexed: 05/25/2023] Open
Abstract
Supralevator fistula stays a challenge in general surgery. We present a case with supralevator anorectal fistula and subsequent retroperitoneal necrotizing fasciitis in which autologous platelet-rich plasma and platelet-rich fibrin glue were used for fistula closure. A 59-year-old man was admitted with pelvic pain and fever. Abdominopelvic sonography and CT scan reported a deep horseshoe-shaped anorectal abscess with extension to the pelvic floor, supralevator, psoas, retroperitoneal muscles, and kidneys. He was managed with antibiotics, abscess drainage, repeated radical surgical debridement, and necrosectomy. After 30 days, he was discharged, but he returned to the office with the complaint of purulent discharge from the hypogastric region and a diagnosis of fistula formation. Platelet-rich plasma was injected around the fistula into the tissue, and platelet-rich fibrin glue was introduced to the fistula tract. At the 11-month follow-up, the patient did not have voiding dysfunction, constipation, diarrhea, or fistula tract infection. Autologous platelet-rich plasma injection and platelet-rich fibrin glue insertion suggest a secure and effective approach for treating supralevator anorectal fistula.
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Affiliation(s)
- Amin Dalili
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Daryoush Hamidi Alamdari
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alimohamad Dalili
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Sarkardeh
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Rezapanah
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nooshin Tafazoli
- MD, Faculty of Medicine, Mashhad University of medical sciences, Mashhad, Iran
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Rational Use of Antibiotics and Education Improved Aeromonas Necrotizing Fasciitis Outcomes in Taiwan: A 19-Year Experience. Antibiotics (Basel) 2022; 11:antibiotics11121782. [PMID: 36551439 PMCID: PMC9774671 DOI: 10.3390/antibiotics11121782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Aeromonas necrotizing fasciitis (NF) causes high rates of amputation and mortality, even after aggressive surgical debridement and antibacterial therapy. This study investigated the effects of rational use of antibiotics and education by infectious disease (ID) physicians on Aeromonas NF treatment outcomes. METHODS Retrospective review for conducted for four years (period I, without an ID physician, December 2001 to December 2005) and 15 years (period II, with an ID physician, January 2006 to March 2021). In period II, the hospital-wide computerized antimicrobial approval system (HCAAS) was also implemented. A pretest-posttest time series analysis compared the two periods. Differences in clinical outcomes, demographics, comorbidities, signs and symptoms, laboratory findings, Aeromonas antibiotic susceptibility, and antibiotic regimens were compared between the two periods. RESULTS There were 19 patients in period I and 53 patients in period II. Patients had a lower rate of amputation or mortality in period II (35.8%) compared with period I (63.2%). Forty-four patients (61.1%) had polymicrobial infections. In the emergency room, the rate of misdiagnosis decreased from 47.4% in period I to 28.3% in period II, while effective empiric antibiotic usage increased from 21.1% in period I to 66.0% in period II. After the ID physician's adjustment, 69.4% received monotherapy in period II compared to 33.3% in period I. CONCLUSIONS Because Aeromonas NF had a high mortality rate and was often polymicrobial, choosing an antibiotic regimen was difficult. Using the HCAAS by an experienced ID physician can improve rational antibiotic usage and clinical outcomes in Aeromonas NF.
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Sharma V, Panda NK, Kapoor A, Angrish P, Raj RR. Necrotising Fasciitis of Neck in a 7 Day Neonate Following Insect Bite. Indian J Otolaryngol Head Neck Surg 2022; 74:5836-5840. [PMID: 36742649 PMCID: PMC9895229 DOI: 10.1007/s12070-021-02421-2] [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: 11/30/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing fasciitis is severe inflammation of the muscle sheath that leads to necrosis of the subcutaneous tissue and adjacent fascia. The disease entity is more commonly described in adults and the literature seems quite sparse with respect to children and even lesser in neonates. Monomicrobial infection with necrotizing fasciitis in Neck following insect bite is rare and even rarer in neonates. 07 day old neonate had history of rapid onset discoloration and swelling of the Right side of Neck following an insect bite which was followed fever and irritability and eventually black discoloration. The neonate was irritable with excessive crying, had tachycardia, tachypnea and was febrile. There was a diffuse swelling in the right side of neck with multiple patchy areas of tissue necrosis in form of blackening of the skin over the swelling Management: Necrotizing fasciitis was identified early and the neonate prepped for surgery. All the biochemical parameters were WNL. CRP was raised. Empirical treatment with Cefotaxime, Clindamycin and cloxacillin started and neonate taken for local debridement. All necrotic tissue was removed including tail of parotid. Over next 5 days serial debridement and wound wash with Hydrogen peroxidase, Betadine, saline and metronidazole was done. The edges of the wound became healthy with no new slough formation and necrotic tissue. An early diagnosis and definitive management with both surgery and antibiotics is the key to a reduce mortality in the neonates. It needs to be followed up with good local wound care.
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Affiliation(s)
- Vikas Sharma
- Department of Otolaryngology and Head and Neck Surgery, PGIMER, Chandigarh, 160012 India
| | - Naresh K. Panda
- Department of Otolaryngology and Head and Neck Surgery, PGIMER, Chandigarh, 160012 India
| | - Archit Kapoor
- Department of Otolaryngology and Head and Neck Surgery, PGIMER, Chandigarh, 160012 India
| | - Prerna Angrish
- Department of Otolaryngology and Head and Neck Surgery, PGIMER, Chandigarh, 160012 India
| | - Reshma R. Raj
- Department of Otolaryngology and Head and Neck Surgery, PGIMER, Chandigarh, 160012 India
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Chaurasiya PS, Gurung S, Karki S, Timilsina B, Shah R, Neupane S. Pseudomonas aeruginosa as a culprit of cervical necrotizing fasciitis: A case report. Int J Surg Case Rep 2022; 99:107713. [PMID: 36261949 PMCID: PMC9568876 DOI: 10.1016/j.ijscr.2022.107713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction and importance Necrotizing fasciitis is usually a polymicrobial infection and odontogenic source is usually the foci for infection in the neck region. Cervical necrotizing fasciitis due to Pseudomonas is a rare and potentially fatal complication in diabetic patients. The study highlights the importance of early intervention to improve the outcome of the patient. Case presentation We report a case of a 48-year female who presented with neck pain for 10 days. On further investigations, she had diabetic ketoacidosis, and a culture of the wound showed Pseudomonas. With appropriate antibiotics and surgical intervention, her condition gradually improved. Clinical discussion Necrotizing fasciitis in the neck region with Pseudomonas without odontogenic infections is a rare occurrence. Early medical and surgical intervention leads to a better outcome. The location of the infection and its extensions can affect the prognosis. Conclusion Physicians should be aware of cervical necrotizing fasciitis as a complication in diabetic ketoacidosis and install early treatment to improve survivability and the outcome. The hallmark of necrotizing fasciitis is the extensive necrosis of subcutaneous tissue and underlying fascia. Cervical necrotizing fasciitis without contiguous spread is a rare occurrence. Early surgical intervention can lead to better outcome of the patient.
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Affiliation(s)
| | | | | | - Bibek Timilsina
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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21
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Iqbal M, Arshad A, Syed J, Saleem A, Khan AS, Khan SI, Khawaja UA. Survival of an 80-Year-Old Male With a Successful Split-Thickness Skin Graft for End-Stage Necrotizing Fasciitis: A Case Report. Cureus 2022; 14:e25829. [PMID: 35836465 PMCID: PMC9273206 DOI: 10.7759/cureus.25829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 12/02/2022] Open
Abstract
Herein, we report a case of an 80-year-old male who was diagnosed with a fatal condition known as necrotizing fasciitis. This devastating soft tissue infection can cause profound damage to multiple tissue planes. Despite its etiology being multifactorial, impaired immunity with increasing age weighs in as the most significant. We intend to shed light on its detrimental clinical features and how we managed to treat the patient both conservatively and surgically. Through our case findings and management plan, we hope this case to be of clinical value and knowledge to clinicians to better diagnose and treat the deleterious condition.
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22
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Wen S, Unuma K, Makino Y, Mori H, Uemura K. Fatal consequence after MiraDry® treatment: Necrotizing fasciitis complicated with streptococcal toxic shock syndrome. Leg Med (Tokyo) 2022; 58:102095. [PMID: 35662070 DOI: 10.1016/j.legalmed.2022.102095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/11/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023]
Abstract
MiraDry® is a microwave-based cosmetic device commonly used to treat hyperhidrosis and osmidrosis by affecting apocrine and eccrine sweat glands. In most countries, its application is limited to the axillary region. A healthy woman received MiraDry® treatment in the perineal, genital, and perianal regions for body odor in a cosmetic clinic. She experienced severe adverse effects after treatment, including persistent fever, sustained pain, and bleeding in the treated area. The condition deteriorated rapidly with systemic symptoms, and she died on the sixth day. Group A Streptococcus was detected in her skin in the treated areas, and in blood obtained in the hospital and during autopsy. Combined with the clinical diagnosis and autopsy findings, the woman's death was attributed to fatal necrotizing fasciitis (Fournier's gangrene) complicated by streptococcal toxic shock syndrome. Pathogen inoculation was most likely attributable to skin disruption caused by MiraDry® treatment. The MiraDry® application on the genital and perineum is occasionally performed by cosmetic surgeons; however, this case demonstrates the possibility of a rare but fatal complication. Therefore, this case report may be noteworthy and beneficial in forensic practice, and relevant in cosmetic clinical practice.
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Affiliation(s)
- Shuheng Wen
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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Li X, Du Z, Tang Z, Wen Q, Cheng Q, Cui Y. Distribution and drug sensitivity of pathogenic bacteria in diabetic foot ulcer patients with necrotizing fasciitis at a diabetic foot center in China. BMC Infect Dis 2022; 22:396. [PMID: 35459117 PMCID: PMC9034620 DOI: 10.1186/s12879-022-07382-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background Diabetic foot ulcer is one of the major complications for patients with diabetes, and has become an important cause of non-traumatic amputation. Necrotizing fasciitis is a life-threatening soft-tissue infection involving the fascia and subcutaneous tissue. When diabetic foot ulcers are complicated by necrotizing fasciitis (DNF), this increases the risk for amputation and mortality, making DNF treatment more complicated, and eventually leading to amputation and mortality. However, studies on pathogenic bacteria’s distribution and drug sensitivity in DNF patients remain lacking. This study investigated the distribution and susceptibility of pathogenic bacteria in DNF patients, and provided empirical antibacterial guidance for the clinic. Methods In a single diabetic foot center, the results from microbial cultures and drug susceptibility tests of patients with DNF from October 2013 to December 2020 were collected and analyzed. Results A total of 101 DNF patients were included in this study, of whom 94 had positive culture test results. A total of 124 pathogens were cultured, including 76 Gram-positive bacterial strains, 42 Gram-negative bacterial strains, and six fungal strains. Polymicrobial infections accounted for 26.7% and monomicrobial infections accounted for 66.3%. Staphylococcus aureus was the most common bacterium isolated, followed by Enterococcus faecalis and Streptococcus agalactiae. Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus mirabilis were the most common Gram-negative bacteria. Thirty-five strains of multi-drug resistant bacteria were isolated, representing 28.2% of the total isolates. Gram-positive bacteria were more sensitive to levofloxacin, moxifloxacin, vancomycin, teicoplanin, tigecycline, and linezolid, while Gram-negative bacteria were more sensitive to amikacin, piperacillin/tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, imipenem, and meropenem. Conclusions Gram-positive bacteria were the main bacteria isolated from DNF patients. The bacterial composition, the proportion of multi-drug resistant bacteria among the pathogens, and the high risk for amputation should be fully considered in the initial empirical medication, and broad-spectrum antibacterials are recommended.
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Affiliation(s)
- Xuemei Li
- Department of Pharmacy, Chongqing Health Center for Women and Children, Chongqing, China.,Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Ziwei Tang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Qin Wen
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Pharmacy, Chongqing Yunyang County Traditional Chinese Medicine Hospital, Chongqing, China
| | - Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Yixueyuan Road, Yuzhong District, Chongqing, 400016, China.
| | - Yunhua Cui
- Department of Respiratory and Critical Care Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, No. 136, Jingzhou Street, Xiangcheng District, Hubei, 441021, China.
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Illg C. First report of polymicrobial necrotizing fasciitis caused by Eggerthia catenaformis and Finegoldia magna. World J Emerg Med 2022; 13:326-329. [DOI: 10.5847/wjem.j.1920-8642.2022.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/02/2022] [Indexed: 11/19/2022] Open
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Management of non-healing lesion from surgical treatment of necrotizing fasciitis through Ayurveda- a case report. J Ayurveda Integr Med 2021; 13:100492. [PMID: 34961686 PMCID: PMC8728067 DOI: 10.1016/j.jaim.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Necrotizing fasciitis is a soft-tissue infection that is rare but life-threatening. The early clinical presentation of necrotizing fasciitis is local erythema, pain, and fever. It occurs in any part of the body, but it is mainly found in the extremities, abdominal wall, and perineum. It needs intensive care with appropriate antibiotics and extensive surgical debridement. This Case of necrotizing fasciitis was initially treated with surgical debridement and splint skin grafting. After two months of failed medical-surgical interventions and dressing, the 17-year old female in an irritable but oriented state approached the outpatient department of kayachikitsa with the unhealed wound. The Ayurvedic diagnosis of Vidradhi was deliberated after considering PittaDosha and Rakta, Mamsa, and MedaDhatu. She was treated with medicines, including external applications, for one month. It resulted in complete wound healing and minimal scarring, and a satisfied patient. This Case can be the basis for future research studies.
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Iwata E, Kusumoto J, Takata N, Furudoi S, Tachibana A, Akashi M. The characteristics of oro-cervical necrotizing fasciitis-Comparison with severe cellulitis of oro-cervical region and necrotizing fasciitis of other body regions. PLoS One 2021; 16:e0260740. [PMID: 34851994 PMCID: PMC8635337 DOI: 10.1371/journal.pone.0260740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/16/2021] [Indexed: 01/02/2023] Open
Abstract
Background Necrotizing fasciitis (NF) is an acute and life-threatening soft-tissue infection however rarely seen in oro-cervical region. Therefore, the details of oro-cervical NF (OCNF) are not well known. The purpose of this study was to investigate the characteristics of OCNF by comparing it with severe cellulitis of oro-cervical region (OCSC) or NF of other body regions (e.g., limb, perineum, and trunk) (BNF), respectively. Materials and methods At first, various risk factors for OCNF in oro-cervical severe infection (OCSI; composed of OCNF and OCSC), including neutrophil-to-lymphocyte ratio (NLR) and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, were investigated by univariate and multivariate analyses. Next, the differences between OCNF and BNF, including inflammatory markers and mortality, were investigated. Results In the present study, 14 out of 231 OCSI patients had OCNF. Multivariate analyses of OCSI patients showed that NLR ≥15.3 and LRINEC score ≥6 points were significantly related to OCNF. During the same period, 17 patients had BNF. The OCNF group had significantly higher inflammatory markers than the BNF group when diagnosis, but significantly lower clinical stages at the time and mortality as outcomes. Conclusion We found that compared to BNF, OCNF can be detected at lower clinical stage by using indexes, such as NLR and LRINEC score, besides clinical findings, which may help contributing to patient’s relief.
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Affiliation(s)
- Eiji Iwata
- Department of Oral and Maxillofacial Surgery, Kakogawa Central City Hospital, Kakogawa, Japan
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
- * E-mail:
| | - Junya Kusumoto
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Takata
- Department of Oral and Maxillofacial Surgery, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Shungo Furudoi
- Department of Oral and Maxillofacial Surgery, Konan Medical Center, Kobe, Japan
| | - Akira Tachibana
- Department of Oral and Maxillofacial Surgery, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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HV C, RG HK, Rani S. Fatal Necrotizing Fasciitis as a Consequence of Blunt Trauma: A Case Report. Acad Forensic Pathol 2021. [DOI: 10.1177/19253621211038108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Necrotizing fasciitis is an uncommon lethal bacterial infection that involves the subcutaneous tissue and fascia. It can be mono or polymicrobial infection. The diagnosis is mainly dependent on clinical signs and symptoms. Trauma is the commonest cause for it. The early signs and symptoms may mimic cellulitis. We present a case of necrotizing fasciitis following an assault. The patient was received in a state of shock. Despite all measures, the patient could not be saved. Early debridement and antibiotic therapy have a key role in the prognosis of the disease. Medicolegal issues can arise when the disease develops post-assault because of the vague and unpredictable nature of the disease and its challenging prognosis.
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Lodhia J, Chussi D, Ngowi E, Laizer L, Leonard L, Mchaile D. Necrotizing fasciitis in a 5-week-old infant: An unusual presentation. SAGE Open Med Case Rep 2021; 9:2050313X211037121. [PMID: 34377491 PMCID: PMC8327223 DOI: 10.1177/2050313x211037121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/16/2021] [Indexed: 11/15/2022] Open
Abstract
Necrotizing fasciitis is a rare and life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. These children should be managed promptly with broad-spectrum antibiotics and possible surgical debridement. Here, we present a 5-week-old female infant who presented with fever and ulcer on right lower jaw. She had a sudden onset of darkening of the right lower jaw, which progressed to reddish discoloration, and then an ulcer developed in the middle of this area of discoloration. She had a tender swelling extending from the right pre-auricular area to the right upper neck, crossing the right jaw and extending toward the right cheek and maxillary area. Swelling had areas of hyperpigmentation with an ulcer measuring 2 by 3 cm at the center of the lesion, oozing purulent fluid, and Staphylococcus aureus was cultured. The surgeons conducted incision and debridement in theater after suspecting necrotizing fasciitis of the jaw and the baby was kept on intravenous antibiotics, antiretroviral therapy and was dressed daily. The child fared well thereafter.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Faculty of Medicine, Moshi, Tanzania
| | - Desderius Chussi
- Department of Otorrhinolaryngology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Otorrhinolaryngology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Elisamia Ngowi
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Loreen Laizer
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Leanji Leonard
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Deborah Mchaile
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Daniels M, Oberländer H, Schiefer J, Sonnenberg P, Jörres A, Lefering R, Fuchs PC, Seyhan H. Lactate based Scoring System in the diagnosis of necrotizing fasciitis. J Burn Care Res 2021; 43:625-631. [PMID: 34324681 DOI: 10.1093/jbcr/irab148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a rare and quickly progressing infection and leads to 100% mortality if untreated. Quick diagnosis and an early and radical surgical treatment are essential for stopping bacterial progression. Unfortunately, the absence of clear clinical signs makes the diagnosis often challenging. Therefore, we searched for easy determinable predictive laboratory markers for NF. This is the first study which includes lactate values in a new score. MATERIAL AND METHODS A retrospective analysis of patients with NF (n = 44) and patients with erysipelas (n = 150) was performed. Lactate values, patients` demographics, clinical presentations, site of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC and modified LRINEC Scores were analyzed. Logistic regression analysis was used to derive adjusted weights, and final simple point score was assessed with a ROC curve analysis. RESULTS Patients with NF had a mean age of 57 years, patients with erysipelas 65 years. The median hospital length of stay was 8 and 49 days in patients with erysipelas and NF, respectively. While only one patient (0.7 %) in the group of erysipelas died, the mortality rate of patients with NF was 9/44 (20.5 %). The lactate values were statistically significant higher in the NF group 4.1 vs. 2.0 mmol/l (p < 0.001). The new created CologNe-FaDe-Score shows the highest AUC-value with 0.907. CONCLUSION With the help of lactate values the CologNe-FaDe-Score consists of easily practicable and highly available parameters, which could sensitize diagnosis.
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Affiliation(s)
- Marc Daniels
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Henrik Oberländer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Jennifer Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Philipp Sonnenberg
- Department of Medicine I, Cologne Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
| | - Achim Jörres
- Department of Medicine I, Cologne Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Paul Christian Fuchs
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Harun Seyhan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
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Necrotizing fasciitis: Usefulness of the LRINEC score in a third-level hospital. Injury 2021; 52 Suppl 4:S8-S15. [PMID: 34011440 DOI: 10.1016/j.injury.2021.02.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
AIM To review patients seen in the emergency room, diagnosed with necrotizing fasciitis (NF) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). The purpose of this study is to assess the use of the LRINEC score for early diagnosis of NF and its prognostic use in a consecutive series of cases treated at our hospital. METHODS Retrospective observational study including patients with a diagnosis of NF in the emergency room of a tertiary hospital over 11 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric rank-ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's exact test. RESULTS A total of 45 patients with a mean age of 51 years were identified. There was a 20% mortality rate (9 cases). The highest mortality rate was registered in the high-risk group (LRINEC greater than 8) with 4 deceased individuals (44.44%), while in the low and moderate-risk groups, 3 and 2 deceased individuals (33% and 22%) were registered, respectively, without considering this result statistically significant (p=0.811). There was an amputation rate of 15.6% (7 cases). The average LRINEC score was greater in the cases that required amputation 9 (95% CI 7; 13) in comparison to the other patients, 6 (95% CI 5; 8), p=0.044. The average hospital stay lasted 32.5 days (95% CI: 25; 40); 30 days in the low-risk group, 41 days in the moderate-risk group and 40 days in the high-risk group. Mortality was associated to a smaller number of interventions (p=0.005) and was preceded by septic shock in all cases. CONCLUSIONS The LRINEC score may be useful to aid diagnosis. However, clinical suspicion is the most important in diagnosis. A LRINEC low score does not exclude NF. In this retrospective series, 35.71% of cases presented a low LRINEC score, making the rate of false negatives high. In view of these results, The LRINEC score cannot be used as a prognostic value since an initial low score does not rule out serious evolution.
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Grier JT, Arivett BA, Ramírez MS, Chosed RJ, Bigner JA, Ohneck EJ, Metz ML, Wood CR, Arce S, Tartaro A, Relich RF, Actis LA, Fiester SE. Two Acinetobacter baumannii Isolates Obtained From a Fatal Necrotizing Fasciitis Infection Display Distinct Genomic and Phenotypic Characteristics in Comparison to Type Strains. Front Cell Infect Microbiol 2021; 11:635673. [PMID: 33912474 PMCID: PMC8072282 DOI: 10.3389/fcimb.2021.635673] [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: 11/30/2020] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Acinetobacter baumannii has been recognized as a critical pathogen that causes severe infections worldwide not only because of the emergence of extensively drug-resistant (XDR) derivatives, but also because of its ability to persist in medical environments and colonize compromised patients. While there are numerous reports describing the mechanisms by which this pathogen acquires resistance genes, little is known regarding A. baumannii’s virulence functions associated with rare manifestations of infection such as necrotizing fasciitis, making the determination and implementation of alternative therapeutic targets problematic. To address this knowledge gap, this report describes the analysis of the NFAb-1 and NFAb-2 XDR isolates, which were obtained at two time points during a fatal case of necrotizing fasciitis, at the genomic and functional levels. The comparative genomic analysis of these isolates with the ATCC 19606T and ATCC 17978 strains showed that the NFAb-1 and NFAb-2 isolates are genetically different from each other as well as different from the ATCC 19606T and ATCC 17978 clinical isolates. These genomic differences could be reflected in phenotypic differences observed in these NFAb isolates. Biofilm, cell viability and flow cytometry assays indicate that all tested strains caused significant decreases in A549 human alveolar epithelial cell viability with ATCC 17978, NFAb-1 and NFAb-2 producing significantly less biofilm and significantly more hemolysis and capacity for intracellular invasion than ATCC 19606T. NFAb-1 and NFAb-2 also demonstrated negligible surface motility but significant twitching motility compared to ATCC 19606T and ATCC 17978, likely due to the presence of pili exceeding 2 µm in length, which are significantly longer and different from those previously described in the ATCC 19606T and ATCC 17978 strains. Interestingly, infection with cells of the NFAb-1 isolate, which were obtained from a premortem blood sample, lead to significantly higher mortality rates than NFAb-2 bacteria, which were obtained from postmortem tissue samples, when tested using the Galleria mellonella in vivo infection model. These observations suggest potential changes in the virulence phenotype of the A. baumannii necrotizing fasciitis isolates over the course of infection by mechanisms and cell processes that remain to be identified.
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Affiliation(s)
- Jennifer T Grier
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Brock A Arivett
- Department of Biology, Middle Tennessee State University, Murfreesboro, TN, United States
| | - Maria S Ramírez
- Department of Biological Science, California State University Fullerton, Fullerton, CA, United States
| | - Renee J Chosed
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Jessica A Bigner
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Emily J Ohneck
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Maeva L Metz
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Cecily R Wood
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Sergio Arce
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States.,Cancer Institute, Prisma Health, Greenville, SC, United States
| | - Andrea Tartaro
- Computer Science Department, Furman University, Greenville, SC, United States
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Luis A Actis
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Steven E Fiester
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States.,Department of Pathology, Prisma Health, Greenville, SC, United States
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Duane TM, Huston JM, Collom M, Beyer A, Parli S, Buckman S, Shapiro M, McDonald A, Diaz J, Tessier JM, Sanders J. Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections. Surg Infect (Larchmt) 2021; 22:383-399. [PMID: 33646051 DOI: 10.1089/sur.2020.436] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.
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Affiliation(s)
| | - Jared M Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | | | - Adam Beyer
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sara Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Sara Buckman
- Department of Surgery, Washington University, St. Louis, Missouri, USA
| | - Mark Shapiro
- Acute Care Surgery, Portsmouth, New Hampshire, USA
| | - Amy McDonald
- Department of Veterans Affairs, Cleveland, Ohio, USA
| | - Jose Diaz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Jeffrey M Tessier
- Division of Infectious Diseases, University of Texas Southwestern, Dallas Texas, USA
| | - James Sanders
- Department of Pharmacy and Division of Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
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Abstract
Acute uncomplicated appendicitis is a common surgical disease that has been well-studied, and its overall mortality has decreased over time. However, delay in treatment can be associated with rare complications such as necrotizing fasciitis, which carries a high mortality rate, and bladder perforation. We present such a case in an 81-year-old female with no significant surgical history who presented to the emergency department with four days of abdominal pain. A CT scan revealed extensive subcutaneous air in the abdominal wall, an inflamed appendix, and a periappendiceal abscess. During subsequent exploratory laparotomy, she was also found to have bladder perforation. She underwent debridement of necrotic tissue of the abdominal wall, appendectomy, drainage of periappendiceal abscess, and bladder perforation repair. She died of septic shock on post-operative day 19, due to gross spillage of urine into the abdomen and ongoing necrotizing fasciitis. Acute perforated appendicitis can lead to rare and fatal complications. Our case presents such a patient with a poor outcome. In approaching a patient with signs of peritonitis, differential diagnoses must remain broad to include late complications such as abscess formation, soft tissue infection, and perforation of surrounding structures.
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Affiliation(s)
- John Oh
- Emergency Department, Kent Hospital, Warwick, USA
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34
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Different types of bullae of limbs with necrotizing fasciitis predict different outcome: a prospective study. Infection 2021; 49:135-144. [PMID: 33389697 PMCID: PMC7851011 DOI: 10.1007/s15010-020-01559-5] [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: 06/25/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
Study objective Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment. Methods From April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups. Results In total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N. Conclusions In southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.
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Narayanan AS, Walley KC, Borenstein T, Luther GA, Jackson JB, Gonzalez TA. Surgical Strategies: Necrotizing Fasciitis of the Foot and Ankle Treated With Dermal Regeneration Matrix for Limb Salvage. Foot Ankle Int 2021; 42:107-114. [PMID: 32975443 DOI: 10.1177/1071100720952087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity.Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain.We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option.Level of Evidence: Level V, expert opinion.
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Affiliation(s)
- Arvind S Narayanan
- WakeMed Health and Hospitals, Raleigh, NC, USA.,Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | | | - J Benjamin Jackson
- Department of Orthopaedic Surgery, University of South Carolina, Columbia, SC, USA
| | - Tyler A Gonzalez
- Department of Orthopaedic Surgery, University of South Carolina, Columbia, SC, USA
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Shivalingappa S, Manjunath KN, Waiker V, Kumaraswamy M, Odeyar U. Necrotising Fasciitis: Appearances Can Be Deceptive. World J Plast Surg 2021; 10:43-52. [PMID: 33833953 PMCID: PMC8016375 DOI: 10.29252/wjps.10.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODS In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre. RESULTS The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases. CONCLUSION Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.
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Affiliation(s)
| | - K N Manjunath
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - Veena Waiker
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - M Kumaraswamy
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
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Adams DD, Schwartz-Fernandes FA. Myoelectric prosthesis: a potential emerging therapeutic in restoring function post-arm amputation complicated by necrotizing fasciitis. J Surg Case Rep 2020; 2020:rjaa381. [PMID: 33072256 PMCID: PMC7550240 DOI: 10.1093/jscr/rjaa381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 12/03/2022] Open
Abstract
A literature search confirmed no previous cases of an arm amputation secondary to necrotizing fasciitis (NF) being successfully treated with a myoelectric prosthesis. This report explores a case of a 55-year-old right-handed male with flexor tenosynovitis infection of the hand after a small laceration. Following infectious disease consult of the infection, a diagnosis of NF was made. Broad-spectrum antibiotics were initiated but the infection worsened after 12 hours. Two debridements with wound vacuum were undertaken in the next 48 hours. After further patient deterioration, a distal left forearm amputation was undertaken. The patient fully recovered and then underwent occupational therapy training with a myoelectric prosthesis to restore hand function. The patient was seen for follow-up 3, 6, 12 and 24 months after amputation. At 2-year follow-up, the patient was continuing rehabilitation with an occupational therapist to acclimate to the prosthesis with some gain of function in gross movement.
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Affiliation(s)
- D’Shaun D Adams
- University of Central Florida College of Medicine, Orlando, FL, USA
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38
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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39
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Abder-Rahman H, Habash I, Alami R, Alnimer T, Al-Abdallat I. Medico-legal importance of necrotizing fasciitis. J Forensic Leg Med 2020; 74:102019. [PMID: 32658769 DOI: 10.1016/j.jflm.2020.102019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/15/2022]
Abstract
Despite the rarity of necrotizing fasciitis (NF), it is a relatively common cause of death in many lawsuits. Families seek financial compensation or legal charges against those they believe to be involved in the death, usually physicians who did not identify the infection soon enough. This paper explores six cases in forensic pathology practice where NF posed a unique medico-legal dilemma.
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Affiliation(s)
- Hasan Abder-Rahman
- Forensic Pathology and Microbiology Department, University of Jordan, Amman, 11942, Jordan.
| | - Ibrahim Habash
- Forensic Pathology and Microbiology Department, University of Jordan, Amman, 11942, Jordan.
| | - Raghad Alami
- Ophthalmology Department, University of Jordan, Amman, 11942, Jordan.
| | - Touleen Alnimer
- Medical Student, University of Jordan, Amman, 11942, Jordan.
| | - Imad Al-Abdallat
- Forensic Pathology and Microbiology Department, University of Jordan, Amman, 11942, Jordan.
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40
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Huang TY, Peng KT, Hsu WH, Hung CH, Chuang FY, Tsai YH. Independent Predictors of Mortality for Aeromonas Necrotizing Fasciitis of Limbs: An 18-year Retrospective Study. Sci Rep 2020; 10:7716. [PMID: 32382057 PMCID: PMC7205975 DOI: 10.1038/s41598-020-64741-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022] Open
Abstract
Necrotizing fasciitis (NF) of the limbs caused by Aeromonas species is an extremely rare and life-threatening skin and soft tissue infection. The purpose of this study was to evaluate the specific characteristics and the independent predictors of mortality in patients with Aeromonas NF. Sixty-eight patients were retrospectively reviewed over an 18-year period. Differences in mortality, demographics data, comorbidities, symptoms and signs, laboratory findings, microbiological analysis, empiric antibiotics treatment and clinical outcomes were compared between the non-survival and the survival groups. Twenty patients died with the mortality rate of 29.4%. The non-survival group revealed significant differences in bacteremia, monomicrobial infection, cephalosporins resistance, initial ineffective empiric antibiotics usage, chronic kidney disease, chronic hepatic dysfunction, tachypnea, shock, hemorrhagic bullae, skin necrosis, leukopenia, band polymorphonuclear neutrophils >10%, anemia, and thrombocytopenia. The multivariate analysis identified four variables predicting mortality: bloodstream infection, shock, skin necrosis, and initial ineffective empirical antimicrobial usage against Aeromonas. NF caused by Aeromonas spp. revealed high mortality rates, even through aggressive surgical debridement and antibacterial therapies. Identifying those independent predictors, such as bacteremia, shock, progressive skin necrosis, monomicrobial infection, and application of the effective antimicrobial agents against Aeromonas under the supervision of infectious doctors, may improve clinical outcomes.
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Affiliation(s)
- Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Kuo-Ti Peng
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Department of Chinese Medicine, School of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Wei-Hsiu Hsu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Department of Chinese Medicine, School of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Chien-Hui Hung
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Fang-Yi Chuang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Hung Tsai
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Department of Chinese Medicine, School of Medicine, Chang Gung University, Chiayi, Taiwan.
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41
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Zhao-Fleming H, Almekdash MH, Cook E, Northcut A, Mitchell D, Rumbaugh K, Dissanaike S. Obesity Is Not an Independent Predictor of Necrotizing Soft Tissue Infection Outcomes. Surg Infect (Larchmt) 2020; 22:187-192. [PMID: 32320347 DOI: 10.1089/sur.2019.283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are a group of rapidly progressive infections of the skin and its underlying tissue. These infections result in substantial morbidity and mortality. The focus of this study was to determine if obesity is associated with a worsened clinical outcome or prolonged hospital course for patients with NSTIs. Patients and Methods: We conducted a retrospective chart review of patients with NSTI presenting to a single tertiary hospital. Fat content, measured with body mass index (BMI) and abdominal fat thicknesses, including subcutaneous and visceral fat, were compared against primary and secondary outcomes of NSTIs. Results: We found that women had a higher mortality rate compared with men (27% vs. 15% mortality). Women also had an increased subcutaneous abdominal fat thickness (55.7 vs. 36.9 mm, p = 0.028). However, no measurements of fat, BMI, subcutaneous fat, or visceral fat differed between survivors and mortalities of NSTIs. In fact, with the exception of a higher BMI in those who developed acute kidney injury (AKI, p = 0.034), we found no correlation between increases in fat measurement and secondary outcome, including propensity to develop sepsis during hospitalization, length of hospital stay, length of intensive care stay, or antibiotic usage. Multivariable logistic regression analysis was conducted, and we found no statistically significant differences in primary or secondary outcomes. Conclusion: Women appear to have a higher mortality in NSTI, although the reasons for this are unclear. Obesity, as measured by BMI, subcutaneous, and visceral fat thicknesses, does not appear to be an independent risk factor.
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Affiliation(s)
- Hannah Zhao-Fleming
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Mhd Hasan Almekdash
- Clinical Research Institute, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Elizabeth Cook
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Armand Northcut
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Diana Mitchell
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Kendra Rumbaugh
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.,Burn Center of Research Excellence, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.,Burn Center of Research Excellence, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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43
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Huang TY, Peng KT, Hsiao CT, Fann WC, Tsai YH, Li YY, Hung CH, Chuang FY, Hsu WH. Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan. BMC Infect Dis 2020; 20:60. [PMID: 31959118 PMCID: PMC6972015 DOI: 10.1186/s12879-020-4796-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 01/15/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs. METHODS A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared. RESULTS A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection. CONCLUSIONS In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.
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Affiliation(s)
- Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Ti Peng
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6, West section, Chia-Pu Road, Pu-Zih city, Chiayi, 61363, Taiwan.,Department of Medicine, School of Medicine, Chang Gung University, Tao Yuan, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Hung Tsai
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6, West section, Chia-Pu Road, Pu-Zih city, Chiayi, 61363, Taiwan
| | - Yen-Yao Li
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6, West section, Chia-Pu Road, Pu-Zih city, Chiayi, 61363, Taiwan
| | - Chien-Hui Hung
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Fang-Yi Chuang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wei-Hsiu Hsu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6, West section, Chia-Pu Road, Pu-Zih city, Chiayi, 61363, Taiwan. .,Department of Medicine, School of Medicine, Chang Gung University, Tao Yuan, Taiwan.
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44
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Liu TJ, Tai HC, Chien KL, Cheng NC. Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: A nationwide population-based case–control study. J Formos Med Assoc 2020; 119:18-25. [DOI: 10.1016/j.jfma.2019.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 11/29/2022] Open
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45
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Antibiotics for the Prevention and Treatment of Postsurgical Obstetric Infections. Obstet Gynecol Surv 2019; 73:475-485. [PMID: 30169886 DOI: 10.1097/ogx.0000000000000590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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46
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Dhawan G, Kapoor R, Dhamija A, Singh R, Monga B, Calabrese EJ. Necrotizing Fasciitis: Low-Dose Radiotherapy as a Potential Adjunct Treatment. Dose Response 2019; 17:1559325819871757. [PMID: 31496924 PMCID: PMC6716184 DOI: 10.1177/1559325819871757] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 12/27/2022] Open
Abstract
Necrotizing fasciitis (NF) is a rapidly spreading bacterial infection causing extensive tissue necrosis and destruction. Despite appropriate therapy, the disease results in significant morbidity/mortality and substantial treatment costs. Several studies published in the early 1900s demonstrated the effective use of low-dose X-ray radiotherapy (RT) for the treatment of many diverse inflammatory conditions and diseases (eg, gas gangrene, sinus infections, arthritis, tendonitis, and serious inflammatory lung conditions). The mechanism by which therapeutic RT doses produce positive patient outcomes is related at least in part to its capacity to induce tissue-based anti-inflammatory responses. This action is due to the polarization of macrophages to an anti-inflammatory or M2 phenotype via optimized low-dose RT. Low-dose RT has the potential to significantly reduce debilitating surgeries and aggressive treatments required for NF, providing a 3-prong benefit in terms of patient mortality, length of hospitalization stays, and cost of health care (both short term and long term). Low cost and easy availability of low-dose RT makes it a potentially useful option for patients of every age-group. In addition, low-dose RT may be a particularly useful option in countries treating many patients who are unable to afford surgeries, antibiotics, and hyperbaric oxygen.
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Affiliation(s)
- Gaurav Dhawan
- Human Research Protection Office, University of Massachusetts, Amherst, MA, USA
| | - Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | | | | | - Bharat Monga
- Division of Hospital Medicine, Mount Sinai St Luke's Hospital, New York, NY, USA
| | - Edward J Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
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47
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A case of necrotizing fasciitis following Edwardsiella tarda septicemia with gastroenteritis. J Infect Chemother 2019; 25:1053-1056. [PMID: 31235349 DOI: 10.1016/j.jiac.2019.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/08/2019] [Accepted: 05/20/2019] [Indexed: 11/21/2022]
Abstract
Edwardsiella tarda is an uncommon pathogen that causes gastroenteritis in humans and is found in the aquatic environment. In rare cases, it also causes fatal infections, including sepsis and necrotizing fasciitis. However, it remains unknown whether E. tarda gastroenteritis could lead to these lethal diseases via hematogenous spread. Here we have reported a previously healthy 64-year-old woman with necrotizing fasciitis consecutively caused by E. tarda septicemia with gastroenteritis. The patient was transferred to the emergency department due to disturbance of consciousness and hypotension after suffering from diarrhea for a month. As whole-body computed tomography (CT) revealed an edematous change in the small intestine, septic shock following gastroenteritis was suspected, and the patient was immediately started on empiric antibiotic therapy and provided critical care. Her general physical conditions gradually began improving, but, on day 7, rapidly appearing blisters on both the lower limbs were noted, and she was accordingly examined again by conducting a CT scan. Based on the results, she was diagnosed with necrotizing fasciitis in both lower extremities, and surgical debridement was rapidly performed. Microbiological analysis of the specimens revealed E. tarda bacteremia, which suggested that E. tarda caused a series of infections in this patient. Finally, she fully recovered and was discharged within 3 months. Cumulatively, we proposed that gastroenteritis by E. tarda could directly result in fatal infections through the blood stream.
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48
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Papanikolas M, Kim TJ, Mackenzie S. Hindquarter amputation resulting from a perforated retroperitoneal appendicitis: a rare case. ANZ J Surg 2019; 90:E46-E47. [PMID: 31069950 DOI: 10.1111/ans.15211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Papanikolas
- Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Tae-Jun Kim
- Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Scott Mackenzie
- Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia
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49
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Abstract
Infections of the hand are common entities that are frequently encountered by orthopaedic surgeons and primary care physicians. A high clinical suspicion and a thorough medical history with information about the social and working history of the patients, correct identification of the type and cause of the infection, and prompt initiation of appropriate treatment by the infectious diseases physicians and orthopaedic surgeons are required. Late diagnosis and inappropriate treatment may be a significant cause of morbidity for the hand and mortality for the patients. This article reviews the clinical spectrum and microbiology of the most common infections of the hand, and discusses the current concepts for their treatment. The aim is to increase the awareness of the treating physicians of the diagnosis and management of infections in the hand.
Cite this article: EFORT Open Rev 2019;4:183-193. DOI: 10.1302/2058-5241.4.180082
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Affiliation(s)
- Dimitrios A Flevas
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Sophia Syngouna
- Department of Upper Extremity Surgery and Microsurgery, KAT Hospital, Athens, Greece
| | - Emmanouel Fandridis
- Department of Upper Extremity Surgery and Microsurgery, KAT Hospital, Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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50
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Wong RM, Chau LTC, Mak MCK, Tse WL, Ho PC. Necrotizing fasciitis induced by Vibrio vulnificus in patients without marine contact in Hong Kong. J Orthop Translat 2019; 19:151-154. [PMID: 31844623 PMCID: PMC6896480 DOI: 10.1016/j.jot.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/30/2019] [Accepted: 03/08/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ronald M.Y. Wong
- Corresponding author. Department of Orthopaedics and Traumatology, 5/F Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, N.T. Shatin, Hong Kong.
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