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Necrotizing Fasciitis

Necrotizing Fasciitis

Necrotizing fasciitis is a life-threatening infection that causes rapid destruction and necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage of the fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis and subcutaneous tissues. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may present with significant pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways out of proportion to the presenting symptoms and rapidly progressive erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion of the affected area. Most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will also have systemic signs of infection, including fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, altered mental status Altered Mental Status Sepsis in Children, and multisystem organ failure. The diagnosis is primarily clinical since patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship can quickly progress to septic shock Septic shock Sepsis associated with hypotension or hypoperfusion despite adequate fluid resuscitation. Perfusion abnormalities may include, but are not limited to lactic acidosis; oliguria; or acute alteration in mental status. Sepsis and Septic Shock without source control Source Control Surgical Infections. This type of infection is a surgical emergency Surgical Emergency Acute Abdomen and requires emergent surgical debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome, parenteral antibiotics, and close hemodynamic monitoring.

Last updated: 1 Mar, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: ≤ 1 case per 100,000 individuals per year
  • 20%‒40% of affected individuals have diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus.
  • Men to women ratio: 3:1
  • Mortality Mortality All deaths reported in a given population. Measures of Health Status: 20%‒80%

Etiology

Necrotizing fasciitis is divided into microbiologic categories based on the causative organism(s):

  • Type I:
    • Polymicrobial infection containing anaerobes Anaerobes Lincosamides and aerobes:
      • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pyogenes
      • Bacteroides Bacteroides Bacteroides is a genus of opportunistic, anaerobic, gram-negative bacilli. Bacteroides fragilis is the most common species involved in human disease and is part of the normal flora of the large intestine. Bacteroides
      • Peptostreptococcus Peptostreptococcus A genus of gram-positive, anaerobic, coccoid bacteria that is part of the normal flora of humans. Its organisms are opportunistic pathogens causing bacteremias and soft tissue infections. Perianal and Perirectal Abscess
      • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli
      • Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections
      • Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella
      • Proteus Proteus Proteus spp. are gram-negative, facultatively anaerobic bacilli. Different types of infection result from Proteus, but the urinary tract is the most common site. The majority of cases are caused by Proteus mirabilis (P. mirabilis). The bacteria are part of the normal intestinal flora and are also found in the environment. Proteus
    • Often seen in older adults with comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus, particularly diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
    • Most common type
  • Type II:
    • Monomicrobial infection: 
      • Group A Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus (most common)
      • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
    • Occurs in any age group
    • Frequently found in individuals with no significant risk factors
  • Type III (the definition or existence of this type varies in the literature):
    • Gas gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction
      • Most commonly from traumatic inoculation with Clostridium perfringens Clostridium perfringens The most common etiologic agent of gas gangrene. It is differentiable into several distinct types based on the distribution of twelve different toxins. Gas Gangrene
      • Clostridium septicum Clostridium septicum A species of gram-positive bacteria in the family clostridiaceae. Infections have a strong association with malignancies and also with gas gangrene. Gas Gangrene is linked with colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy cancer and leukemia.
    • Vibrio Vibrio Vibrio is a genus of comma-shaped, gram-negative bacilli. It is halophilic, acid labile, and commonly isolated on thiosulfate-citrate-bile-sucrose (TCBS) agar. There are 3 clinically relevant species: Vibrio cholerae (V. cholerae), Vibrio vulnificus (V. vulnificus), and Vibrio parahaemolyticus (V. parahaemolyticus). Vibrio vulnificus
      • From aquatic injuries or consumption of raw seafood
      • More often seen in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with chronic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy disease

Risk factors

  • Immunosuppression:
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus 
    • HIV HIV Anti-HIV Drugs
    • Neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions damage: 
    • Major penetrating trauma or minor laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma 
    • Intravenous drug abuse 
    • Recent surgery
    • Insect bite
  • Malignancy Malignancy Hemothorax
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • Smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases
  • Alcoholism Alcoholism A primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. Wernicke Encephalopathy and Korsakoff Syndrome 
  • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis

Pathophysiology

  • Bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology extend into the subcutaneous tissue Subcutaneous tissue Loose connective tissue lying under the dermis, which binds skin loosely to subjacent tissues. It may contain a pad of adipocytes, which vary in number according to the area of the body and vary in size according to the nutritional state. Soft Tissue Abscess from:
    • Nearby ulcer or superficial infection
    • Trauma
    • Bloodstream (most often S. pyogenes)
  • Even in monomicrobial infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease, other aerobic and anaerobic pathogens may play a role.
  • Infection causes occlusion of subcutaneous vessels → tissue and fascial ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage → necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage
    • Damage occurs to superficial nerves → localized anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts
    • Hypoxic conditions → ↓ neutrophil function → proliferation of bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology
  • Infection and necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage can rapidly travel along fascial planes, possibly due to bacterial enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes and toxins.
  • Gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction may develop:
    • Anaerobic metabolism by facultative organisms → carbon dioxide, hydrogen, and nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle production
    • Hydrogen and nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle are insoluble and accumulate in the subcutaneous tissues.

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Toxic Shock Syndrome and Necrotizing Fasciitis (Flesh-Eating Disease)

Clinical Presentation

Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions and soft tissue Soft Tissue Soft Tissue Abscess findings

Early signs:

  • Acute, severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways out of proportion with physical findings
  • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion that quickly spreads over hours to days.
  • Warmth
  • Tense, indurated skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions

Late signs:

Common sites of infection:

  • Extremities (most common)
  • Fournier gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction (necrotizing fasciitis of the perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy):
    • Presents as pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, redness Redness Inflammation, and swelling Swelling Inflammation in the genital area
    • Rapidly spreads to the anterior abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen and gluteal muscles
  • Head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess:
    • Often has a dental or pharyngeal origin from procedures or trauma
    • May spread to the face, lower neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, and mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels: Anatomy
  • Necrotizing fasciitis - painful erythema

    Rapidly spreading erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, ulceration Ulceration Corneal Abrasions, Erosion, and Ulcers, and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema of the right leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy due to necrotizing fasciitis

    Image: “Preoperative photograph” by Department of Family Medicine, Morehouse School of Medicine, 1513 East Cleveland Avenue, Building 100, Suite 300A, Atlanta, GA 30344, USA. License: CC BY 3.0
  • Necrotizing fasciitis on left leg

    Bullae Bullae Erythema Multiforme and erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion resulting from necrotizing fasciitis

    Image: “Superficial skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions manifestations of necrotizing fasciitis” by National Hospital of Sri Lanka, Regent Street, Colombo 10, Sri Lanka. License: CC BY 4.0
  • Necrotizing fasciitis on left leg

    Cutaneous necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage, erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, and bullous changes due to necrotizing fasciitis of the leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy

    Image: “Necrotizing fasciitis” by Piotr Smuszkiewicz et al AL Amyloidosis. License: CC BY 2.0
  • Fournier’s gangrene

    Fournier gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction:
    Significant erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema is noted throughout the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy and gluteal regions.

    Image: “Fournier’s gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction” by 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece. License: CC BY 4.0
  • Cervical necrotizing fasciitis caused by dental extraction

    Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and necrotic tissue due to necrotizing fasciitis of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess:
    This developed after a dental extraction.

    Image: “Necrotic tissue” by Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil. License: CC BY 4.0
  • Sinus discharging necrotizing fasciitis

    Necrotizing fasciitis of the lip and face:
    Significant swelling Swelling Inflammation, erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, exfoliation, and purulent drainage is noted.

    Image: “Patient with painful lower lip swelling Swelling Inflammation” by Khartoum Teaching Dental Hospital, P.O box 122, Khartoum, Sudan. License: CC BY 4.0

Evidence of systemic toxicity Toxicity Dosage Calculation

  • High fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension 
  • Altered mentation:
    • Confusion
    • Obtundation

Diagnosis

A definitive diagnosis of necrotizing fasciitis is made by surgical exploration and debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome. These processes should not be delayed to obtain diagnostic information, if the clinical suspicion is high.

However, the following may be helpful:

  • Laboratory evaluation:
    • Gram stain Gram stain Klebsiella and cultures Cultures Klebsiella should be obtained from:
      • Blood (preferably before antibiotics are given)
      • Intraoperative specimens 
    • ↑ WBC with left shift Left Shift Yersinia pestis/Plague
    • ↑ erythrocyte sedimentation rate Erythrocyte Sedimentation Rate Soft Tissue Abscess and c-reactive proteins Proteins Linear polypeptides that are synthesized on ribosomes and may be further modified, crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific sequence of amino acids determines the shape the polypeptide will take, during protein folding, and the function of the protein. Energy Homeostasis
    • ↓ HCO3 → metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
    • ↑ lactic acid 
    • ↑ blood urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle and creatinine → acute renal failure Renal failure Conditions in which the kidneys perform below the normal level in the ability to remove wastes, concentrate urine, and maintain electrolyte balance; blood pressure; and calcium metabolism. Renal insufficiency can be classified by the degree of kidney damage (as measured by the level of proteinuria) and reduction in glomerular filtration rate. Crush Syndrome
    • ↑ glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance
    • ↓ Na
  • Laboratory Risk Indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments for Necrotizing Fasciitis (LRINEC) Score:
    • Calculates a score using WBC, c-reactive protein, hemoglobin, creatinine, sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia, and glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance
    • Has a high specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays but low sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques
    • Should not be used alone to rule out infection
  • Imaging:
    • CT scan is the best imaging modality and may show:
      • Subcutaneous gas 
      • Inflammatory changes along fascial planes
      • Fluid collections
    • Radiographs can reveal gas in the tissues, particularly in the extremities.
  • Abnormal air accumulation in left thigh

    CT findings in necrotizing fasciitis:
    Gas is noted in the subcutaneous space.

    Image: “Abnormal air accumulation” by Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest, Graduate School of Biomedical Science, Hiroshima University, Minami-ku, Hiroshima, Japan. License: CC BY 2.0
  • Perforated diverticulitis presenting as necrotising fasciitis

    CT findings in necrotizing fasciitis:
    This scan demonstrates fascial edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, subcutaneous fat Subcutaneous fat Fatty tissue under the skin throughout the body. Erythema Nodosum stranding, and gas in the muscle compartments.

    Image: “Computed tomography” by Poole Hospital NHS Foundation Trust Trust Confidence in or reliance on a person or thing. Conflict of Interest, Longfleet Road, Poole, BH15 2JB, UK. License: CC BY 2.0
  • Subcutaneous gas in leg in necrotizing fasciitis

    CT findings in necrotizing fasciitis:
    This scan demonstrates subcutaneous gas tracking along fascial planes of the left leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy and pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy.

    Image: “ Frontal view Frontal View Imaging of the Spine and Spinal Cord of CT” by Henrik Galust et al AL Amyloidosis. License: CC BY 3.0

Management

Surgery

Surgical debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome is the mainstay of treatment.

  • Necrotic tissue is removed.
  • Multiple serial debridements are often required to control the infection completely.
  • Amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation may be required for severe disease affecting an extremity.
  • Tissue samples can be obtained and sent for culture.
Management of necrotizing fasciitis

Surgical excision of necrotic tissues in necrotizing fasciitis

Image: “Management of necrotizing fasciitis” by 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece. License: CC BY 4.0

Antibiotic therapy

  • Early intravenous antibiotics should be given for coverage of gram-positive Gram-Positive Penicillins, gram-negative, and anaerobic bacteria Anaerobic Bacteria Nitroimidazoles.
  • An initial therapy regimen should include each of the following:
    • Carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam or piperacillin Piperacillin Semisynthetic, broad-spectrum, ampicillin derived ureidopenicillin antibiotic proposed for pseudomonas infections. It is also used in combination with other antibiotics. Penicillins– tazobactam Tazobactam A penicillanic acid and sulfone derivative and potent beta-lactamase inhibitor that enhances the activity of other anti-bacterial agents against beta-lactamase producing bacteria. Cephalosporins
    • Vancomycin Vancomycin Antibacterial obtained from streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear. Glycopeptides or daptomycin Daptomycin A cyclic lipopeptide antibiotic that inhibits gram-positive bacteria. Lipopeptides and Lipoglycopeptides ( MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus coverage)
    • Clindamycin Clindamycin An antibacterial agent that is a semisynthetic analog of lincomycin. Lincosamides (for antitoxin effects against toxin-producing streptococci or staphylococci)
  • Therapy should eventually be tailored to culture data (when available).

Post-operative care Post-operative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

  • The majority of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will require monitoring in an intensive care unit.
  • Hemodynamic support:
    • Aggressive resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome with intravenous crystalloid Crystalloid Isotonic solutions of mineral salts, such as ringer’s lactate and sodium chloride (saline solution), used in fluid therapy to rehydrate blood volume. Intravenous Fluids fluids
    • Vasopressor Vasopressor Acute Cholangitis support for septic shock Septic shock Sepsis associated with hypotension or hypoperfusion despite adequate fluid resuscitation. Perfusion abnormalities may include, but are not limited to lactic acidosis; oliguria; or acute alteration in mental status. Sepsis and Septic Shock ( norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS is first line)
  • Monitor hemoglobin and transfuse for blood loss associated with repeated debridements.

Complications

  • Septic shock Septic shock Sepsis associated with hypotension or hypoperfusion despite adequate fluid resuscitation. Perfusion abnormalities may include, but are not limited to lactic acidosis; oliguria; or acute alteration in mental status. Sepsis and Septic Shock
  • Toxic shock syndrome Toxic Shock Syndrome Toxic shock syndrome (TSS) is an acute, multi-systemic disease caused by the toxin-producing bacteria, Staphylococcus aureus and Streptococcus pyogenes. Staphylococcal TSS is more common and associated with tampons and nasal packing. Toxic Shock Syndrome
  • Multisystem organ failure
  • Limb loss and severe scarring Scarring Inflammation
  • Death

Differential Diagnosis

  • Cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis: a common bacterial skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions infection which that affects the deeper layers of the dermis Dermis A layer of vascularized connective tissue underneath the epidermis. The surface of the dermis contains innervated papillae. Embedded in or beneath the dermis are sweat glands; hair follicles; and sebaceous glands. Skin: Structure and Functions and subcutaneous tissue Subcutaneous tissue Loose connective tissue lying under the dermis, which binds skin loosely to subjacent tissues. It may contain a pad of adipocytes, which vary in number according to the area of the body and vary in size according to the nutritional state. Soft Tissue Abscess. This condition is most commonly caused by S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus and S. pyogenes. Cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis presents as an erythematous, edematous area that is warm and tender to the touch. Crepitus Crepitus Osteoarthritis, necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage, and systemic toxicity Toxicity Dosage Calculation are not usually present. Diagnosis is clinical, and management involves antibiotics tailored to the suspected organism.
  • Pyoderma gangrenosum Pyoderma gangrenosum An idiopathic, rapidly evolving, and severely debilitating disease occurring most commonly in association with chronic ulcerative colitis. It is characterized by the presence of boggy, purplish ulcers with undermined borders, appearing mostly on the legs. The majority of cases are in people between 40 and 60 years old. Its etiology is unknown. Crohn’s Disease: neutrophilic dermatosis Neutrophilic Dermatosis Rheumatoid Arthritis that presents with inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and ulceration Ulceration Corneal Abrasions, Erosion, and Ulcers of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with a painful, inflamed papule Papule Elevated lesion < 1 cm in diameter Generalized and Localized Rashes that progresses to an ulcer with irregular borders and purulent drainage. Unlike necrotizing fasciitis, there is rarely systemic toxicity Toxicity Dosage Calculation, the involvement of the fascial planes, or improvement with antibiotics. This condition will worsen with debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome. Pyoderma gangrenosum Pyoderma gangrenosum An idiopathic, rapidly evolving, and severely debilitating disease occurring most commonly in association with chronic ulcerative colitis. It is characterized by the presence of boggy, purplish ulcers with undermined borders, appearing mostly on the legs. The majority of cases are in people between 40 and 60 years old. Its etiology is unknown. Crohn’s Disease is based on the clinical assessment and histologic findings. This is managed with immunosuppressive therapy.
  • Gas gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction: clostridial myonecrosis Clostridial myonecrosis Gas gangrene, also known as clostridial myonecrosis, is a life-threatening muscle and soft tissue infection that usually develops after traumatic inoculation with clostridium perfringens (C. perfringens), but can also develop spontaneously in association with other Clostridium species. Gas Gangrene (gas gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction) is a life-threatening muscle and soft tissue Soft Tissue Soft Tissue Abscess infection that often develops after traumatic inoculation with Clostridium perfringens Clostridium perfringens The most common etiologic agent of gas gangrene. It is differentiable into several distinct types based on the distribution of twelve different toxins. Gas Gangrene. Sudden, severe muscle pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways develops shortly after the injury. Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions changes (red/purple to black), tenderness, bullae Bullae Erythema Multiforme formation, and crepitus Crepitus Osteoarthritis are also present and progress rapidly.  Diagnosis is clinical. Once suspected, intravenous antibiotic therapy should be started, and emergent surgical debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome should be undertaken. 
  • Pyomyositis: infection of the skeletal muscle that results from hematogenous Hematogenous Hepatocellular Carcinoma (HCC) and Liver Metastases spread from a primary infected source. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, fevers, and a variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables degree of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions findings from minimal erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion to severe tenderness, induration Induration Dermatologic Examination, and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. The diagnosis is made with imaging and culture data. Management typically consists of percutaneous drainage Percutaneous Drainage Echinococcus/Echinococcosis or, in severe cases, open surgical drainage with antibiotic therapy.

References

  1. Stevens, D.L., and Baddour, L.M. (2021). Necrotizing soft tissue infections. In Baron, E.L. (Ed.), UpToDate. Retrieved February 12, 2021, from https://www.uptodate.com/contents/necrotizing-soft-tissue-infections
  2. Schultz, S.A. (2020). Necrotizing fasciitis. In Bronze, M.S. (Ed.), Medscape. Retrieved February 12, 2021, from https://emedicine.medscape.com/article/2051157-overview#a4
  3. Dhar, A.D. (2019). Necrotizing soft tissue infection. [online] MSD Manual Professional Version. Retrieved February 17, 2021, from https://www.msdmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/necrotizing-soft-tissue-infection
  4. Wallace, H.A., and Perera, T.B. (2020). Necrotizing fasciitis. [online] StatPearls. Retrieved February 17, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK430756/
  5. Schadt, C. (2021). Pyoderma gangrenosum: Pathogenesis, clinical features and diagnosis. In Ofori, A.O. (Ed.), UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/pyoderma-gangrenosum-pathogenesis-clinical-features-and-diagnosis
  6. Baddour, L.M., and Keerasuntornpong, A. (2021). Pyomyositis. In Baron, E.L. (Ed.), UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/pyomyositis

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