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Salim OA, Hillier-Smith R, Ardolino A. Necrotising fasciitis, invasive Group A Streptococcus (iGAS) infection; a case series of 8 patients requiring surgical debridement in one trauma unit within 9 months. J Surg Case Rep 2024; 2024:rjad708. [PMID: 38966684 PMCID: PMC11222963 DOI: 10.1093/jscr/rjad708] [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: 11/07/2023] [Accepted: 12/11/2023] [Indexed: 07/06/2024] Open
Abstract
Necrotising fasciitis (NF) is a rare but life-threatening skin and soft tissue infection. It requires urgent surgical debridement. The most common cause of monomicrobial NF is invasive Group A Streptococcus (IGAS). We present eight patients who were all treated in a single trauma unit within a 9-month period. All cases required surgical debridement and had positive microbiology testing for IGAS. The eight patients did not present typically for NF, nor did they all have typical risk factors for the development of NF. The in-hospital mortality rate was 37.5%. This series represents an epidemiological spike of IGAS infections causing NF. The findings from this series could inform future practice if similar spikes were to be encountered.
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Affiliation(s)
- Omar-Adam Salim
- Trauma and Orthopaedics, Basingstoke and North Hampshire NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
| | - Ryan Hillier-Smith
- Hampshire Hospitals NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
| | - Antonella Ardolino
- Hampshire Hospitals NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
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2
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Xu R, Fang T, Cai W. Case report: A rare case of simultaneous necrotizing fasciitis of the breast and forearm. Front Med (Lausanne) 2024; 11:1413593. [PMID: 38947243 PMCID: PMC11211525 DOI: 10.3389/fmed.2024.1413593] [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: 04/07/2024] [Accepted: 05/30/2024] [Indexed: 07/02/2024] Open
Abstract
Necrotizing fasciitis is an aggressive bacterial infection that causes necrosis of the fascia and subcutaneous tissues with rapid progression and high mortality. Early stages often lead to misdiagnosis, resulting in improper treatment and severe implications. This case study presents a patient with diabetes mellitus combined with hepatitis B who rapidly developed necrotizing fasciitis of the left forearm and left breast after trauma and controlled the infection with early surgical treatment. It is worth noting that early surgical exploration is the gold standard for the diagnosis of necrotizing fasciitis and is the most effective means of reducing mortality and amputation rates in necrotizing fasciitis.
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Affiliation(s)
- Ruofei Xu
- Orthopedics Department, Longyou County People's Hospital, Longyou, China
| | - Tingting Fang
- Dermatology Department, Longyou County People's Hospital, Longyou, China
| | - Weikang Cai
- Orthopedics Department, Yongkang Hospital of Traditional Chinese Medicine, Yongkang, China
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3
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Ray GS, Streeter SS, Bateman LM, Elliott JT, Henderson ER. Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging. JOURNAL OF BIOMEDICAL OPTICS 2024; 29:066003. [PMID: 38745983 PMCID: PMC11092151 DOI: 10.1117/1.jbo.29.6.066003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/02/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024]
Abstract
Significance Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI. Aim A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis. Approach Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis. Results Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (p -value ≥ 0.22 ). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (p -value < 0.05 ). Conclusions Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.
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Affiliation(s)
- Gabrielle S. Ray
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Samuel S. Streeter
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Logan M. Bateman
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Jonathan Thomas Elliott
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Eric R. Henderson
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - NEFARIOUS Study Group
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
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Domakunti R, Khedkar K, Kulkarni V. Successful Outcome With a Multimodal Approach in the Management of Pediatric Necrotizing Fasciitis: A Report of a Rare Case. Cureus 2023; 15:e50807. [PMID: 38249214 PMCID: PMC10797228 DOI: 10.7759/cureus.50807] [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: 10/22/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Necrotizing fasciitis is a commonly encountered modality by a practicing clinician which needs urgent and vigilant management. To decrease the potential morbidity and mortality of the pathology, an aggressive multimodal approach shows promising results. In our report, we present a case of a three-year-old male child who presented to us with the findings consistent with necrotizing fasciitis. The case report highlights the importance of multimodal approach in such a case.
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Affiliation(s)
- Rajesh Domakunti
- Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Kiran Khedkar
- Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Varun Kulkarni
- Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
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DeGenova DT, Hyland SS, Peabody T, Schmitz NP, Myers D, Patterson R, Patel J. Differences Between Patients With Diabetes Mellitus and Those Without in Cases of Necrotizing Fasciitis. Cureus 2023; 15:e36576. [PMID: 37101987 PMCID: PMC10123239 DOI: 10.7759/cureus.36576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 04/28/2023] Open
Abstract
Purposes This study aims to evaluate further differences between patients with diabetes and those without who have been diagnosed with necrotizing fasciitis (NF) to assist clinicians in improving morbidity and mortality. Methods All patients diagnosed with NF of an extremity were retrospectively reviewed and divided into two groups based on a diagnosis of diabetes. Patient charts were reviewed to obtain multiple variables, which were compared between groups. Results From 2015 to 2021, 115 patients underwent surgical intervention due to concern for NF of an extremity with 92 patients included for data computation. Patients with diabetes had an average Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score of 9.02 compared to 7.24 (p=0.02). Patients with diabetes had a significantly higher rate of undergoing amputation when diagnosed with NF (p<0.0001). The mortality rate for diabetes and non-diabetes cohorts were 30.9% and 18.9%, respectively (p=0.2). Conclusion This study demonstrated that patients with diabetes with confirmed NF of an extremity had a significantly higher LRINEC score were more likely to undergo an amputation primarily, and were more likely to have a polymicrobial infection compared to those without. The overall mortality rate of NF was 26.1%.
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Affiliation(s)
| | | | | | | | - Devon Myers
- Orthopedic Surgery, OhioHealth System, Columbus, USA
| | - Robert Patterson
- Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, USA
| | - Jignesh Patel
- Orthopedic Surgery, OhioHealth System, Columbus, USA
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6
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Zhang R, Zhang Y, Hou L, Yan C. Vacuum-assisted closure versus conventional dressing in necrotizing fasciitis: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:85. [PMID: 36737764 PMCID: PMC9898985 DOI: 10.1186/s13018-023-03561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Necrotizing fasciitis is a rapid and severe soft tissue infection that targets subcutaneous fat tissue, muscle, and fascia. This study compares the clinical outcomes of vacuum-assisted closure (VAC) versus conventional dressing on necrotizing fasciitis. METHODS We systematically searched Embase, Cochrane, and PubMed for clinical trials (published between January 1, 1995 and September 30, 2021), which compared VAC with conventional dressing for necrotizing fasciitis. The mortality rate of necrotizing fasciitis was the primary outcome of this study. The number of debridements, the total length of hospital stay, and the complication rate were secondary outcomes. A random effects model assessed all pooled data. RESULTS A total of 230 identified studies and seven controlled clinical trials met the inclusion criteria and were included in this analysis (n = 249 participants). Compared to the conventional dressing, patients treated with VAC had a significantly lower mortality rate [OR = 0.27, 95% CI (0.09, 0.87)] (P = 0.03). Total length of hospital stays [MD = 8.46, 95% CI (- 0.53, 17.45)] (P = 0.07), number of debridements [MD = 0.86, 95% CI (- 0.58, 2.30)] (P = 0.24), and complication rate [OR = 0.64, 95% CI (0.07, 5.94)] (P = 0.69) were not significant. These results did not show significant differences between both groups treated with VAC or conventional treatment. CONCLUSION VAC could significantly decrease the death rate compared to conventional dressing. No significant impacts were found on the number of debridements, the total length of hospital stay, and the complication rate in this study. Level of evidence Level-III. Registration Research Registry (reviewregistry1246).
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Affiliation(s)
- Rongli Zhang
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yahui Zhang
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Liyuan Hou
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chengyong Yan
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
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Saela S, Decilveo A, Isaac R, Patel DV. Traumatic subcutaneous emphysema of the hand/forearm: A case report. Chin J Traumatol 2022; 25:395-399. [PMID: 35450804 PMCID: PMC9751530 DOI: 10.1016/j.cjtee.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Subcutaneous emphysema is commonly associated with infection caused by gas-producing organisms. In this case report, we describe a rare instance of traumatic subcutaneous emphysema of the hand and forearm caused by a puncture injury to the first web space of the hand. Our objective is to increase awareness of the potential for seemingly minor trauma to cause entrapment of significant air in subcutaneous tissues, thereby decreasing the likelihood that a clinically benign-appearing patient will be started down an unnecessarily aggressive treatment pathway. A 16-year-old, otherwise healthy white female, presented to the pediatric emergency room with an impressive amount of subcutaneous emphysema that developed over a 12-h period after sustaining an accidental laceration to the first web space of her right hand. She appeared nontoxic and had a clinically benign presentation. A comprehensive work-up was performed. She was splinted by the orthopedic surgery resident on call, and was admitted to the Pediatric Intensive Care Unit for overnight monitoring. She received tetanus vaccination and broad-spectrum antibiotics. The patient was discharged 2 days after admittance, with a splint applied to her right hand and forearm. She undertook home-based physical and occupational therapy. She had a pain-free range-of-motion in the right wrist, elbow and shoulder. The swelling in the right hand subsided completely. Although initially alarming, traumatic subcutaneous emphysema in an otherwise healthy patient from minor wounds (as featured in this case) does not necessarily mean one ought to proceed down an aggressive treatment algorithm. Careful evaluation of the patient's history, clinical examination findings, and determination of the Laboratory Risk Indicator for Necrotizing Fasciitis score can help guide physicians in the management of traumatic subcutaneous emphysema and potentially avoid unnecessary and costly interventions.
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Affiliation(s)
- Stephen Saela
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA,Corresponding author.
| | - Alexander Decilveo
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA
| | - Roman Isaac
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA
| | - Deepak V. Patel
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA,Department of Orthopaedic Surgery, Seton Hall University, South Orange, NJ 07079, USA
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Breidung D, Grieb G, Malsagova AT, Barth AA, Billner M, Hitzl W, Reichert B, Megas IF. Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis. Surg Infect (Larchmt) 2022; 23:747-753. [PMID: 36191292 DOI: 10.1089/sur.2022.222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Berlin, Germany
- Burn Center, Department of Plastic Surgery and Hand Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Asja T Malsagova
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Andrè A Barth
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Wolfgang Hitzl
- Research and Innovation Management (RIM), Paracelsus Medical University Salzburg, Department of Ophthalmology and Optometry, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
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Household Transmission of Group A Streptococcus Necrotizing Fasciitis. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202208000-00001. [PMID: 35930803 PMCID: PMC9351906 DOI: 10.5435/jaaosglobal-d-21-00171] [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: 06/23/2021] [Accepted: 06/07/2022] [Indexed: 11/22/2022]
Abstract
A healthy 40-year-old woman was diagnosed with necrotizing fasciitis 2 days after her husband's death from the same infectious process. Prompt identification and immediate surgical intervention prevented a similar result in this patient. Additional investigation into both patients' medical records found the inciting organism to be group A streptococcus. Although the exact mechanism of inoculation is unknown, the spread of this infection within a household prompts the question of whether antibiotic prophylaxis should be given among close contacts in future cases of necrotizing fasciitis.
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The acute necrotizing periorbital fasciitis. Clinical case. OPHTHALMOLOGY JOURNAL 2022. [DOI: 10.17816/ov100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND: A rare severe, characterized by high mortality in some localizations (up to 70%) necrotizing periorbital fasciitis has not been described previously in the national literature.
AIM: to show a multidisciplinary approach to the treatment and rehabilitation of patients with periorbital necrotizing fasciitis on the example of the clinical case.
CLINICAL CASE: Patient with the acute necrotizing fasciitis of both eyelids, with the dissemination to the superficial face and neck fascies, the sepsis development is given. Monitoring of vital functions, homeostasis indicators, repeated inoculations, computed tomography, regular examination by an ophthalmologist included the control of visual functions, anterior and posterior segments, closure of the eye fissure. Conservative and surgical treatment applied by a multidisciplinary team is presented, which allowed to save the patients life, overpass the purulent-necrotic, and then the rough scar process and to achieve satisfactory anatomical and functional results.
CONCLUSION: Timely multidisciplinary treatment of periorbital necrotizing fasciitis is necessary for the life preservation, prevention of severe complications from the eye. With the threat of developing lagophthalmos, it is necessary to perform permanent blepharoraphy for 36 months after the first surgery and further surgical and pharmacological correction of scarring processes.
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Tsai YH, Huang TY, Kuo LT, Chuang PY, Hsiao CT, Huang KC. Comparison of Surgical Outcomes and Predictors in Patients with Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria. Surg Infect (Larchmt) 2022; 23:288-297. [PMID: 35180367 DOI: 10.1089/sur.2021.337] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria are often associated with high mortality rates. The purpose of this study was to compare the independent predictors related to outcomes between Vibrio vulnificus and Aeromonas species necrotizing fasciitis. Patients and Methods: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus (60 patients) and Aeromonas species (31 patients) over an 11-year period were reviewed retrospectively. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the Vibrio vulnificus and Aeromonas species groups, and between the death and the survival subgroups of patients with Aeromonas species. Results: Six patients in the Vibrio vulnificus group (10%) and 11 in the Aeromonas species group (32.3%) died. Fifty-nine patents had bacteremia and 16 patients died (27.1%). Patients who had Vibrio vulnificus had a higher incidence of bacteremia. The patients who had Aeromonas species presenting with bacteremia were significantly associated with death. The death subgroup of patients with Aeromonas necrotizing fasciitis had a higher incidence of bacteremia, higher counts of banded leukocytes, lower platelet counts, lower total lymphocyte counts, and lower serum albumin level than the survival subgroup. Conclusions: Monomicrobial necrotizing fasciitis caused by Aeromonas species was characterized by more fulminating and higher mortality than that of Vibrio vulnificus, even after early fasciotomy and third-generation cephalosporin antibiotic therapy. Those risk factors, such as bacteremia, shock, lower platelet counts, lower albumin levels, and antibiotic resistance were associated with mortality, which should alert clinicians to pay more attention to and aggressively treat those patients with Aeromonas and Vibrio necrotizing fasciitis.
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Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Tsung-Yu Huang
- College of Medicine, Chang Gung University at Taoyuan, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chia-Yi Chang Gung Memorial Hospital, Taiwan
| | - Liang Tseng Kuo
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Po-Yao Chuang
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University at Taoyuan, Taiwan.,Department of Emergency Medicine, Chia-Yi Chang Gung Memorial Hospital, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
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12
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Ravins M, Ambalavanan P, Biswas D, Tan RYM, Lim KXZ, Kaufman Y, Anand A, Sharma A, Hanski E. Murine Soft Tissue Infection Model to Study Group A Streptococcus (GAS) Pathogenesis in Necrotizing Fasciitis. Methods Mol Biol 2022; 2427:185-200. [PMID: 35619035 DOI: 10.1007/978-1-0716-1971-1_16] [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: 06/15/2023]
Abstract
Group A streptococcus (GAS) necrotizing fasciitis (NF) causes high morbidity and mortality despite prompt intravenous administration of antibiotics, surgical soft-tissue debridement, and supportive treatment in the intensive care unit. Since there is no effective vaccine against GAS infections, a comprehensive understanding of NF pathogenesis is required to design more efficient treatments. To increase our understanding of NF pathogenesis, we need a reliable animal model that mirrors, at least in part, the infectious process in humans. This chapter describes a reliable murine model of human NF that mimics the histopathology observed in humans, namely the destruction of soft tissue, a paucity of infiltrating neutrophils, and the presence of many gram-positive cocci at the center of the infection.
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Affiliation(s)
- Miriam Ravins
- Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Poornima Ambalavanan
- Singapore-HUJ Alliance for Research and Enterprise, MMID Phase II, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore
- Department of Microbiology and Immunology, National University of Singapore, Singapore, Singapore
| | - Debabrata Biswas
- Singapore-HUJ Alliance for Research and Enterprise, MMID Phase II, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore
- Department of Microbiology and Immunology, National University of Singapore, Singapore, Singapore
| | - Rachel Ying Min Tan
- Singapore-HUJ Alliance for Research and Enterprise, MMID Phase II, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore
- Department of Microbiology and Immunology, National University of Singapore, Singapore, Singapore
| | - Kimberly Xuan Zhen Lim
- Singapore-HUJ Alliance for Research and Enterprise, MMID Phase II, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore
- Department of Microbiology and Immunology, National University of Singapore, Singapore, Singapore
| | - Yael Kaufman
- Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aparna Anand
- Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Abhinay Sharma
- Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Emanuel Hanski
- Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
- Singapore-HUJ Alliance for Research and Enterprise, MMID Phase II, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore.
- Department of Microbiology and Immunology, National University of Singapore, Singapore, Singapore.
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Lahham S, Shniter I, Desai M, Andary R, Saadat S, Fox JC, Pierce S. Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis. Am J Emerg Med 2021; 51:397-400. [PMID: 34837886 DOI: 10.1016/j.ajem.2021.10.033] [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: 07/02/2021] [Revised: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Shadi Lahham
- University of California Irvine, Department of Emergency Medicine, United States.
| | - Inna Shniter
- University of California Irvine, Department of Emergency Medicine, United States
| | - Monica Desai
- University of California Irvine, Department of Emergency Medicine, United States
| | - Rana Andary
- University of California Irvine, Department of Emergency Medicine, United States
| | - Soheil Saadat
- University of California Irvine, Department of Emergency Medicine, United States
| | - John C Fox
- University of California Irvine, Department of Emergency Medicine, United States
| | - Scott Pierce
- University of California Irvine, Department of Emergency Medicine, United States
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Rampal S, Ganesan T, Sisubalasingam N, Neela VK, Tokgöz MA, Arunasalam A, Ab Halim MAH, Shamsudin ZB, Kumar S, Sinniah A. Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia. Antibiotics (Basel) 2021; 10:1120. [PMID: 34572702 PMCID: PMC8470198 DOI: 10.3390/antibiotics10091120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the soft tissue (also known as the fascia) with a secondary necrosis of the subcutaneous tissues, leading to a systemic inflammatory response syndrome (SIRS), shock and eventually death despite the availability of current medical interventions. The clinical management of this condition is associated with a significant amount of morbidity with a high rate of mortality. The prognosis of the disease is affected by multiple factors, which include the virulence of the causative pathogen, local host immunity, local wound factors and empirical antibiotics used. The local trends in the prescription of empirical antibiotics are often based on clinical practice guidelines (CPG), the distribution of the causative microorganism and the cost-effectiveness of the drug. However, there appears to be a paucity of literature on the empirical antibiotic of choice when dealing with necrotizing fasciitis in the clinical setting. This paper will outline common causative microorganisms and current trends of prescription in two tertiary centres in Central Malaysia. METHODS This was a cross-sectional study using retrospective data of patients treated for NF collected from two tertiary care hospitals (Hospital Seremban and Hospital Ampang) in Central Malaysia. A total of 420 NF patients were identified from the five years of retrospective data obtained from the two hospitals. RESULTS The top three empirical antibiotics prescribed are ampicillin + sulbactam (n = 258; 61.4%), clindamycin (n = 55; 13.1%) and ceftazidime (n = 41; 9.8%). The selection of the antibiotic significantly impacts the outcome of NF. The top three causative pathogens for NF are Streptococcus spp. (n = 79; 18.8%), Pseudomonas aeruginosa (n = 61; 14.5%) and Staphylococcus spp. (n = 49; 11.7%). The patients who received antibiotics had 0.779 times lower chances of being amputated. Patients with a lower laboratory risk indicator for necrotizing fasciitis (LRINEC) score had 0.934 times lower chances of being amputated. CONCLUSIONS In this study, the most common empirical antibiotic prescribed was ampicillin + sulbactam followed by clindamycin and ceftazidime. The antibiotics prescribed lower the risk of having an amputation and, hence, a better prognosis of the disease. Broad-spectrum empirical antibiotics following surgical debridement reduce the mortality rate of NF.
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Affiliation(s)
- Sanjiv Rampal
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Thanusha Ganesan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Narresh Sisubalasingam
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Vasantha Kumari Neela
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Mehmet Ali Tokgöz
- Kecioren Education and Training Hospital, Pınarbaşı Quarter Sanatoryum Street Keçiören, Ankara, Turkey;
| | - Arun Arunasalam
- Urology Department, Hospital Serdang, Ministry of Health of Malaysia, Putrajaya 62590, Malaysia;
| | - Mohd Asyraf Hafizuddin Ab Halim
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | | | - Suresh Kumar
- Centre for Materials Engineering and Regenerative Medicine, Bharath Institute of Higher Education and Research, Chennai 600173, India;
| | - Ajantha Sinniah
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
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15
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Bodansky DMS, Begaj I, Evison F, Webber M, Woodman CB, Tucker ON. A 16-year Longitudinal Cohort Study of Incidence and Bacteriology of Necrotising Fasciitis in England. World J Surg 2021; 44:2580-2591. [PMID: 32383053 PMCID: PMC7326791 DOI: 10.1007/s00268-020-05559-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Necrotising fasciitis (NF) is a rapidly progressive, destructive soft tissue infection with high mortality. The primary aim of this study was to evaluate the incidence and mortality of NF amongst patients admitted to English National Health Service (NHS) hospitals. The secondary aims included the identification of risk factors for mortality and causative pathogens. Methods The Hospital Episodes Statistics database identified patients with NF admitted to English NHS Trusts from 1/1/2002 to 31/12/2017. Information on patient demographics, co-morbid conditions, microbiology specimens, surgical intervention and in-hospital mortality was collected. Uni- and multivariable analyses were performed to investigate factors related to in-hospital mortality. Results A total of 11,042 patients were diagnosed with NF. Age-standardised incidence rose from 9 per million in 2002 to 21 per million in 2017 (annual percentage change = 6.9%). Incidence increased with age and was higher in men. Age-standardised mortality rate remained at 16% over the study period, while in-hospital mortality declined. On multivariable analysis, the following factors were associated with increased risk of in-hospital mortality: emergency admission, female sex, history of congestive heart failure, peripheral vascular disease, chronic kidney disease and cancer. Admission year and diabetes, which was significantly prevalent at 27%, were not associated with increased risk of mortality. Gram-positive pathogens, particularly Staphylococci, decreased over the study period with a corresponding increase in Gram-negative pathogens, predominantly E. coli. Conclusion The incidence of NF increased markedly from 2002 to 2017 although in-hospital mortality did not change. There was a gradual shift in the causative organisms from Gram-positive to Gram-negative.
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Affiliation(s)
- David M S Bodansky
- The Departments of Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Irena Begaj
- Health Informatics and Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Felicity Evison
- Health Informatics and Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Mark Webber
- Quadram Institute Bioscience, Norwich, NR4 7UQ, UK
| | - Ciaran B Woodman
- Cancer Sciences, University of Birmingham, Birmingham, B15 2SG, UK
| | - Olga N Tucker
- Health Informatics and Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK.
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16
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Shivalingappa S, Manjunath KN, Waiker V, Kumaraswamy M, Odeyar U. Necrotising Fasciitis: Appearances Can Be Deceptive. World J Plast Surg 2021; 10:43-52. [PMID: 33833953 PMCID: PMC8016375 DOI: 10.29252/wjps.10.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODS In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre. RESULTS The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases. CONCLUSION Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.
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Affiliation(s)
| | - K N Manjunath
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - Veena Waiker
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - M Kumaraswamy
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
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17
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Herzwurm ZP, Murphy CS, Griswold BG, Webber CRJ, Mahoney KM. From Lateral Ankle Sprain to Above-Knee Amputation: A Unique Case Report of Group A Streptococcus Necrotizing Soft-tissue Infection. J Orthop Case Rep 2020; 10:52-55. [PMID: 34169017 PMCID: PMC8046446 DOI: 10.13107/jocr.2020.v10.i09.1900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Necrotizing fasciitis, also referred to necrotizing soft-tissue infection (NSTI), is an infrequent entity that results in orthopedic consultation. It is a rapidly spreading typically associated with a contaminated wound that spreads rapidly along fascial planes resulting in significant morbidity and mortality. However, it is a rare occurrence that such pathology occurs in an atraumatic fashion, which is without a wound through the skin. Case Report: A 33-year-old female with no significant medical history presented to a walk-in orthopedic clinic with increasing ankle pain after a lateral ankle sprain 2 days prior. Patient denies any fevers, chills, shortness of breath, numbness, tingling, paresthesia, or any additional trauma since the initial ankle sprain. The patient was afebrile, maintaining oxygenation, normotensive, but tachycardic to just over 100. Physical examination was only significant for moderate swelling and ecchymosis about the lateral malleolus. X-rays and venous ultrasound were negative for any associated pathology. After a period of observation, the patient acutely decompensated with a significant increase in pain in the lower leg on passive stretch, an increase in compartment firmness and a worsening tachycardia up to the 120’s. The patient was taken emergently for fasciotomies for presumed compartment syndrome. The patient was hemodynamically unstable during the case and transferred to the intensive care unit where she continued to decompensate, requiring multiple vasopressors. The affected extremity became necrotic at the level of the foot and her hemodynamic instability continued, causing a return to the operating room for an emergent guillotine above-knee amputation. The patient progressively stabilized and underwent a formal above-knee amputation 2 days later. Cultures obtained during the second case were positive for Group A Streptococcus. Conclusion: This case highlights the variable presentation of NSTIs as well as has having a high index of suspicion to ensure this highly morbid and fatal disease process is diagnosed expeditiously. This case is also unique in that it developed without any obvious wounds and that monomicrobial Group A Streptococcus was the culprit, while most NSTIs are polymicrobial.
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Affiliation(s)
- Zachary P Herzwurm
- Department of Orthopaedic Surgery, Augusta University Medical Office Building, Augusta, Georgia
| | - Cameron S Murphy
- Department of Orthopaedic Surgery, Augusta University Medical Office Building, Augusta, Georgia
| | - B Gage Griswold
- Department of Orthopaedic Surgery, Augusta University Medical Office Building, Augusta, Georgia
| | - Colton R J Webber
- Department of Orthopaedic Surgery, Augusta University Medical Office Building, Augusta, Georgia
| | - Kyle M Mahoney
- Department of Orthopaedic Surgery, Augusta University Medical Office Building, Augusta, Georgia
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18
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Cai Y, Cai Y, Shi W, Feng Q, Zhu L. Necrotizing Fasciitis of the Breast: A Review of the Literature. Surg Infect (Larchmt) 2020; 22:363-373. [PMID: 33026953 DOI: 10.1089/sur.2020.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Necrotizing fasciitis (NF) is a rare, rapidly progressing, and potentially fatal tissue infection involving subcutaneous tissue, superficial fascia, and the overlying skin. Breast NF is often misdiagnosed because of the thick breast tissue between the skin and deep fascia. Only early diagnosis followed by prompt antibiotic treatment and surgical therapy can prevent disastrous consequences. There are many case reports on breast NF, but a systematic review is lacking. Methods: Using PubMed and Scopus we performed a systematic review of the literature covering a period of 20 years. We reviewed articles with predisposing comorbidities (risk factors), triggering factors, laboratory examinations, culture of organisms, antibiotic treatment, surgical interventions, the presence of septic shock, and final outcome. We also performed statistical tests of all these factors in relation to death. Results: Forty cases identified from 38 articles were included in our literature review. Twenty-one cases (52.5%) were primary, whereas 15 cases (37.5%) occurred after surgery. In 15 cases (37.5%), the single organism responsible for NF was Streptococcus pyogenes, whereas mixed organisms were found in 17 cases (42.5%). Surgical debridement was performed in 39 (97.5%) cases. Septic shock was found in all five (12.5%) deceased cases and was associated with patient's mortality (p < 0.001). Conclusions: Breast NF is a rare, severe, and easily misdiagnosed complication. Breast NF could differ from that in other body regions in etiology pattern and clinical manifestations. Confirmed diagnosis of breast NF is based on the combination of clinical, cultural, laboratory, and imaging findings. Urgent subsequent treatments, including surgical debridement, antibiotic therapy, and reconstructive surgery, are critical for better prognosis and survival of patients.
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Affiliation(s)
- Yuchen Cai
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China
| | - Youquan Cai
- Department of Orthopedic Surgery, Hunan Want Want Hospital, Changsha, Hunan, China
| | - Wenjun Shi
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China
| | - Qiuyun Feng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China
| | - Lian Zhu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China
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19
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Fozard J, Shafer K, Kehrl T. Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report. Ultrasound J 2020; 12:24. [PMID: 32323044 PMCID: PMC7176767 DOI: 10.1186/s13089-020-00168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Necrotizing skin and soft tissue infections are life-threatening conditions. Reliance on gas in tissue planes leads to worsened outcomes in patients with non-gas forming types of necrotizing fasciitis (NF). CASE PRESENTATION We present a case of Group A Strep (GAS) necrotizing fasciitis, which was identified at bedside with point-of-care ultrasound (US) including an area of subfascial fluid. Computerized tomography only revealed diffuse cellulitic changes. Patient was taken to the operating room where fascial exploration was not performed at the concerning area seen on ultrasound and thus falsely negative. The patient subsequently developed multi-system organ failure and required amputation of the limb due to rapid spread of GAS NF. CONCLUSION We suggest an US protocol to help identify optimal areas for fascial exploration-sonographic exploration for fascial exploration (SEFE).
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Affiliation(s)
- Jessica Fozard
- WellSpan York Hospital Emergency Medicine Residency Program, WellSpan York Hospital, York, PA, USA
| | - Krystle Shafer
- WellSpan York Hospital Emergency Medicine Residency Program, WellSpan York Hospital, York, PA, USA.
| | - Thompson Kehrl
- WellSpan York Hospital Emergency Medicine Residency Program, WellSpan York Hospital, York, PA, USA
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20
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Nissen M, Bahr M, Sander V, Finke W, Tröbs RB. Benign muscular emphysema mimicking gas-forming infection. Arch Dis Child 2020; 105:398. [PMID: 30636222 DOI: 10.1136/archdischild-2018-316219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Matthias Nissen
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Micha Bahr
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Volker Sander
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Werner Finke
- Department of Anesthesiology and Surgical Intensive Care, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Ralf-Bodo Tröbs
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
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21
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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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22
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Fernández-Bravo A, Kilgore PB, Andersson JA, Blears E, Figueras MJ, Hasan NA, Colwell RR, Sha J, Chopra AK. T6SS and ExoA of flesh-eating Aeromonas hydrophila in peritonitis and necrotizing fasciitis during mono- and polymicrobial infections. Proc Natl Acad Sci U S A 2019; 116:24084-24092. [PMID: 31712444 PMCID: PMC6883842 DOI: 10.1073/pnas.1914395116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
An earlier report described a human case of necrotizing fasciitis (NF) caused by mixed infection with 4 Aeromonas hydrophila strains (NF1-NF4). While the NF2, NF3, and NF4 strains were clonal and possessed exotoxin A (ExoA), the NF1 strain was determined to be phylogenetically distinct, harboring a unique type 6 secretion system (T6SS) effector (TseC). During NF1 and NF2 mixed infection, only NF1 disseminated, while NF2 was rapidly killed by a contact-dependent mechanism and macrophage phagocytosis, as was demonstrated by using in vitro models. To confirm these findings, we developed 2 NF1 mutants (NF1ΔtseC and NF1ΔvasK); vasK encodes an essential T6SS structural component. NF1 VasK and TseC were proven to be involved in contact-dependent killing of NF2 in vitro, as well as in its elimination at the intramuscular injection site in vivo during mixed infection, with overall reduced mouse mortality. ExoA was shown to have an important role in NF by both NF1-exoA (with cis exoA) and NF2 during monomicrobial infection. However, the contribution of ExoA was more important for NF2 than NF1 in the murine peritonitis model. The NF2∆exoA mutant did not significantly alter animal mortality or NF1 dissemination during mixed infection in the NF model, suggesting that the ExoA activity was significant at the injection site. Immunization of mice to ExoA protected animals from NF2 monomicrobial challenge, but not from polymicrobial infection because of NF2 clearance. This study clarified the roles of T6SS and ExoA in pathogenesis caused by A. hydrophila NF strains in both mouse peritonitis and NF models in monomicrobial and polymicrobial infections.
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Affiliation(s)
- Ana Fernández-Bravo
- Unidad de Microbiología, Departamento de Ciencias Médicas Básicas, Facultad de Medicina y Ciencias de la Salud, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, 43201 Reus, Spain
| | - Paul B Kilgore
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, 77555
| | - Jourdan A Andersson
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, 77555
- Department of Pathology and Immunology and Texas Children's Microbiome Center, Baylor College of Medicine, Houston, TX, 77030
| | - Elizabeth Blears
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, 77555
| | - Maria José Figueras
- Unidad de Microbiología, Departamento de Ciencias Médicas Básicas, Facultad de Medicina y Ciencias de la Salud, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, 43201 Reus, Spain
| | - Nur A Hasan
- Research and Development Department, CosmosID Inc., Rockville, MD 20850
- Center for Bioinformatics and Computational Biology, University of Maryland Institute for Advanced Computer Studies, University of Maryland, College Park, MD 20742
| | - Rita R Colwell
- Research and Development Department, CosmosID Inc., Rockville, MD 20850
- Center for Bioinformatics and Computational Biology, University of Maryland Institute for Advanced Computer Studies, University of Maryland, College Park, MD 20742
- Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD 21205
| | - Jian Sha
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, 77555;
| | - Ashok K Chopra
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, 77555;
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23
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Howell EC, Keeley JA, Woods AL, Kaji AH, Deane MR, Kim DY, Neville AL. Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection. Am Surg 2019. [DOI: 10.1177/000313481908501022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.
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Affiliation(s)
- Erin C. Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | | | - Alexis L. Woods
- David Geffen School of Medicine at UCLA, Los Angeles, California; and
| | - Amy H. Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Molly R. Deane
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Angela L. Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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De Roeck L, Van Assche L, Verhoeven V, Vrints I, Van Thielen J, Tondu T, Thiessen F. Progressive subcutaneous emphysema of unknown origin: a surgical dilemma. Acta Chir Belg 2019; 119:251-253. [PMID: 29475402 DOI: 10.1080/00015458.2018.1438560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: Subcutaneous emphysema can be an alarming sign of a necrotizing soft tissue infection. However, non-infectious etiologies exist that can be treated conservatively. This case report describes a subcutaneous emphysema of unknown origin and highlights the importance of distinguishing these clinical entities. Methods: We present a 17-year old female with pain and subcutaneous emphysema of the left arm. There were no systemic symptoms. Inflammatory parameters were slightly elevated. Computed tomography (CT) scan of the chest excluded intrathoracic abnormalities. Despite antibiotic treatment, the pain increased and the emphysema extended. Necrotizing fasciitis was feared. A surgical exploration was performed and hyperbaric oxygen therapy was started. Results: Intraoperatively, puncture marks were identified on the left arm. Air noticeably escaped, but normal, unaffected tissues were identified and microbiological cultures remained negative. We observed a good clinical evolution. Conclusion: The lack of apparent causes, the unexplained puncture marks and psychiatric comorbidity suggests the possibility of subcutaneous emphysema due to factitious manipulations. Patients with subcutaneous emphysema who remain clinically stable, have minimal pain and no significant inflammatory changes could be treated conservatively. Close clinical monitoring is essential to avoid delayed intervention in case of a necrotizing soft tissue infection.
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Affiliation(s)
- Lynn De Roeck
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Lauranne Van Assche
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Veronique Verhoeven
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Ina Vrints
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Jana Van Thielen
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Thierry Tondu
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Filip Thiessen
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim Hospital, Antwerp, Belgium
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A multiplex PCR assay for detection of Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus agalactiae from the isolates of patients with necrotizing fasciitis. Int J Infect Dis 2019; 81:73-80. [PMID: 30690211 DOI: 10.1016/j.ijid.2019.01.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/11/2019] [Accepted: 01/19/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus (MRSA), group A Streptococcus, and group B Streptococcus are commonly detected causative agents of necrotizing fasciitis (NF) in Chia-Yi Chang Gung Memorial Hospital. The aim of this study was to develop and evaluate a multiplex PCR method for the simultaneous detection of five of the most important human pathogens involved in NF by using a novel combination of species-specific genes. METHODS The samples used were collected from 99 patients with surgically confirmed NF of the extremities who were hospitalized consecutively between June 2015 and November 2017. Two sets of blood and tissue samples were collected from all patients; one set was sent to a microbiology laboratory for bacterial identification and the other set was sent to an immunohistochemistry laboratory for PCR amplification. RESULTS The multiplex PCR results for the blood samples showed negative findings. The multiplex PCR results for the tissue specimens showed 28 positive findings. Fourteen (87.5%) of the 16 V. vulnificus culture-positive tissue specimens, six (75%) of the eight A. hydrophila culture-positive tissue specimens, and four (100%) of the four MRSA culture-positive tissue specimens were positive by PCR. Similarly, two (100%) of the group A Streptococcus and two (100%) of the group B Streptococcus were PCR-positive. CONCLUSIONS The accuracy rate of the multiplex PCR presenting positive results in these culture-positive tissue samples was 87.5% (28/32). This suggests that multiplex PCR of tissue specimens may be a useful and rapid diagnostic tool for the detection of these lethal microorganisms in patients with NF.
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Cai Y, Gan Y, Yu C, Tang J, Sun Y. A successful treatment of necrotizing fasciitis following the surgery of distal radius plate removal: A case report and literature review. Medicine (Baltimore) 2018; 97:e0305. [PMID: 29642157 PMCID: PMC5908577 DOI: 10.1097/md.0000000000010305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Necrotizing fasciitis (NF) is defined as a rare, rapidly progressive, and highly lethal skin infection characterized by necrosis of the fascia and subcutaneous tissue. PATIENT CONCERNS The present study aims to discuss the case of a 35-year-old man who developed NF following a routine sterile right distal radius bone plate removal surgery. DIAGNOSES The patient was suspected of NF based on his clinical manifestations, laboratory tests, and imaging results. The diagnosis of NF was confirmed by histological examinations. INTERVENTIONS Serial prompt and extensive debridement was performed during the rapid and aggressive extension of the skin infection, together with antibiotics and supportive treatments. OUTCOMES The condition of the patient finally improved on the sixth day of disease progression. Skin grafting of his right forearm wound was performed successfully 2 months after the admission. LESSONS NF can occur during the perioperative period for routine clean radius plate removal operation in patients with no risk factor for NF. The objective is to remind the physicians to stay aware of this disease, especially its early clinical signs and symptoms. Urgent subsequent treatment, including surgical debridement, antibiotic therapy, and supporting management, is the key to ensure the survival and better prognosis of patients.
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Hong CK, Chen HC, Su WR, Lee PY. Rapid progression and mortality of necrotizing fasciitis caused by Aeromonas hydrophila in a patient with type I open tibial fracture. Kaohsiung J Med Sci 2017; 34:307-309. [PMID: 29699639 DOI: 10.1016/j.kjms.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/10/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Hsin-Chuan Chen
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
| | - Pei-Yuan Lee
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.
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Learning from Clinical Experience with Necrotizing Fasciitis: Treatment and Management. Adv Skin Wound Care 2017; 30:486-493. [PMID: 29049256 DOI: 10.1097/01.asw.0000525791.33664.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
GENERAL PURPOSE To provide information about necrotizing fasciitis (NF), how to recognize it, and evidence-based treatment. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After completing this continuing education activity, you should be able to: ABSTRACT: Necrotizing fasciitis is a threatening, rapidly progressive, infectious disease of the soft tissue. In this article, based on 3 cases, the authors aim to summarize the clinical experience of patients with necrotizing fasciitis and the current concepts of the treatment and management of this disease.
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Shang S, Zhang R, Hou Z. Necrotizing fasciitis-A catastrophic complication following routine tibia fracture surgery: A case report and literature review. Medicine (Baltimore) 2017; 96:e6908. [PMID: 28591027 PMCID: PMC5466205 DOI: 10.1097/md.0000000000006908] [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: 11/25/2022] Open
Abstract
RATIONALE Necrotizing fasciitis (NF) is defined as a rare, life-threatening, rapidly spreading soft tissue infection resulting from a polymicrobial origin, with a predominance of anaerobic organisms that presents with necrosis of the muscle, fascia, and surrounding soft tissue. PATIENT CONCERNS AND DIAGNOSES A 64-year-old male who sustained tibia fracture caused by falling from a height underwent a tibia surgery with minimally invasive plate osteosynthesis technique in another institution. Postoperatively, the patient had development of a very uncommon NF at the site of the tibia procedure. When the patient was transferred to our unit, he rapidly processed to toxic shock and coagulopathy. INTERVENTIONS AND OUTCOMES Although the patient underwent antibiotics treatment in the emergency room and was transferred to the operating room for surgery promptly, the patient's condition deteriorated rapidly and he died of septic shock and multiple organ failure unfortunately. LESSONS Our study aims to highlight the risk of NF in the elderly with diabetes during the perioperative period even if the injury is a simple closed fracture. Physicians must be vigilant to early inflammatory signs and pain in immunosuppressed patients.
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Clostridial Gas Gangrene of the Abdominal Wall After Laparoscopic Cholecystectomy: A Case Report and Review. Surg Laparosc Endosc Percutan Tech 2017; 26:278-81. [PMID: 27490157 DOI: 10.1097/sle.0000000000000294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Clostridial gas gangrene is a rare, yet severe, complication after laparoscopic cholecystectomy. We present a case report of a 48-year-old man with obesity, coronary artery disease, and diabetes, who developed clostridial gas gangrene of the abdominal wall after an uncomplicated laparoscopic cholecystectomy. Although the diagnosis was missed initially, successful radical surgical debridement was performed and the patient survived. Pathogenesis, symptoms, prognostic factors, and the best treatment are discussed.
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Thom C, Warlaumont M. A Necrotizing Fasciitis Fake Out on Point-of-Care Ultrasound—Watch the Shadow. J Emerg Med 2017; 52:523-526. [DOI: 10.1016/j.jemermed.2016.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/05/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022]
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Clark ML, Fisher KL. Sonographic Detection of Necrotizing Fasciitis. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2017. [DOI: 10.1177/8756479317701412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Necrotizing fasciitis is a rare, life-threatening, flesh-eating bacterial infection that quickly destroys soft tissue beneath the skin. Left untreated, it can result in the loss of limbs or even death. A diagnosis is most often made through laboratory tests and diagnostic imaging such as magnetic resonance imaging, computed tomography (CT), and sonography. This case study demonstrates the use of sonography to assist in the detection and characterization of necrotizing fasciitis. In this case, CT provided the necessary diagnostic information to accurately diagnose necrotizing fasciitis. The prompt diagnosis for this patient facilitated expedited treatment in an effort to stem progressive damage to the affected limb.
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Affiliation(s)
- Melissa L. Clark
- Diagnostic Medical Ultrasound Program, University of Missouri, Columbia, MO, USA
| | - Kelsy L. Fisher
- Diagnostic Medical Ultrasound Program, University of Missouri, Columbia, MO, USA
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Corona PS, Erimeiku F, Reverté-Vinaixa MM, Soldado F, Amat C, Carrera L. Necrotising fasciitis of the extremities: implementation of new management technologies. Injury 2016; 47 Suppl 3:S66-S71. [PMID: 27692110 DOI: 10.1016/s0020-1383(16)30609-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Necrotising fasciitis (NF) is potentially life-threatening soft-tissue infection. Early diagnosis and aggressive surgical debridement are critical to decrease mortality and morbidity. The impacts of new management technologies such as hydro-bisturi-assisted debridement (HAD) and negative pressure wound therapy (NPWT) are not yet clear with respect to treatment of NF. The objective of this study was to describe laboratory (including LRINEC score), clinical and microbiological factors, treatment methods and outcomes related to managing necrotising fasciitis, focusing on the implementation of new treatment methods in our centre. METHODS From June 2010 to June 2014, adult patients diagnosed with necrotising fasciitis affecting an upper or lower limb that were admitted to our hospital, a referral tertiary care centre, were eligible to participate in this study. Demographic data, clinical features, location of infection, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score on the day of admission, microbiology and laboratory results, use of HAD, wound management using NPWT, and patient outcomes were retrospectively analysed. A univariate risk factor analysis was performed, in an attempt to define prognostic factors for mortality. RESULTS A total of 20 patients satisfied the inclusion criteria. Type II NF (Group A ß-haemolytic streptococci) was found in 8 cases (40%). The average LRINEC score on the day of admission was 6. The lower extremity was affected in 60% of the cases. All patients were treated operatively, with 2.5 interventions on average. Hydro-bisturi was used in the first debridement in 40% of the cases (8 out 20). In 75% of the studied cases, Negative Pressure Wound Therapy (NPWT) was the technique selected for surgical wound management. The global mortality rate was 30%. On univariate analysis, the only factors significantly associated with mortality were high levels of creatinin (p=0.033) and low blood glucose levels (p=0.012). Finally, four amputations were observed in this series. CONCLUSION We confirm that necrotising fasciitis (NF) of the extremities, despite new advancements in treatment and critical care management, is still a potentially life-threatening soft-tissue infection (30% mortality). New, advanced wound management modalities have been heavily used in management of necrotising fasciitis, but these have not had significant impacts on morbidity and mortality rates.
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Affiliation(s)
- Pablo S Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Frank Erimeiku
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Francisco Soldado
- Paediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Carles Amat
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lluis Carrera
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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Park M, Park JS, Ahn SE, Ryu KN, Park SY, Jin W. Sonographic Findings of Common Musculoskeletal Diseases in Patients with Diabetes Mellitus. Korean J Radiol 2016; 17:245-54. [PMID: 26957910 PMCID: PMC4781764 DOI: 10.3348/kjr.2016.17.2.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/28/2015] [Indexed: 12/18/2022] Open
Abstract
Diabetes mellitus (DM) can accompany many musculoskeletal (MSK) diseases. It is difficult to distinguish the DM-related MSK diseases based on clinical symptoms alone. Sonography is frequently used as a first imaging study for these MSK symptoms and is helpful to differentiate the various DM-related MSK diseases. This pictorial essay focuses on sonographic findings of various MSK diseases that can occur in diabetic patients.
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Affiliation(s)
- Minho Park
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Ji Seon Park
- Department of Radiology, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Sung Eun Ahn
- Department of Radiology, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Kyung Nam Ryu
- Department of Radiology, Kyung Hee University Hospital, Seoul 02447, Korea
| | - So Young Park
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
| | - Wook Jin
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
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Gothner M, Dudda M, Kruppa C, Schildhauer TA, Swol J. Fulminant Necrotizing Fasciitis of the Thigh, Following an Infection of the Sacro-iliac Joint in an Immunosuppressed, Young Woman. Orthop Rev (Pavia) 2015; 7:5825. [PMID: 26605024 PMCID: PMC4592927 DOI: 10.4081/or.2015.5825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 09/13/2015] [Indexed: 11/23/2022] Open
Abstract
Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient's history revealed intravenous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.
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Affiliation(s)
- Martin Gothner
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil , Bochum, Germany
| | - Marcel Dudda
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil , Bochum, Germany
| | - Christiane Kruppa
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil , Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil , Bochum, Germany
| | - Justyna Swol
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil , Bochum, Germany
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Kulasegaran S, Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotizing fasciitis: 11-year retrospective case review in South Auckland. ANZ J Surg 2015. [PMID: 26211758 DOI: 10.1111/ans.13232] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile. METHODS A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed. RESULTS Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval (CI) 13.9%-28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71-0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002-July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens. CONCLUSION This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality.
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Affiliation(s)
- Suheelan Kulasegaran
- Department of Surgery, South Auckland Clinical School, The University of Auckland, Auckland, New Zealand.
| | - Benjamin Cribb
- Department of Surgery, South Auckland Clinical School, The University of Auckland, Auckland, New Zealand
| | - Alain C Vandal
- Ko Awatea, Counties Manukau Health, Middlemore Hospital, Auckland, New Zealand.,Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Stephen McBride
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - David Holland
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Manukau Health, Middlemore Hospital, Auckland, New Zealand
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Mack JA, Woo SL, Haase SC. Noninfectious subcutaneous emphysema of the upper extremity. J Hand Surg Am 2015; 40:1233-6. [PMID: 25910589 DOI: 10.1016/j.jhsa.2015.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Jacob A Mack
- University of Michigan Medical School, Ann Arbor, MI
| | - Shoshana L Woo
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Steven C Haase
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
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Kaufmann JA, Ramponi D. Recognition of Risk Factors and Prognostic Indicators in Fournier's Gangrene. Crit Care Nurs Q 2015; 38:143-53. [DOI: 10.1097/cnq.0000000000000055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tsai YH, Shen SH, Yang TY, Chen PH, Huang KC, Lee MS. Monomicrobial Necrotizing Fasciitis Caused by Aeromonas hydrophila and Klebsiella pneumoniae. Med Princ Pract 2015; 24:416-23. [PMID: 26066555 PMCID: PMC5588256 DOI: 10.1159/000431094] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 05/04/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare specific characteristics and clinical outcomes of monomicrobial necrotizing fasciitis caused by Aeromonashydrophila and Klebsiella pneumoniae. MATERIAL AND METHODS Cases of monomicrobial necrotizing fasciitis caused by A. hydrophila (n = 11) and K. pneumoniae (n = 7) over an 8-year period were retrospectively reviewed. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the A. hydrophila and the K. pneumoniae groups. RESULTS The clinical signs and symptoms at the time of presentation did not differ significantly (p > 0.05) between the two groups. The A. hydrophila group had a significantly shorter interval between contact and admission (1.55 ± 0.52 vs. 5.14 ± 2.12 days, p < 0.001) and significant lower total white blood cell counts (10,245 ± 5,828 vs. 19,014 ± 11,370 cells/mm(3), p < 0.045) than the K. pneumoniae group in the emergency room. Hepatic dysfunction was associated with mortality in patients with A. hydrophila infection, while diabetes mellitus was associated with mortality in patients with K. pneumoniae infection. Overall, 5 (45.5%) patients in the A. hydrophila group and 3 (42.8%) in the K. pneumoniae group died. CONCLUSION The initial clinical course of A. hydrophila monomicrobial necrotizing fasciitis was characterized by more rapidly progressive disease than that of the K. pneumoniae infection. Patients with hepatic dysfunction and necrotizing fasciitis should be suspected of having A. hydrophila infection, and diabetic patients with necrotizing fasciitis should be suspected of having K. pneumoniae infection initially.
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Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
- *Yao-Hung Tsai, MD, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, No. 6, West Sec, Chia-Pu Road, Puzi City, Cha-I 613 Taiwan (ROC), E-Mail
| | - Shih-Hsun Shen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Tien-Yu Yang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
| | - Po-Han Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
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Palvolgyi R, Kaji AH, Valeriano J, Plurad D, Rajfer J, Virgilio CD. Fournier's Gangrene: A Model for Early Prediction. Am Surg 2014. [DOI: 10.1177/000313481408001003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early diagnosis remains the cornerstone of management of Fournier's gangrene. As a result of variable progression of disease, identifying early predictors of necrosis becomes a diagnostic challenge. We present a scoring system based on objective admission criteria, which can help distinguish Fournier's gangrene from nonnecrotizing scrotal infections. Ninety-six patients were identified, 38 diagnosed with Fournier's gangrene and 58 diagnosed with scrotal cellulitis or abscess. Statistical analyses comparing admission vital signs, laboratory values, and imaging studies were performed and Classification and Regression Tree analysis was used to construct a scoring system. Admission heart rate greater than 110 beats/minute, serum sodium less than 135 mmol/L, blood urea nitrogen greater than 15 mg/dL, and white blood cell count greater than 15 x 103/mL were significant predictors of Fournier's gangrene. Using a threshold score of two or greater, our model differentiates patients with Fournier's gangrene from those with nonnecrotizing infections with a sensitivity of 84.2 per cent. Only 34.2 per cent of patients with Fournier's gangrene had hard signs of necrotizing infection on admission, which were not observed in patients with nonnecrotizing infections. Objective admission criteria assist in distinguishing Fournier's gangrene from scrotal cellulitis or abscess. In situations in which results of the physical examination are ambiguous, this scoring system can heighten the index of suspicion for Fournier's gangrene and prompt rapid surgical intervention.
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Affiliation(s)
- Roland Palvolgyi
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy H. Kaji
- Los Angeles Biomedical Research Institute, the
- Department of Emergency Medicine, the
| | - Javier Valeriano
- Los Angeles Biomedical Research Institute, the
- Division of Urology, Department of Surgery, the
| | - David Plurad
- Division of Trauma and Critical Care, Department of Surgery
| | - Jacob Rajfer
- Los Angeles Biomedical Research Institute, the
- Division of Urology, Department of Surgery, the
| | - Christian De Virgilio
- Los Angeles Biomedical Research Institute, the
- Department of Surgery, Harbor UCLA Medical Center, Los Angeles, California
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Monié M, Drieux L, Nzili B, Dicko M, Goursot C, Greffard S, Decré D, Mézière A. Klebsiella pneumoniae necrotizing fasciitis of the leg in an elderly French woman. Clin Interv Aging 2014; 9:1171-4. [PMID: 25071368 PMCID: PMC4111645 DOI: 10.2147/cia.s60812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Klebsiella pneumoniae necrotizing fasciitis is a rare infection in regions outside of Asia. Here, we present a case of necrotizing fasciitis of the leg caused by K. pneumoniae in a 92-year-old French woman hospitalized in a geriatric rehabilitation unit. The patient initially presented with dermohypodermitis of the leg that developed from a dirty wound following a fall. A few hours later, this painful injury extended to the entire lower limb, with purplish discoloration of the skin, bullae, and necrosis. Septic shock rapidly appeared and the patient died 9 hours after the onset of symptoms. The patient was Caucasian, with no history of travel to Asia or any underlying disease. Computed tomography revealed no infectious metastatic loci. Blood cultures showed growth of capsular serotype K2 K. pneumoniae strains with virulence factors RmpA, yersiniabactin and aerobactin. This rare and fatal case of necrotizing fasciitis caused by a virulent strain of K. pneumoniae occurred in a hospitalized elderly woman without risk factors. Clinicians and geriatricians in particular should be aware of this important albeit unusual differential diagnosis.
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Affiliation(s)
- Marguerite Monié
- Assistance Publique-Hôpitaux de Paris (AP-HP), GHU Pitié Salpêtrière-Charles Foix, site Charles Foix, Service de Soins de Suite et Réadaptation orthogériatrique et polyvalent, Fondation d’Heur et Chemin Delatour, Ivry s/Seine, Paris, France
| | - Laurence Drieux
- Assistance Publique-Hôpitaux de Paris, Hôpital Charles-Foix, Bactériologie-Hygiène, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, CR7, Centre d’Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), Paris, France
- INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), Paris, France
| | - Bernadette Nzili
- Assistance Publique-Hôpitaux de Paris (AP-HP), GHU Pitié Salpêtrière-Charles Foix, site Charles Foix, Service de Soins de Suite et Réadaptation orthogériatrique et polyvalent, Fondation d’Heur et Chemin Delatour, Ivry s/Seine, Paris, France
| | - Michèle Dicko
- AP-HP, GHU Henri Mondor, Département de Médecine Interne et Gériatrie, Créteil, France
| | - Catherine Goursot
- Assistance Publique-Hôpitaux de Paris (AP-HP), GHU Pitié Salpêtrière-Charles Foix, site Charles Foix, Service de Soins de Suite et Réadaptation orthogériatrique et polyvalent, Fondation d’Heur et Chemin Delatour, Ivry s/Seine, Paris, France
| | - Sandrine Greffard
- AP-HP, GHU Pitié Salpêtrière-Charles Foix, site Pitié Salpêtrière, Service de Médecine Gériatrique, Paris, France
| | - Dominique Decré
- Sorbonne Universités, UPMC Univ Paris 06, CR7, Centre d’Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), Paris, France
- INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), Paris, France
- AP-HP, Hôpital Saint-Antoine, Bactériologie-Hygiène, Paris, France
| | - Anthony Mézière
- Assistance Publique-Hôpitaux de Paris (AP-HP), GHU Pitié Salpêtrière-Charles Foix, site Charles Foix, Service de Soins de Suite et Réadaptation orthogériatrique et polyvalent, Fondation d’Heur et Chemin Delatour, Ivry s/Seine, Paris, France
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Marto G, Molinar G. Necrotizing soft-tissue infection in an adult. J Emerg Med 2014; 46:826-827. [PMID: 24642044 DOI: 10.1016/j.jemermed.2013.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 06/18/2013] [Accepted: 08/15/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Gonçalo Marto
- Internal Medicine Department, Centro Hospitalar Baixo-Vouga, Aveiro, Portugal
| | - Gonçalo Molinar
- Surgical Department, Centro Hospitalar Baixo-Vouga, Aveiro, Portugal
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Kim SW, Choi IK, Lee JH, Ahn ST, Rhie JW. Treatment of necrotising fasciitis using glycerol-preserved skin allografts for temporary wound coverage. J Wound Care 2014; 23:S20-2. [PMID: 24526170 DOI: 10.12968/jowc.2014.23.sup2b.s20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Allografts of human skin have been used for both temporary and permanent wound coverage. They are useful as temporary bridges for the critically ill patient who is not allowed to receive definite wound coverage, or for wound bed preparation before permanent grafting. Glycerol-preserved skin allografts have several benefits including good adherence to the wound bed, water vapour transport, antimicrobial characteristics, low toxicity and antigenicity, ease of application and removal, a long shelf-life, and minimal storage requirements. We achieved lower limb salvage using a glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis.
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Affiliation(s)
- S W Kim
- MD, Fellow, Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - I K Choi
- MD, Resident, Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - J H Lee
- Clinical Assistant Professor, Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - S T Ahn
- PhD, Professor, Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - J W Rhie
- PhD, Professor, Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
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Fasciitis necroticans after elective hernia inguinal surgery. Case Rep Surg 2014; 2014:981262. [PMID: 24511409 PMCID: PMC3912891 DOI: 10.1155/2014/981262] [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: 09/12/2013] [Accepted: 11/26/2013] [Indexed: 11/17/2022] Open
Abstract
Necrotising fasciitis is a rare but disastrous complication after elective surgery. We present two patients (both male, 58 and 18 years old) who developed necrotising fasciitis following elective inguinal hernia repair according to Lichtenstein. The importance of both recognition and time interval between symptom occurrence and surgical intervention is illustrated, emphasising the need for immediate action when necrotising fasciitis is suspected. A high index of suspicion of necrotising fasciitis should be maintained when a wound infection is accompanied by disproportional pain, lethargy, or sepsis. Epidermolysis and subcutaneous emphysema are often very late symptoms. Recognition and immediate intervention decrease mortality and morbidity.
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Abstract
Benign subcutaneous emphysema is a rare clinical entity, documented by only a small collection of case reports. The presence of crepitus on physical examination and subcutaneous gas on radiographs is concerning for necrotizing fasciitis. Necrotizing fasciitis is a dangerous and deadly infection accounting for 500 to 1000 cases annually in the United States, with mortality rates of up to 76%. Delay in surgical treatment is related to increased morbidity and mortality; therefore, a high clinical suspicion should be maintained in patients with subcutaneous emphysema and/or crepitus. It is critical to recognize that no laboratory result or radiologic finding should delay surgical intervention if a high clinical suspicion for necrotizing fasciitis exists. However, not all subcutaneous emphysema represents a life-threatening infection. This article presents a case of benign subcutaneous emphysema treated with close observation and prophylactic antibiotics. Patients with necrotizing fasciitis typically appear ill and have the triad of swelling, erythema, and disproportionate pain. Patients who are not systemically ill and have minimal pain, no significant inflammatory changes at the site of crepitus, and stable hemodynamic parameters can be treated conservatively, with the caveat that close clinical monitoring is essential to avoid the unnecessary morbidity and mortality that can result from delaying intervention in the case of necrotizing fasciitis.
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Abstract
Few studies have analyzed necrotizing fasciitis in children, and all have relied on cases of necrotizing fasciitis in the abdomen, head, and neck region. The authors sought to correlate the preoperative values of several laboratory tests previously validated in the adult literature, such as the Laboratory Risk Indicator for Necrotizing Fasciitis, with surgically confirmed necrotizing fasciitis in children to provide clinical guidance for the preoperative laboratory workup of necrotizing fasciitis. A retrospective chart review was performed on consecutive patients younger than 18 years with a diagnosis of necrotizing fasciitis. A total of 13 patients with an average age of 7.9 years (range, 9 months-16 years) were included. Ten (76.9%) infections were found in the lower extremity and 3 (23.1%) in the upper extremity. Seven (53.8%) patients had ecchymosis on examination. All patients presented with an elevated white blood cell count. No amputations were performed, and no mortality occurred. All patients underwent surgery within 24 hours of presentation. Elevated temperature, white blood count, erythrocyte sedimentation rate, and C-reactive protein values are typically seen in pediatric patients with necrotizing fasciitis; however, no correlation existed between other the preoperative laboratory values with the previously described scoring systems, such as the Laboratory Risk Indicator for Necrotizing Fasciitis. Aggressive monitoring of signs and symptoms is suggested, even if a patient does not meet all conventional diagnostic criteria. The authors recommend prompt surgical debridement and early administration of antibiotics, which should include clindamycin.
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Affiliation(s)
- Aleksandar Tancevski
- Mount Carmel Medical Center, Nationwide Children’s Hospital, Columbus, OH 43205-2696, USA
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Pérez-García A, Lorca-García C, Pérez-García MP, Cuesta-Romero C, Safont J. Necrotizing fasciitis following calf augmentation. Aesthet Surg J 2013; 33:293-4. [PMID: 23388649 DOI: 10.1177/1090820x12471528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. J Am Acad Dermatol 2012; 67:177.e1-9; quiz 185-6. [PMID: 22794816 DOI: 10.1016/j.jaad.2012.03.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/27/2012] [Accepted: 03/29/2012] [Indexed: 11/22/2022]
Abstract
Several common conditions can mimic cellulitis, creating a potential for misdiagnosis and incorrect management. The most common disorders mistaken for lower limb cellulitis include venous eczema, lipodermatosclerosis, irritant dermatitis, and lymphedema. The dermatologist is often consulted when a patient has failed to respond to therapy, and a thorough knowledge of the differential diagnosis is essential. This article focuses on entities that can mimic cellulitis, with an emphasis of elements of the history and physical examination that can help to distinguish between lower limb cellulitis and its simulators.
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