Necrotizing fasciitis

Necrotising fasciitis, invasive Group A Streptococcus (iGAS) infection; a case series of 8 patients requiring surgical debridement in one trauma unit within 9 months

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.

Case report: A rare case of simultaneous necrotizing fasciitis of the breast and forearm

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.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging

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.

Successful Outcome With a Multimodal Approach in the Management of Pediatric Necrotizing Fasciitis: A Report of a Rare Case

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.

Differences Between Patients With Diabetes Mellitus and Those Without in Cases of Necrotizing Fasciitis

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%.

Vacuum-assisted closure versus conventional dressing in necrotizing fasciitis: a systematic review and meta-analysis

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).

Traumatic subcutaneous emphysema of the hand/forearm: A case report

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.

Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis

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.

Household Transmission of Group A Streptococcus Necrotizing Fasciitis

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.

The acute necrotizing periorbital fasciitis. Clinical case

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.

Comparison of Surgical Outcomes and Predictors in Patients with Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria

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.

Murine Soft Tissue Infection Model to Study Group A Streptococcus (GAS) Pathogenesis in Necrotizing Fasciitis

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.

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia

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.

A 16-year Longitudinal Cohort Study of Incidence and Bacteriology of Necrotising Fasciitis in England

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.

Necrotising Fasciitis: Appearances Can Be Deceptive

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.

From Lateral Ankle Sprain to Above-Knee Amputation: A Unique Case Report of Group A Streptococcus Necrotizing Soft-tissue Infection

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.

Necrotizing Fasciitis of the Breast: A Review of the Literature

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.

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report

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).

Pyoderma gangrenosum underrepresentation in non-dermatological literature

Background

Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).

Methods

We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).

Results

Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.

Conclusions

There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

T6SS and ExoA of flesh-eating Aeromonas hydrophila in peritonitis and necrotizing fasciitis during mono- and polymicrobial infections

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.

Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection

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.

Progressive subcutaneous emphysema of unknown origin: a surgical dilemma

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.

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

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.

A successful treatment of necrotizing fasciitis following the surgery of distal radius plate removal: A case report and literature review

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.

Learning from Clinical Experience with Necrotizing Fasciitis: Treatment and Management

GENERAL PURPOSE

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

TARGET AUDIENCE

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

LEARNING OBJECTIVES/OUTCOMES

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

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

RATIONALE

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

PATIENT CONCERNS AND DIAGNOSES

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

INTERVENTIONS AND OUTCOMES

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

LESSONS

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

Clostridial Gas Gangrene of the Abdominal Wall After Laparoscopic Cholecystectomy: A Case Report and Review

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.

Sonographic Detection of Necrotizing Fasciitis

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.

Necrotising fasciitis of the extremities: implementation of new management technologies

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sonographic Findings of Common Musculoskeletal Diseases in Patients with Diabetes Mellitus

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.

Fulminant Necrotizing Fasciitis of the Thigh, Following an Infection of the Sacro-iliac Joint in an Immunosuppressed, Young Woman

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.

Necrotizing fasciitis: 11-year retrospective case review in South Auckland

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.

Monomicrobial Necrotizing Fasciitis Caused by Aeromonas hydrophila and Klebsiella pneumoniae

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.

Fournier's Gangrene: A Model for Early Prediction

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.

Klebsiella pneumoniae necrotizing fasciitis of the leg in an elderly French woman

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.

Treatment of necrotising fasciitis using glycerol-preserved skin allografts for temporary wound coverage

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.

Fasciitis necroticans after elective hernia inguinal surgery

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.

Benign subcutaneous emphysema of the upper extremity

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.

Necrotizing fasciitis in a pediatric orthopedic population

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.

Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis

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.