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Tarekegn NG, Moges TG, Guluju FA. Retroperitoneal necrotizing fasciitis mimicking perforated appendicitis: A case report. Int J Surg Case Rep 2024; 116:109412. [PMID: 38382145 PMCID: PMC10943963 DOI: 10.1016/j.ijscr.2024.109412] [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: 11/10/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a rare and rapidly progressing soft tissue infection. The commonly involved body parts are the extremities and trunk. Necrotizing fasciitis (NF) involving the retroperitoneum is very uncommon but associated with higher morbidity and mortality. There are only a few patients survived according to the report. PRESENTATION OF CASE This is a 19-year-old male patient presented with abdominal pain, high-grade fever, vomiting and abdominal distension for 3 days. On physical examination, he was hypotensive, tachycardic and febrile. He had a distended, tender abdomen, and hypoactive bowel sound. There were no significant pertinent findings on the other systems. Laboratory tests showed leukocytosis, thrombocytopenia, and elevated liver enzymes. After optimizing with resuscitation and initiating antibiotics, a laparotomy was performed. The finding was 300 ml of hemorrhagic fluid, ischemic cecum and ascending colon, and retroperitoneal necrosis. Subsequently, multiple debridement and right hemicolectomy with stoma was performed. Despite the close monitoring in the ICU, the patient died of uncontrolled sepsis. CLINICAL DISCUSSION Necrotizing fasciitis (NF) is a rapidly progressing infectious condition that requires urgent intervention. While it is rare for the retroperitoneum to be affected by NF, it is associated with a high mortality rate. The symptoms of retroperitoneal NF are not specific, making it difficult to diagnose. Here, we present a case of retroperitoneal NF with signs and symptoms of generalized peritonitis, resembling perforated appendicitis. CONCLUSION When patients are presented with a case of generalized peritonitis, it is important to include retroperitoneal NF as a potential differential diagnosis.
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Affiliation(s)
| | - Tadesse Girma Moges
- Department of Surgery, Faculty of Medicine, Institute of Health, Jimma University, Ethiopia
| | - Feyera Abetu Guluju
- Department of Surgery, Faculty of Medicine, Institute of Health, Jimma University, Ethiopia
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Iacopi E, Sbarbaro C, Pieruzzi L, Lorenzi I, Baroni L, Goretti C, Malacarne P, Piaggesi A. Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol. INT J LOW EXTR WOUND 2023; 22:733-741. [PMID: 34488474 DOI: 10.1177/15347346211041452] [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: 11/16/2022]
Abstract
Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.
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Affiliation(s)
| | - Catia Sbarbaro
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | | | - Irene Lorenzi
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | - Luisa Baroni
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | | | - Paolo Malacarne
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
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Daga LK, Gatchalian L. Necrotizing Fasciitis in a Patient With Signet-Ring Cell Gastric Adenocarcinoma. Cureus 2023; 15:e51198. [PMID: 38283521 PMCID: PMC10818090 DOI: 10.7759/cureus.51198] [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: 03/08/2023] [Indexed: 01/30/2024] Open
Abstract
Necrotizing fasciitis is an aggressive infection of the skin and soft tissues that requires prompt recognition and management. Immediate source control and adjunctive antibiotic therapy are the cornerstones of management. There are limited reported cases of necrotizing fasciitis related to gastrointestinal malignancy, including gastric cancer. This report describes the case of a 36-year-old male who developed left abdominal wall necrotizing fasciitis related to perforated gastric adenocarcinoma with signet-ring features. Signet-ring adenocarcinoma is associated with a more aggressive malignancy. The rapid progression of the infection leading to refractory shock and acute respiratory distress rendered the patient a poor candidate for surgical source control because of high surgical risk. Patient eventually expired. Immediate recognition of necrotizing fasciitis and perforated gastric cancer can prompt early surgical referral for definitive source control and gastric resection or repair.
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Affiliation(s)
| | - Lovell Gatchalian
- Section of Gastroenterology, East Avenue Medical Center, Quezon City, PHL
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Hsiao CY, Huang TY, Teng LY, Chen HY, Hsiao CT, Tsai YH, Kuo SF. Initial skin necrosis presentation at emergency room was associated with fulminant clinical course and mortality in patients with Vibrio necrotizing fasciitis. Sci Rep 2023; 13:18410. [PMID: 37891231 PMCID: PMC10611701 DOI: 10.1038/s41598-023-45854-1] [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: 03/20/2023] [Accepted: 10/25/2023] [Indexed: 10/29/2023] Open
Abstract
Necrotizing fasciitis (NF) is a life-threatening infection. Skin necrosis is an important skin sign of NF. The purposes of this study was to investigate the initial skin conditions of Vibrio NF patients between emergency room (ER) to preoperative status, to compare the clinical and laboratory risk indicators of the skin necrosis group and non-skin necrosis group when they arrived at ER, and to evaluate whether initial cutaneous necrosis related to fulminant course and higher fatalities. From 2015 to 2019, seventy-two Vibrio NF patients with surgical confirmation were enrolled. We identified 25 patients for inclusion in the skin necrosis group and 47 patients for inclusion in the non-skin necrosis group due to the appearance of skin lesion at ER. Seven patients died, resulting in a mortality rate of 9.7%. Six patients of skin necrosis group and one patient of non-skin necrosis group died, which revealed the skin necrosis group had a significantly higher mortality rate than the non-skin necrosis group. All the patients in the skin necrosis group and 30 patients of non-skin necrosis group developed serous or hemorrhagic bullous lesions before operation (p = 0.0003). The skin necrosis group had a significantly higher incidence of APACHE score, postoperative intubation, Intensive care unit stay, septic shock, leukopenia, higher counts of banded leukocytes, elevated C-reactive protein (CRP), and lower serum albumin level. Vibrio NF patients presenting skin necrosis at ER were significantly associated with fulminant clinical courses and higher mortality. Physicians should alert the appearance of skin necrosis at ER to early suspect NF and treat aggressively by those clinical and laboratory risk indicators, such as elevated APACHE score, shock, leukopenia, higher banded leukocytes, elevated CRP, and hypoalbuminia.
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Affiliation(s)
- Chun-Yuan Hsiao
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, No. 8, West Sec, Chia-Pu Road, Putz City, Chiayi County, 61363, Taiwan, Republic of China
| | - Tsung-Yu Huang
- College of Medicine, Chang Gung University at Taoyuan, Taoyuan City, Taiwan, Republic of China
- Division of Infectious Diseases, Department of Internal Medicine, Chia-Yi Chang Gung Memorial Hospital, Chiayi County, Taiwan, Republic of China
- Microbiology Research and Treatment Center, Chia-Yi Chang Gung Memorial Hospital, Chiayi County, Taiwan, Republic of China
| | - Li-Yun Teng
- Department of Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Taichung City, Taiwan
| | - Hung-Yen Chen
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, No. 8, West Sec, Chia-Pu Road, Putz City, Chiayi County, 61363, Taiwan, Republic of China
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University at Taoyuan, Taoyuan City, Taiwan, Republic of China
- Department of Emergency Medicine, Chia-Yi Chang Gung Memorial Hospital, Chiayi County, Taiwan, Republic of China
| | - Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, No. 8, West Sec, Chia-Pu Road, Putz City, Chiayi County, 61363, Taiwan, Republic of China.
- College of Medicine, Chang Gung University at Taoyuan, Taoyuan City, Taiwan, Republic of China.
| | - Shu-Fang Kuo
- Microbiology Research and Treatment Center, Chia-Yi Chang Gung Memorial Hospital, Chiayi County, Taiwan, Republic of China
- Departments of Laboratory Medicine, Chia-Yi Chang Gung Memorial Hospital, Chiayi County, 61363, Taiwan
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Killblane T, Milsap D, Vetos D, Grantham DC, Hagan M. Cryptococcal Necrotizing Fasciitis in a Patient With Sarcoidosis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Anshu DA, Dwivedi DS, Murali DM, MP DH. Necrotising Soft Tissue Infection in Present Era: A Clinicopathological Analysis & Predictors of Mortality. SURGERY IN PRACTICE AND SCIENCE 2023. [DOI: 10.1016/j.sipas.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Cantarella S, Casamassima A, Bussone DM, Baldini E, Kersik A, Boccia O, Gianotti C. A necrotising fasciitis: case report. J Ultrasound 2023; 26:147-150. [PMID: 36609958 PMCID: PMC10063729 DOI: 10.1007/s40477-022-00717-9] [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: 03/21/2022] [Accepted: 07/21/2022] [Indexed: 01/09/2023] Open
Abstract
Necrotizing fasciitis is one of the most common soft tissue infections, with a high risk of major amputation and a mortality ranging from 6 to 33% which has not changed in the past 20 years. Early surgical resection of necrotic tissue plays a key role in determining the prognosis. Nawijn et al. identified an optimal 6 hours window from presentation to surgery. Symptoms of necrotizing fasciitis mimic those of common skin infections, such as erysipelas and cellulitis, making rapid surgical management difficult. In this context, the aid of point-of-care-ultrasound is a valuable tool for early diagnosis, detecting the presence of subcutaneous thickening, gas and perifascial liquid. Other characteristic ultrasound findings include the "cobblestone" appearance of the subcutaneous soft tissues and reverberation artifacts due to hyperechoic outbreaks, defined as "snow globes" due to the presence of heterogeneous swirling material, and "dirty shadowing" due to the foggy shadow created by the gas.
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Affiliation(s)
- S Cantarella
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy.
| | - A Casamassima
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - Dott M Bussone
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - E Baldini
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - A Kersik
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
| | - O Boccia
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
| | - C Gianotti
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
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Muacevic A, Adler JR, Ludlow K, Merideth D, Haynes W, Shrivastava V. Relevant Dermatoses Among U.S. Military Service Members: An Operational Review of Management Strategies and Telemedicine Utilization. Cureus 2023; 15:e33274. [PMID: 36741595 PMCID: PMC9891841 DOI: 10.7759/cureus.33274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
Despite skin being the largest and most exposed organ of the human body, skin issues can be challenging to diagnose in deployed military service members. Common reasons deployed soldiers seek dermatological evaluation include infections, inflammatory skin conditions, and skin growth. Due to limited access to specialized care in deployed settings, dermatological conditions are undertreated and underdiagnosed. As a result, dermatological conditions are a leading contributor to decreased combat effectiveness among deployed medical forces. To lessen the burden of dermatological diseases, military providers should promptly identify operational skin diseases and alleviate modifiable barriers faced by service members. In a post-pandemic era with novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and monkeypox infections, the duty to effectively treat operational skin lesions is ever important. The need for military dermatologists continues to rise as the global landscape continues to evolve with unprecedented infections and increased bioterrorism threats. Teledermatology offers many solutions to mitigate the high demand for dermatologists during pandemics. Dermatological consultations account for the highest number of telemedicine visits in the US Military Health System (MHS). As such, increased utilization of teledermatology will reduce infection-related dermatological sequelae and prevent the medical evacuation of service members from military operations. This review collates and categorizes relevant dermatological conditions encountered among deployed personnel. This report outlines the standard of care and modified treatments recommended according to potential barriers faced in operational settings.
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Muacevic A, Adler JR, Maloof J. An Unusual Case of Deep Vein Thrombosis and Concurrent Necrotizing Fasciitis Following a Fall. Cureus 2023; 15:e33934. [PMID: 36819317 PMCID: PMC9937681 DOI: 10.7759/cureus.33934] [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: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
A 74-year-old male patient presented to the emergency department following a fall with signs and symptoms consistent with right lower extremity (RLE) deep vein thrombosis (DVT) and non-specific skin changes. Further imaging confirmed the initial diagnosis of DVT, and the patient was appropriately treated. However, his condition continued to deteriorate with worsening overlying skin changes, which prompted a computed tomography (CT) scan of his right femur without intravenous (IV) contrast. This revealed fluid tracking along the lateral compartment muscles, which raised suspicion of an abscess. Suspicion for necrotizing fasciitis (NF) was raised with a subsequent CT of the right femur with IV contrast that demonstrated a considerable increase in rim-enhancing fluid collections intramuscularly and extending into both the anterior and posterior compartments, likely correlating with increasing intermuscular abscesses. On imaging, no subcutaneous emphysema or gas accumulation was found, which is a common finding in NF. However, necrotic-appearing muscle was found on surgical debridement and wound cultures confirmed the diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) NF. The patient was then treated with appropriate IV antibiotics and was discharged to long-term inpatient wound care. Similar presentations of DVT and NF made a prompt diagnosis of NF difficult, and it highlights the need for further imaging to rule out NF when a patient has a confirmed diagnosis of DVT.
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Necrotizing fasciitis and toxic shock syndrome due to Streptococcus pyogenes in a female adolescent – A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2023. [DOI: 10.1016/j.epsc.2023.102582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Muacevic A, Adler JR, Huang A, Usman M, Seale JR. Necrotizing Fasciitis Presenting as Generalized Weakness, Malaise, and Acute Kidney Injury. Cureus 2022; 14:e31674. [PMID: 36545158 PMCID: PMC9762526 DOI: 10.7759/cureus.31674] [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: 10/27/2022] [Accepted: 11/19/2022] [Indexed: 11/21/2022] Open
Abstract
Necrotizing fasciitis (NF) is a surgical emergency that must be diagnosed promptly in order to avoid serious consequences or death. Additionally, symptoms of this condition are similar to less severe skin and soft tissue infections such as cellulitis or erysipelas and can be easily confused. In this case, the patient presented to the emergency department with systemic symptoms, notably malaise and generalized weakness. A cutaneous complaint, a "labial cyst", was only elicited after more specific questioning. Laboratory investigations revealed abnormal renal function tests (RFTs), suggestive of an acute kidney injury. An abdominal/pelvic computed tomography (CT) showed gas in the subcutaneous tissue. These findings led to clinical suspicion of NF, prompting a general surgery consultation. The surgeon proceeded to perform extensive debridement following the discovery of necrotic tissue. The prompt diagnosis and treatment of this condition resulted in patient survival and expected recovery. It is, therefore, critical to keep this condition in mind when diagnosing apparent skin and soft tissue infections presenting with abnormal RFTs due to the possibility of rapid decline and death if the NF is left untreated. Additionally, this is a case of less frequent Fournier's gangrene in a non-diabetic female. Finally, it underlines the importance of eliciting additional symptoms, even those that may seem unrelated, or less concerning, to the patient's initial complaint.
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Rastätter M, Walter N, Bärtl S, Alt V, Rupp M. [Septic patient with gangrenous foot : A report of a surgical emergency with a foudroyant course]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:1095-1098. [PMID: 35731283 PMCID: PMC9592627 DOI: 10.1007/s00104-022-01674-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Mario Rastätter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Nike Walter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Susanne Bärtl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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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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Skin Preservation in the Debridement of Necrotizing Fasciitis: A Demonstrative Case Report. Plast Reconstr Surg Glob Open 2022; 10:e4227. [PMID: 35402126 PMCID: PMC8987216 DOI: 10.1097/gox.0000000000004227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
Necrotizing fasciitis (NF) is a rare yet potentially fatal soft-tissue, polymicrobial infection. Aggressive debridement of the fascia and overlying skin as well as antimicrobial coverage constitute the mainstay of management, often leaving large skin defects. However, we demonstrate in this paper a case of a young woman who developed NF after liposuction and was treated by fascial debridement with minimal skin excision. Skin preservation will reduce the morbidity and improve the final aesthetic outcome.
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Stowell JT, Walker CM, Chung JH, Bang TJ, Carter BW, Christensen JD, Donnelly EF, Hanna TN, Hobbs SB, Johnson BD, Kandathil A, Lo BM, Madan R, Majercik S, Moore WH, Kanne JP. ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain. J Am Coll Radiol 2021; 18:S394-S405. [PMID: 34794596 DOI: 10.1016/j.jacr.2021.08.004] [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: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 10/19/2022]
Abstract
Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Jonathan H Chung
- Panel Chair; and Vice-Chair, Quality and Section Chief, Chest Imaging, Department of Radiology, University of Chicago, Chicago, Illinois
| | - Tami J Bang
- Co-Director, Cardiothoracic Imaging Fellowship Committee, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Co-Chair, membership committee, NASCI; and Membership committee, ad-hoc online content committee, STR
| | - Brett W Carter
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jared D Christensen
- Vice-Chair, Department of Radiology, Duke University Medical Center, Durham, North Carolina; and Chair, Lung-RADS
| | - Edwin F Donnelly
- Chief, Thoracic Imaging, Ohio State University, Columbus, Ohio; Co-Chair Physics Module Committee, RSNA
| | - Tarek N Hanna
- Associate Director, Emergency and Trauma Imaging, Emory University, Atlanta, Georgia; and Director-at-Large, American Society of Emergency Radiology
| | - Stephen B Hobbs
- Vice-Chair, Informatics and Integrated Clinical Operations and Division Chief, Cardiovascular and Thoracic Radiology, University of Kentucky, Lexington, Kentucky
| | | | | | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; and Board Member, American College of Emergency Physicians
| | - Rachna Madan
- Associate Fellowship Director, Division of Thoracic Imaging, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Majercik
- Vice-Chair, Surgery for Research and Director, Trauma Research, Intermountain Medical Center, Salt Lake City, Utah; and American Association for the Surgery of Trauma
| | - William H Moore
- Associate Chair, Clinical Informatics and Chief, Thoracic Imaging, New York University Langone Medical Center, New York, New York
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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16
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Bahl N, Long AS, Vemuri A, Jessee T. A Case of Necrotizing Soft Tissue Infection Secondary to Perforated Colon Cancer. Cureus 2021; 13:e17663. [PMID: 34646705 PMCID: PMC8487249 DOI: 10.7759/cureus.17663] [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] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Necrotizing soft tissue infections are aggressive infections that cause necrosis of muscle, fascia, and tissue. They typically follow fascial planes that lack insufficient blood supply. Early drainage and debridement are essential for survival in these patients. This is a case of a patient who presented in diabetic ketoacidosis with a necrotizing soft tissue infection localized to the left flank and abdomen with underlying colon cancer pathology. The patient was a 54-year-old female who initially presented with acute dyspnea and left flank pain for two weeks. On admission, she was afebrile, tachycardic, tachypneic, and hypertensive. After being transferred to the ICU for diabetic ketoacidosis management, she began complaining of left abdominal pain and the CT showed concerns for a possible necrotizing soft tissue infection in the left flank region. She was taken to the operating room immediately for debridement and started on broad-spectrum antibiotics. The next day, an exploratory laparotomy was performed with a hemicolectomy and creation of an end colostomy due to concern for a perforated colonic malignancy. A final debridement was completed and a wound vacuum-assisted closure (VAC) was placed. Final pathology demonstrated well-differentiated colonic adenocarcinoma invading into the muscularis propria. Overall, necrotizing soft tissue infections can be related to a perforated viscus especially a colonic malignancy and this case demonstrates the importance of proper surgical management and high clinical suspicion for possible underlying pathology in a soft tissue infection.
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Affiliation(s)
- Nicholas Bahl
- Surgery, Regional Medical Center Bayonet Point, Hudson, USA
| | - Ashley S Long
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Adithi Vemuri
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
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Demir Çuha M, Er AG, Durukan BM, Karagöz A, Hazırolan G, Ünal S. A rare case of necrotizing fasciitis of the abdominal wall due to Hungatella effluvii and Streptococcus constellatus. Anaerobe 2021; 70:102409. [PMID: 34171472 DOI: 10.1016/j.anaerobe.2021.102409] [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] [Received: 03/09/2021] [Revised: 06/20/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
We report a rare case of necrotizing fasciitis of the abdominal wall caused by Hungatella effluvii and Streptococcus constellatus. Necrotizing fasciitis has high mortality, so early diagnosis and aggressive treatment are essential for good clinical outcome. Identification of the microbial contribution to these infections is crucial for targeted antibiotic treatment.
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Affiliation(s)
- Mervenur Demir Çuha
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Ahmet Görkem Er
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Bekir Mert Durukan
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alper Karagöz
- Department of Microbiology, Faculty of Molecular Biology and Genetics, Usak University, Usak, Turkey
| | - Gülşen Hazırolan
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Serhat Ünal
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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18
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Necrotizing Fasciitis: a Clinical Case and a Review of the Literature. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2021. [DOI: 10.2478/sjdv-2020-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Necrotizing fasciitis is a soft tissue, life-threatening infection with a fulminant and often fatal course. Early diagnosis is usually delayed as the onset of the disease is often masked in the form of erysipelas or cellulite. The condition is characterized by necrosis of the skin, subcutaneous tissue and underlying fascia. We describe a case of a 42-year-old man with a complaint of erythema, fever and severe pain in his right leg 4 days before hospitalization. The patient was admitted and treated with a diagnosis of erysipelas. A few hours after admission, in connection with a drastic deterioration in the general condition and dermatological status, he was transferred to a purulentseptic ward with a fulminant picture of necrotizing fasciitis. Debridement and fasciotomy were performed successfully and timely. Good prognosis and survival in patients with NF correlate directly with the complex of measures. Appropriate antibiotics and intensive general support avoid massive systemic diffusion. Early and adequate surgical debridement and fasciotomy are associated with improved survival.
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Chávez-Reyes J, Escárcega-González CE, Chavira-Suárez E, León-Buitimea A, Vázquez-León P, Morones-Ramírez JR, Villalón CM, Quintanar-Stephano A, Marichal-Cancino BA. Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia. Front Public Health 2021; 9:559595. [PMID: 33665182 PMCID: PMC7921169 DOI: 10.3389/fpubh.2021.559595] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.
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Affiliation(s)
- Jesús Chávez-Reyes
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Carlos E Escárcega-González
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Erika Chavira-Suárez
- Unidad de Vinculación Científica de la Facultad de Medicina, Universidad Nacional Autónoma de México en el Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Angel León-Buitimea
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Priscila Vázquez-León
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - José R Morones-Ramírez
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico
| | - Andrés Quintanar-Stephano
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
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Tanaka T, Shimizu M, Tokuda O, Yamamoto H, Matsunoshita N, Takenaka K, Kawasaki K. Kawasaki Disease with an Initial Manifestation Mimicking Bacterial Inguinal Cellulitis. Case Rep Pediatr 2020; 2020:8889827. [PMID: 33194239 PMCID: PMC7641693 DOI: 10.1155/2020/8889827] [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: 05/23/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) is typically characterized by fever, oral cavity erythematous changes, bilateral bulbar conjunctival injection, skin rash, erythema and edema of the hands and feet, and cervical lymphadenopathy. Some atypical patients with KD initially develop cervical and pharyngeal cellulitis; however, an initial presentation with inguinal cellulitis is extremely rare. In addition, to our knowledge, no report has documented the cytokine profile in a KD patient with cellulitis. Case presentation. A previously healthy 8-year-old Japanese girl was hospitalized following a 2-day history of fever and a 5-day history of pain and erythema in the left inguinal region. She was diagnosed with bacterial inguinal cellulitis and was administered antibiotics. The next day, a polymorphous rash emerged on her trunk. After 3 days of antibiotics, however, her fever continued and the cellulitis had spread over the entire lower abdomen. Simultaneously, the bilateral bulbar conjunctival injection without exudate became more prominent and her lips became erythematous. In addition, erythematous changes on her palms appeared a few hours later, which led to the diagnosis of KD. Since she had a high risk score that predicted no response to initial intravenous immunoglobulin (IVIG) at the initiation of treatment, she was treated with IVIG, intravenous prednisolone (PSL), and oral aspirin. The KD symptoms improved the next day, but the cellulitis did not completely resolve until 2 months after discharge. The patient's serum cytokine profile at admission had an IL-6 dominant pattern which was consistent with that of patients with KD despite her initial lack of KD symptoms, and the pattern observed at admission was sustained until IVIG and PSL administration. CONCLUSION KD should be included in the differential diagnosis for patients presenting with inguinal cellulitis who are unresponsive to initial empiric antibiotics.
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Affiliation(s)
- Tsukasa Tanaka
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | - Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, Health Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Oshi Tokuda
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | - Hiroko Yamamoto
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
| | | | - Kanae Takenaka
- Department of Pediatrics, Kita-Harima Medical Center, Ono, Hyogo, Japan
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21
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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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22
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Pieruzzi L, Napoli V, Goretti C, Adami D, Iacopi E, Cicorelli A, Piaggesi A. Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit. INT J LOW EXTR WOUND 2020; 19:315-333. [PMID: 32820699 DOI: 10.1177/1534734620948351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ultrasound (US) is a noninvasive and versatile technology that in recent years found acceptance in almost all the medical specialties, with diagnostic and interventional applications. In the diabetic foot syndrome (DFS), US found specific indications mainly in the screening, quantification, and follow-up of the vascular component of the pathology, but also in the study of the deformities and structural modifications induced by neuropathy and in the diagnosis and surgical management of infections, especially those that induce anatomical changes, like abscesses and fasciitis. This review will summarize all these application of US, giving special attention to the vascular aspects, and on the predominant role that US gained in recent times to guide the indication to revascularization, on the new standardized approach to the study of the arterial tree of the limb and the foot, the so-called duplex ultrasound arterial mapping, which significantly increased the utilization of US to plan the revascularizations in this complex pathology. Outside the vascular fields, the diagnosis of neuropathy and infection and the intraoperative use of US in the surgical management of abscesses and fasciitis will be discussed, leaving the last part to the new and interesting applications of US in the management of DFU, a field that is still in evolution, offering new possibilities to the health care professionals involved in the management of these chronic wounds. The variety of applications both in diagnostic and operative fields makes US a rather versatile technology-a toolkit-that should have a special place among those at reach of the specialists of DFS care.
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23
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Maghsoudi LH, Navab M, Pak H. A rare presentation of xanthogranulomatous pyelonephritis and emphysematous pyelonephritis complicated with necrotizing fasciitis of scrotum and perineum (fournier gangrene). Urol Case Rep 2020; 33:101299. [PMID: 33102002 PMCID: PMC7573818 DOI: 10.1016/j.eucr.2020.101299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/13/2020] [Indexed: 11/02/2022] Open
Abstract
We report a case of cooccurrence of xanthogranulomatous and emphysematous pyelonephritis along with necrotizing fasciitis (NF) of scrotum and premium in a patient was nondiabetic and the history of kidney stones. This case a unique presentation of NF due to two pyelonephritis causing fournier gangrene. Surgical management and antibiotics provide an effective management of the disease.
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Affiliation(s)
- Leila Haji Maghsoudi
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Mojdeh Navab
- Department of Urology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Haleh Pak
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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24
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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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25
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Reese AM, Haag CK, Jung E, Nauta AC, Swerlick RA, Ortega-Loayza AG. Pyoderma gangrenosum underrepresentation in non-dermatological literature. Diagnosis (Berl) 2020; 8:85-90. [DOI: 10.1515/dx-2019-0079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/06/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).
Methods
We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).
Results
Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.
Conclusions
There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.
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Affiliation(s)
- Ashley M. Reese
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Carter K. Haag
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Enjae Jung
- Division of Vascular Surgery , Oregon Health and Science University , Portland , OR , USA
| | - Allison C. Nauta
- Division of Plastic and Reconstructive Surgery , Oregon Health and Science University , Portland , OR , USA
| | | | - Alex G. Ortega-Loayza
- Department of Dermatology , Oregon Health and Science University , Portland , OR , USA
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Suijker J, de Vries A, de Jong VM, Schepers T, Ponsen KJ, Halm JA. Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections. J Surg Res 2019; 245:516-522. [PMID: 31450039 DOI: 10.1016/j.jss.2019.07.097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/26/2019] [Accepted: 07/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE Level 3, prognostic and epidemiological.
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Affiliation(s)
- Jaco Suijker
- Burn Centre, Red Cross Hospital, Beverwijk, the Netherlands.
| | - Annebeth de Vries
- Burn Centre, Red Cross Hospital, Beverwijk, the Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, the Netherlands.
| | | | - Tim Schepers
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, the Netherlands
| | - Kees J Ponsen
- Department of Surgery, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, the Netherlands
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27
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Liu CH, Wang TS, Wang PH, Yen MS. Necrotizing fasciitis following a preterm caesarean delivery. Taiwan J Obstet Gynecol 2019; 58:577-578. [DOI: 10.1016/j.tjog.2019.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 10/26/2022] Open
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29
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Raya-Cruz M, Payeras-Cifre A, Ventayol-Aguiló L, Díaz-Antolín P. Factors associated with readmission and mortality in adult patients with skin and soft tissue infections. Int J Dermatol 2019; 58:916-924. [PMID: 30770547 DOI: 10.1111/ijd.14390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 01/09/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are a common cause of consultation, and complicated cases require hospitalization. We describe factors that are related to readmission and/or mortality of hospitalized patients diagnosed with SSTIs. METHODS Retrospective review of hospital-admitted patients with a diagnosis of cellulitis, abscess, hidradenitis, fasciitis, and Fournier's gangrene. Cases from January 2002 to October 2015 were extracted from the diagnostic codification database of the Archives and Clinical Documentation Department. FINDINGS We studied 1,482 episodes of hospitalized patients diagnosed with SSTIs. There were 187 (12.3%) readmissions, the most frequent diagnosis was cellulitis (72.7%), and the most commonly isolated microorganism was Staphylococcus aureus (25; 30.1%). Factors associated with readmissions were healthcare-related infections (P = 0.002), prior antibiotic therapy (P < 0.001), ischemic heart disease (P = 0.01), chronic liver disease (P = 0.001), and diabetes mellitus (DM) (P = 0.006). The number of patients who died as a result of an infection was 34 (2.2%) and, in these patients, the most common diagnosis was also cellulitis (79.4%), which in 52.9% (P = 0.001) was community acquired. DM (P = 0.01), heart failure (P = 0.001), and chronic liver disease (P = 0.003) were the most frequent comorbidities. This group presented more complications (P < 0.005) such as endocarditis (P < 0.005), amputation (P = 0.018), severe sepsis (P < 0.005), and septic shock (P < 0.001). CONCLUSIONS Readmitted patients had healthcare-related S. aureus infection, had received prior antibiotic therapy, and presented comorbid conditions such as ischemic heart disease, peripheral vascular disease, chronic liver disease, or DM. Comorbidities such as advanced age, DM, heart failure, and chronic liver disease were associated with complications and higher infection-related mortality.
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Affiliation(s)
- Manuel Raya-Cruz
- Internal Medicine and Infectious Diseases, Son Llàtzer Hospital, Balearic Islands, Spain
| | - Antonio Payeras-Cifre
- Head of Internal Medicine and Infectious Diseases, Son Llàtzer Hospital, Balearic Islands, Spain
| | - Lola Ventayol-Aguiló
- Internal Medicine and Infectious Diseases, Son Llàtzer Hospital, Balearic Islands, Spain
| | - Paz Díaz-Antolín
- Clinical Microbiology Department, Son Llàtzer Hospital, Balearic Islands, Spain
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30
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Albadri Z, Salman K. Necrotizing fasciitis of the finger. IDCases 2019; 17:e00560. [PMID: 31384560 PMCID: PMC6667696 DOI: 10.1016/j.idcr.2019.e00560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 11/30/2022] Open
Abstract
A 62 year old woman with a medical history of hypertension presented to her local general practice with moderate pain in the right ring finger which worsened over a few hours after onset. Her condition progressed swiftly into sepsis and required hospital admission in the intensive care unit. Over the course of 24 h the patient was diagnosed with necrotizing fasciitis in the finger but unfortunately despite treatment with antimicrobials and surgical debridement the patient’s finger could not be saved and she had amputation of her finger.
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31
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López-Simarro F, Redondo Margüello E, Mediavilla Bravo JJ, Soriano Llora T, Iturralde Iriso J, Hormigo Pozo A. [Prevention and treatment of infectious diseases in diabetic patients]. Semergen 2018; 45:117-127. [PMID: 30580897 DOI: 10.1016/j.semerg.2018.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 01/13/2023]
Abstract
The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.
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Affiliation(s)
- F López-Simarro
- Área Básica de Salud Martorell Urbano, Institut Català de la Salut, Martorell, Barcelona, España; Grupo de Trabajo Diabetes de SEMERGEN, España.
| | - E Redondo Margüello
- Centro de Salud Internacional Madrid Salud, Ayuntamiento de Madrid, Madrid, España; Grupo de Actividades Preventivas y Salud Pública de SEMERGEN, España
| | - J J Mediavilla Bravo
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud Burgos Rural, Burgos, España
| | - T Soriano Llora
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud Canal de Panamá, Madrid, España
| | - J Iturralde Iriso
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud La Habana, Vitoria-Gasteiz, España
| | - A Hormigo Pozo
- Grupo de Trabajo Diabetes de SEMERGEN, España; Unidad de Gestión Clínica Puerta Blanca, Málaga, España
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Early intervention for evolving necrotizing soft tissue infection stops flesh eating bacteria! JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Yii YC, Hsieh VCR, Lin CL, Wang YC, Chen WK. Alcohol use disorder increases the risk of necrotizing fasciitis: A nationwide retrospective cohort study. Medicine (Baltimore) 2017; 96:e7509. [PMID: 28796035 PMCID: PMC5556201 DOI: 10.1097/md.0000000000007509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This nationwide retrospective cohort study determined the association between alcohol use disorder (AUD) and the risk of necrotizing fasciitis (NF).This study used health insurance claims data of 52,212 in-patients with AUD and 208,848 controls randomly frequency-matched by age and sex at a 1:4 ratio. The AUD cohort included patients newly diagnosed with AUD between January 1, 2000 and December 31, 2008. The NF event occurrence was observed until December 31, 2011. We used the Kaplan-Meier method to present the cumulative incidence curve and Cox proportional hazard models to depict the risk of NF in patients with AUD.The incidence of NF was 19.4 per 10,000 person-years in the AUD cohort, which was nearly 7.73-fold higher than that in the comparison cohort (2.54 per 10,000 person-years). After adjustment for age, sex, and comorbidities, the patients with AUD exhibited a 3.55-fold higher risk of NF than did the controls (hazard ratio [HR] = 3.55, 95% confidence interval [CI] = 3.00-4.20). Nevertheless, in the AUD groups without any comorbidity, patients with AUD exhibited a significant 15.2-fold higher risk of NF than did the comparison cohort (HR = 15.2, 95% CI = 10.9-21.3). Moreover, the adjusted HRs of NF risk with respect to the severity of AUD were 2.15 (95% CI = 1.76-2.62), 4.54 (95% CI = 3.67-5.62), and 10.7 (95% CI = 8.66-13.2) for mild, moderate, and severe AUD, respectively.This study indicated that AUD should be considered an independent and significant risk factor for NF.
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Affiliation(s)
- Yong-Cheng Yii
- Department of Emergency Medicine, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
| | | | - Cheng-Li Lin
- College of Medicine, China Medical University
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Chiao Wang
- College of Medicine, China Medical University
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Kung Chen
- Department of Emergency Medicine, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
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Abstract
OBJECTIVE The purpose of this study was to evaluate the epidemiology and outcome of hospitalized children with a diagnosis of necrotizing soft-tissue infections (NSTIs). METHODS Demographic and outcome data of children 1 month to 18 years of age with a diagnosis of NSTI (International Classification of Diseases, 9th revision diagnosis codes 728.86 and 729.4) were extracted from the Kids' Inpatient Database 2009 and 2012. Univariate and multivariate analyses were done to determine the factors affecting mortality. The sample data were weighted to get national estimates. RESULTS A total of 446 children with NSTI (prevalence of 1.12/10,000 discharges) were included. Males comprised 54%. The median age was 10 (interquartile range 4-16) years. The mortality rate was 6%. In addition, 29.3% of children with NSTI were discharged to either skilled nursing facilities or to home health care compared with 4.5% of children without NSTI (odds ratio 8.9; 95% confidence interval 7.3-10.9; P < 0001). A bacterial infection was reported in 72.1% of children. An infection with Staphylococcus, Streptococcus, Gram-negative bacteria, anaerobic bacteria, methicillin-resistant Staphylococcus areus and polymicrobia was present in 34.5%, 21.8%, 8.6%, 3.9%, 18.7% and 13.6% of cases, respectively. A compartment syndrome, severe sepsis/septic shock and toxic shock were documented in 4.4%, 22.2% and 3.2% of the cases, respectively. Severe sepsis/septic shock, the need for mechanical ventilation and Hispanic race were associated with increased mortality, whereas skin/muscle surgery was associated with lower mortality. CONCLUSIONS NSTI in children is associated with high morbidity. The mortality is higher with the presence of severe sepsis/septic shock and among Hispanics and lower with surgical intervention.
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Misiakos EP, Bagias G, Papadopoulos I, Danias N, Patapis P, Machairas N, Karatzas T, Arkadopoulos N, Toutouzas K, Alexakis N, Konstantoulakis MN, Zografos G, Smyrniotis V, Kouraklis G, Machairas A. Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study. Front Surg 2017; 4:5. [PMID: 28224127 PMCID: PMC5293831 DOI: 10.3389/fsurg.2017.00005] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/19/2017] [Indexed: 11/13/2022] Open
Abstract
Background Necrotizing fasciitis (NF) is a group of relatively rare infections, usually caused by two or more pathogens. It affects the skin and subcutaneous tissues of lower and upper limbs, perineal area (Fournier’s gangrene), and the abdominal wall. Early diagnosis and aggressive surgical management are of high significance for the management of this potentially lethal disease. Methods We conducted a retrospective study in patients who presented, during the last decade, at four University Surgical Departments in the area of Athens, Greece, with an admission diagnosis of NF. Demographic, clinical, and laboratory data were gathered, and the preoperative and surgical treatment, as well as the postoperative treatment was analyzed for these patients. Results A total of 62 patients were included in the study. The mean age of patients was 63.7 (47 male patients). Advanced age (over 65 years) (P < 0.01) and female sex (P = 0.04) correlated significantly with mortality. Perineum was the mostly infected site (46.8%), followed by the lower limbs (35.5%), the upper limbs, and the axillary region (8.1%). Diabetes mellitus was the most common coexisting disease (40.3%), followed by hypertension (25.8%) and obesity (17.7%). The most common symptom was local pain and tenderness (90.3%). Septic shock occurred in eight patients (12.9%) and strongly correlated with mortality (P < 0.01). Laboratory data were used to calculate the LRINEC score of every patient retrospectively; 26 patients (41.9%) had LRINEC score under 6, 20 patients (32.3%) had LRINEC score 6–8, and 16 patients (25.8%) had LRINEC score >9. Surgical debridement was performed in all patients (mean number of repeated debridement 4.8), and in 16 cases (25.8%) the infected limb was amputated. The mean length of hospital stay was 19.7 days, and the overall mortality rate of our series was 17.7%. Conclusion Diagnosis of NF requires high suspect among clinicians, as its clinical image is non-specific. Laboratory tests can depict the severity of the disease; therefore, they must be carefully evaluated. Urgent surgical debridement is the mainstay of treatment in all patients; the need of repetitive surgical debridement is undisputed.
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Affiliation(s)
- Evangelos P Misiakos
- 3rd Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - George Bagias
- 3rd Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Iordanis Papadopoulos
- 4th Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Nickolaos Danias
- 4th Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Paul Patapis
- 3rd Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Nickolaos Machairas
- 2nd Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Laikon General Hospital , Athens , Greece
| | - Theodore Karatzas
- 2nd Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Laikon General Hospital , Athens , Greece
| | - Nickolaos Arkadopoulos
- 4th Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Konstantinos Toutouzas
- 1st Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Nickolaos Alexakis
- 1st Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Manousos N Konstantoulakis
- 1st Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - George Zografos
- 1st Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Vasilis Smyrniotis
- 4th Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Gregory Kouraklis
- 2nd Propedeutic Department of Surgery, Medical School, National and Kapodistrian University of Athens, Laikon General Hospital , Athens , Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
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Chaudhary D, Subhash A, Galvis J, Guardiola J. Bilateral thigh methicillin-resistant Staphylococcus aureus necrotising fasciitis in a man with newly diagnosed Human Immunodeficiency Virus (HIV). BMJ Case Rep 2017; 2017:bcr-2016-218468. [PMID: 28137904 DOI: 10.1136/bcr-2016-218468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) necrotising fasciitis (NF) is rare and constitutes a medical and surgical emergency. We report a case of a 53-year-old man with type-2 diabetes mellitus and newly diagnosed HIV infection who presented with 1 week of progressively worsening bilateral sharp thigh pain. On presentation, he was febrile, tachycardic and had bilateral thigh erythema and mild tenderness without open wounds. He had leucocytosis, lactic acidosis and acute kidney injury. Urgent incision and drainage (I&D) was performed for suspected NF. Blood cultures and I&D were positive for MRSA. Biopsy of bilateral thighs showed NF. He was treated with wound washout and 6 weeks of intravenous antibiotics. After undergoing skin graft for wounds, he was discharged to physical rehabilitation. Here we report severe sepsis from bilateral thigh MRSA NF in a patient with newly diagnosed HIV.
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Affiliation(s)
| | | | - Juan Galvis
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Juan Guardiola
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Uncommon Locations of Gas Gangrene Treated Successfully With Surgical Debridement and the Vacuum-Assisted Closure Device. Int Surg 2016. [DOI: 10.9738/intsurg-d-14-00296.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Gas gangrene is a life-threatening condition implying necrosis of dermis and hypodermis, along with necrosis of the superficial muscular aponeurosis. Fournier s gangrene is a subtype of the disease affecting the perineal and genital area. The aim of this study is to analyze the clinical presentation, diagnosis, medical, and surgical treatment of three cases of gas gangrene affecting uncommon locations in the human body, treated with extensive surgical debridement followed by the vacuum assisted closure method in two of these cases. Three cases of gas gangrene affecting uncommon locations treated surgically in our Department are presented. In one case the perineal and scrotal region was infected with invasion of the lateral abdominal wall and the peritoneal cavity. In the second case the axillary regions were infected bilaterally and in the third case the left axillary and subscapular regions were infected after a left arm disarticulation. All cases were treated successfully with successive surgical debridement and/or the vacuum-assisted closure method. Gas gangrene is a curable disease if diagnosed early and treated effectively with successive surgical wound cleaning and debridement. The vacuum assisted closure method can be helpful in promoting wound healing.
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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Rajak SN, Figueira EC, Haridas AS, Satchi K, Uddin JM, McNab AA, Rene C, Sullivan TJ, Rose GE, Selva D. Periocular necrotising fasciitis: a multicentre case series. Br J Ophthalmol 2016; 100:1517-1520. [DOI: 10.1136/bjophthalmol-2015-307445] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 11/04/2022]
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Hung TH, Tsai CC, Tsai CC, Tseng CW, Hsieh YH. Liver cirrhosis as a real risk factor for necrotising fasciitis: a three-year population-based follow-up study. Singapore Med J 2015; 55:378-82. [PMID: 25091887 DOI: 10.11622/smedj.2014090] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Necrotising fasciitis (NF) is often found in patients with diabetes mellitus, chronic renal failure, alcoholism, malignancy or liver cirrhosis. However, it remains unknown whether liver cirrhosis is an independent risk factor for the occurrence of NF. This study aimed to determine whether liver cirrhosis is an independent risk factor for the occurrence of NF, and to identify the relationship between severity of liver cirrhosis and occurrence of NF. METHODS The National Health Insurance Research Database, maintained by Taiwan's National Health Insurance programme, was retrospectively analysed, and the hospitalisation data of 40,802 cirrhotic patients and 40,865 randomly selected, age‑ and gender‑matched non‑cirrhotic control patients was collected. The medical records of all patients were individually followed for a three‑year period from the patients' first hospitalisation in 2004. RESULTS During the three‑year follow‑up period, there were 299 (0.7%) cirrhotic patients with NF and 160 (0.4%) non‑cirrhotic patients with NF. Cox regression analysis showed that liver cirrhosis was a risk factor for the occurrence of NF during the study period (hazard ratio 1.982; p < 0.001). Among cirrhotic patients, those with complicated liver cirrhosis had a higher risk for the occurrence of NF than patients with non‑complicated liver cirrhosis (hazard ratio 1.320; p = 0.028). CONCLUSION Cirrhotic patients had a higher risk for the occurrence of NF than non‑cirrhotic patients, and the risk for NF was especially high among patients with complicated liver cirrhosis.
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Affiliation(s)
| | | | | | | | - Yu-Hsi Hsieh
- Endoscopy Section, Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No 2, Minsheng Road, Dalin Township, Chiayi County 62247, Taiwan.
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Iacopi E, Coppelli A, Goretti C, Piaggesi A. Necrotizing Fasciitis and The Diabetic Foot. INT J LOW EXTR WOUND 2015; 14:316-27. [PMID: 26415868 DOI: 10.1177/1534734615606534] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.
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Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult. Case Rep Emerg Med 2015; 2015:956156. [PMID: 26347831 PMCID: PMC4546953 DOI: 10.1155/2015/956156] [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: 06/23/2015] [Accepted: 07/28/2015] [Indexed: 11/18/2022] Open
Abstract
A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.
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Koch C, Hecker A, Grau V, Padberg W, Wolff M, Henrich M. Intravenous immunoglobulin in necrotizing fasciitis - A case report and review of recent literature. Ann Med Surg (Lond) 2015; 4:260-3. [PMID: 26288730 PMCID: PMC4539184 DOI: 10.1016/j.amsu.2015.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction Necrotizing fasciitis (NF) is an inflammatory disease of the soft tissue, which causes local tissue destruction and can lead to lethal septic shock. The therapy consists of early surgical treatment of the septic focus and an accompanying broad spectrum antibiotic therapy. Recent literature considers the additional use of immunoglobulin therapy in severe soft skin and tissue infections. Presentation of case In this report, we describe the case of a 33-year-old male patient treated at a university hospital intensive care unit because of an NF of his left leg. The patient rapidly developed a complicated septic disease after a minor superficial trauma. Despite intense microbiological diagnosis, no causative pathogens were identified. After non-responding to established broad anti-infective treatment, the patient received intravenous immunoglobulin, that rapidly improved his clinical condition. Discussion NF represents a disease processes, which is characterized by fulminant, widespread necrosis of soft tissue, systemic toxicity, and high mortality (>30%). Beside the surgical debridement and broad spectrum antibiotic therapy IVIg therapy might be an additional option in the treatment of NF. But the current literature supporting the use of IVIG in NF is largely based on retrospective or case-controlled studies, and only small randomized trials. Conclusion The demonstrated case suggests that IVIg treatment of patients with NF can be considered in case of hemodynamic unstable, critically ill patients. Although randomized controlled trials are missing, some patients might benefit from diminishing hyperinflammation by immunoglobins. Necrotizing fasciitis (NF) is an inflammatory disease, which causes local tissue destruction up to lethal septic shock. We describe the case of a 33-year-old male patient representing an NF of his left leg. After non-responding to established broad anti-infective treatment, the patient received immunoglobulin (IVIg). The presented case suggests that IVIg treatment of patients with NF might be considered in case of critically ill patients.
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Affiliation(s)
- C Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
| | - A Hecker
- Department General and Thoracic Surgery, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
| | - V Grau
- Department General and Thoracic Surgery, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
| | - W Padberg
- Department General and Thoracic Surgery, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
| | - M Wolff
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
| | - M Henrich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg, 35392 Giessen, Germany
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Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E. Improvement of a Clinical Score for Necrotizing Fasciitis: 'Pain Out of Proportion' and High CRP Levels Aid the Diagnosis. PLoS One 2015. [PMID: 26196941 PMCID: PMC4511009 DOI: 10.1371/journal.pone.0132775] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Necrotizing fasciitis (NF) is a rare mono-/polymicrobial skin infection that spreads to underlying tissues. NF is quickly progressing and leads to life threatening situations. Immediate surgical debridement together with i.v. antibiotic administration is required to avoid fatal outcome. Early diagnosis is often delayed due to underestimation or confusion with cellulitis. We now compared the initial clinical and laboratory presentation of NF and cellulitis in detail to assess if a typical pattern can be identified that aids timely diagnosis of NF and avoidance of fatal outcome. 138 different clinical and laboratory features of 29 NF patients were compared to those of 59 age- and gender matched patients with severe erysipelas requiring a subsequent hospitalization time of ≥10 days. Differences in clinical presentation were not obvious; however, NF patients suffered significantly more often from strong pain. NF patients exhibited dramatically elevated CRP levels (5-fold, p>0.001). The overall laboratory risk indicator for necrotizing fasciitis (LRINEC) score was significantly higher in NF patients as compared to cellulitis. However, a modification of the score (alteration of laboratory parameters, addition of clinical parameters) led to a clear improvement of the score with a higher positive predictive value without losing specificity. In summary, clinical differentiation of NF from cellulitis appears to be hard. ‘Pain out of proportion’ may be an early sign for NF. An improvement of the LRINEC score emphasizing only relevant laboratory and clinical findings as suggested may aid the early diagnosis of NF in the future leading to improvement of disease outcome by enabling rapid adequate therapy.
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Affiliation(s)
| | - Svenja Schlicht
- Department of Dermatology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ekkehard Siegel
- Institute for Medical Microbiology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eric Hanke
- Department of Traumatology/Orthopedics, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Esther von Stebut
- Department of Dermatology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
- * E-mail:
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Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg 2014; 1:36. [PMID: 25593960 PMCID: PMC4286984 DOI: 10.3389/fsurg.2014.00036] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/24/2014] [Indexed: 01/18/2023] Open
Abstract
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.
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Affiliation(s)
- Evangelos P. Misiakos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - George Bagias
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Paul Patapis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Sotiropoulos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Prodromos Kanavidis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
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Necrotizing fasciitis: an urgent diagnosis. Skeletal Radiol 2014; 43:577-89. [PMID: 24469151 DOI: 10.1007/s00256-013-1813-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/10/2013] [Accepted: 12/29/2013] [Indexed: 02/02/2023]
Abstract
Necrotizing fasciitis (NF) is a rare, life-threatening soft-tissue infection and a medical and surgical emergency, with increasing incidence in the last few years. It is characterized by a rapidly spreading, progressive necrosis of the deep fascia and subcutaneous tissue. Necrotizing fasciitis is often underestimated because of the lack of specific clinical findings in the initial stages of the disease. Many adjuncts such as laboratory findings, bedside tests--e.g., the "finger test" or biopsy--and imaging tests have been described as being helpful in the early recognition of the disease. Imaging is very useful to confirm the diagnosis, but also to assess the extent of the disorder, the potential surgical planning, and the detection of underlying etiologies. The presence of gas within the necrotized fasciae is characteristic, but may be lacking. The main finding is thickening of the deep fasciae due to fluid accumulation and reactive hyperemia, best seen on magnetic resonance imaging.
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Krieg A, Dizdar L, Verde PE, Knoefel WT. Predictors of mortality for necrotizing soft-tissue infections: a retrospective analysis of 64 cases. Langenbecks Arch Surg 2014; 399:333-41. [DOI: 10.1007/s00423-014-1162-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 01/01/2014] [Indexed: 10/25/2022]
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Necrotizing Soft Tissue Infections: Surgeon's Prospective. Int J Inflam 2013; 2013:609628. [PMID: 24455410 PMCID: PMC3886590 DOI: 10.1155/2013/609628] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 09/08/2013] [Accepted: 10/11/2013] [Indexed: 12/17/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier's gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases.
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Abstract
Necrotizing fasciitis (NF) is a severe infection characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. Periorbital NF is uncommon because of the excellent blood supply to that area; nevertheless, it can sometimes result in death. The aim of this study is to present a systematic review and analyse the factors associated with death. We carried out a systematic literature review of all cases of periorbital NF published in the English language over the past 20 years and present the predisposing conditions, triggering factors, organisms causing NF, presence or absence of toxic shock and the prognosis. The significance of various risk factors leading to death was analysed. We traced a total of 94 patients with periorbital NF from 61 reports. There were no triggering incidents in 25 cases (26.6%). In 48 cases (51.1%), the organism responsible for NF was Group A beta haemolytic Streptococcus. Toxic shock occurred in 29 (30.9%) cases, and loss of vision in 13 (13.8%). Surgical debridement was carried out in 80 (85.1%) cases. There were eight cases (8.5%) of death. This seems to be less than previously reported figures. Toxic shock syndrome (p < 0.001), type 1 infections (p = 0.018), facial involvement (p = 0.032) and blindness because of periorbital NF (p = 0.035) were significantly associated with mortality. Mortality caused by NF arising from the periorbital area seems to be on the decline. However, it is important to recognize it early and institute treatment to avoid toxic shock that leads to death. Type 1 infections, although rare in periorbital area, are not associated with immunocompromised status and nevertheless carry a significant risk of mortality. Major morbidity is loss of vision followed by soft-tissue defects affecting function and cosmesis.
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Affiliation(s)
- Shantha Amrith
- Department of Ophthalmology, National University Health System, Singapore City, SingaporeDepartment of Ophthalmology, Kasturba Medical College, Manipal University, Manipal, IndiaSingapore Eye Research Institute, Singapore National Eye Center, Singapore City, Singapore
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