Necrotizing fasciitis

Surgical Management of Necrotizing Fasciitis of the Head and Neck

OBJECTIVE

The purpose of this study was to highlight risk factors and surgeries for necrotizing fasciitis (NF) of the head and neck in the literature. NF is rare but can rapidly progress.

MATERIALS AND METHODS

A literature search was done using PubMed and SCOPUS. Articles that discussed NF of the head and neck and a specific surgical technique were included. A bivariate Pearson correlation was conducted using an α level of 0.05.

RESULTS

The study included 31 articles encompassing 77 patients who presented with head and neck NF. Diabetes mellitus (23.4%) was the most common comorbidity observed. Surgical techniques, such as debridement (96.10%) and incision/exploration (97.40%), were common.

CONCLUSION

Immediate surgical intervention should be performed when treating patients presenting with NF of the head and neck.

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection requiring prompt diagnosis and immediate surgical debridement. Imaging, including a computed tomography (CT) scan, can often aid in the diagnosis, though it can prolong time to treatment and diagnosis. Point-of-care ultrasound (POCUS) is often used in the ED to identify soft tissue infections. The objective of this study is to evaluate the use of POCUS to identify NF in patients presenting to the emergency department.

METHODS

We prospectively enrolled patients who presented to the emergency department (ED) with suspected soft tissue infection who received a computed tomography and/or surgical consult. POCUS images of the suspected site of infection were obtained by the emergency medicine physician and interpreted based on sonographic findings of NF. These findings were compared with CT scan or surgical impression.

RESULTS

We enrolled 64 patients in this study. Eight were determined to be at high risk of having NF based on CT scan and/or surgical impression. All of these patients also had POCUS images interpreted as concerning for NF. Furthermore, 56 patients were classified as being low risk for having NF based on CT scan and/or surgical impression. All but one of these patients had POCUS images interpreted as not concerning for NF.

CONCLUSIONS

Our data indicates that POCUS can be used to identify NF with a high sensitivity and specificity.

[Monomicrobian necrotizing fasciitis of the leg due to multidrug-resistant Acinetobacter baumannii in a healthy adult: about a case]

La fasciite nécrosante est une infection des tissus mous qui se propage rapidement et se caractérise par une nécrose étendue du fascia profond et superficiel. Il s’agit d’une infection polymicrobienne dans environ 70% des cas. L’infection monomicrobienne est généralement due aux streptocoques β-hémolytiques du groupe A. La fasciite nécrosante monomicrobienne due à l’Acinetobacter baumannii multirésistante est rare et survient généralement chez les patients immunodéprimés, ayant des antécédents médicaux, chez ces sujets l’infection est grave et mortelle à cause de la décompensation des tares sous-jacentes et le choc septique. La survenue de cette entité clinique chez le sujet sain est rare. Nous rapportons l’observation d’un homme âgé de 54 ans en bonne santé atteint d’une fasciite nécrosante monomicrobienne de la jambe gauche due à l’Acinetobacter baumannii multirésistante dont l’évolution était favorable après un débridement chirurgical étendu.

Ayurveda management of Nicolau syndrome W.S.R to Kotha - a case report

Administration of intramuscular, intraarterial or subcutaneous injection of particular drugs ends up into a rare entity known as Nicolau syndrome (NS). The viscous nature of these drugs sometimes triggers acute vasospasm and even arterial embolism. There is no consensus on treatment of NS so far. Phasic treatments depend on the extent of the necrotic lesion and ranges from medication to surgical debridement. Here we report a case of 60 year female known case of Knee Osteoarthritis who was dependent on Diclofenac injection IM for relief of pain. She presented with complaints of fever with chills, rigors, discoloration of skin at the gluteal region right side, later turned into necrosis of skin and adipose tissue, pus formation and associated with loss of appetite, dryness of mouth, pedal oedema. The case was diagnosed as NS according to contemporary science and Kotha (Gangrene) as per Ayurveda. The case was treated successfully with Chedana karma (Surgical debridement) followed by Vrana shodhana (making free from undesirable healing factors), Ropana (Closure of wound) and oral medications.

Necrotizing Fasciitis: A Predictable Burden in Rural Kenya

BACKGROUND

Necrotizing fasciitis (NF) is a devastating disease with substantial morbidity and mortality. Poor outcomes are attributed to delayed diagnosis and management. Tenwek Hospital, a teaching and referral center in rural Kenya, manages many cases despite variable resources. We aimed to understand the burden of NF.

METHODS

All patients with admission NF diagnosis who presented in 2017 were reviewed for demographics, investigations, treatment, and outcomes. The primary outcome was unfavorable outcome defined as in-hospital mortality or amputation. Secondary outcomes were discharge diagnosis of NF and cost. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Logistic regression models were utilized to assess the impact of risk factors.

RESULTS

Sixty-seven patients were identified with an average age of 49.2 (±21) years. Medical comorbidities were present in 48% and history of trauma in 58%. Discharge diagnosis of NF occurred in 61% (N = 41). Overall, mortality occurred in 10% (N = 7) of patients with an initial NF diagnosis. At discharge, patients without NF had favorable outcomes in 96% (N = 25) compared to 78% (N = 32) with NF (p = 0.043). Final NF diagnosis costs 122,098 Kenyan Shillings more (95% confidence interval 36,142-208,054) than non-NF diagnosis (p value = 0.006). Factors associated with unfavorable outcome include diabetes mellitus, any comorbidity, increased heart rate, fever, hyperglycemia, anemia, and discharge NF diagnosis. Increased LRINEC score was associated with discharge NF diagnosis (p = 0.0006) and unfavorable outcome (p = 0.0157).

CONCLUSIONS

Patients with NF in rural Kenya experience delays to presentation, unfavorable outcomes, and substantial costs. Certain factors, including LRINEC score, help predict diagnosis and outcome.

Pyoderma gangrenosum underrepresentation in non-dermatological literature

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.

Efficacy of colistimethate sodium as local application in necrotising fasciitis

Necrotising fasciitis (NF) is a rapidly progressive severe soft tissue infection of the deep fascia resulting in the destruction of overlying subcutaneous tissue and skin. We report the case of NF of the lower limb with a poor prognosis due to multidrug-resistant (MDR) Klebsiella pneumoniae (K. pneumoniae) sensitive only to colistin. In view of the worsening condition of the wound, risk of deterioration of renal function and economic constraints, it was decided to start on colistin therapy locally by colistimethate sodium (CMS). The patient responded well to the treatment and got clinically better. Subsequent culture sent for post-treatment showed no growth of the organism. The wound healed with regular dressings by 8 weeks. This was found to be a very cost-effective treatment modality. Local use of CMS was found to be a novel method of achieving infection-free wound especially against MDR K. pneumoniae.

Abdominal Necrotising Fascitis Mimicking Peritonitis in a Gatka Playing Indian Male: A Case Report

The present case report is of abdominal Necrotising Fascitis in a young Gatka player. The patient was clinically diagnosed to have peritonitis with plan for laparotomy but since ultrasound abdomen showed no free intra-abdominal fluid and any other pathology a Contrast Enhanced Computed tomography (CECT) abdomen was done. CECT showed fluid collections in rectus sheath and superficial fascia. Patient was thus, diagnosed as having abdominal myofascitis and treated accordingly. A review of literature showed that such a clinical presentation of this disease is quite rare and can lead to unnecessary laparotomy and delay in diagnosis leading to morbidity.

Early diagnosis of post-varicella necrotising fasciitis: A medical and surgical emergency

Necrotising fasciitis (NF) is an extremely rare complication of a rather common paediatric viral exanthem varicella. Delayed diagnosis and treatment can lead to significant morbidity and mortality. Laboratory risk indicator of NF score aids in early clinical diagnosis in suspected cases of post-varicella NF thus enabling timely intervention. Surgery delayed for more than 24 hours, is an independent risk factor for death. Surgical debridement with good antibiotic coverage is the definitive treatment for NF.

Necrotizing fasciitis in patients with head and neck cancer

Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 patients with head and neck cancers who developed necrotizing fasciitis during the postoperative period.

[Streptococcal infection in surgery]

INTRODUCTION

Despite the advances of modern medicine purulent-inflammatory diseases of soft tissues continue to occupy a leading position in surgical practice. Streptococcal surgical infection does not refer to specific category, but it has a number of significant features and its definition as separate type is necessary.

MATERIAL AND METHODS

Based on the results of treatment of 312 patients with streptococcal infection of soft tissues we studied the prevalence of this disease in overall structure of surgical infection of soft tissue, main clinical courses are defined. We performed molecular genetic typing of pathogens that allows to predict the course of pathological process taking into account microorganism's characteristics.

RESULTS AND DISCUSSION

On the basis of obtained data basic medical and diagnostic concept of surgical care for these patients depending on clinical course of disease was formulated. It allowed to improve significantly the results of treatment of such patients.

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

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