Necrotizing fasciitis precipitating diabetic ketoacidotic coma

Necrotizing fasciitis is a rapidly spreading infection of the subcutaneous tissue and fascia; diabetes mellitus appears to be the most frequent underlying disease. Early diagnosis and immediate aggressive surgical therapy are paramount to curtail morbidity and mortality, but diagnosis is often difficult and unnecessarily delayed. We describe a case of necrotizing fasciitis precipitating diabetic ketoacidotic coma where correct diagnosis was not made until the 14th hospital day. We stress the fact that physicians caring for critically ill patients should be keenly aware of the possibility of necrotizing fasciitis when tending diabetic patients with unexplained fever; failure to recognize the disease can have devastating results. Finally, we believe this to be the first reported case of diabetic ketoacidotic coma precipitated by necrotizing fasciitis.     

综合护理干预在糖尿病坏死性筋膜炎患者中的应用及效果观察

目的:探讨综合护理干预在糖尿病坏死性筋膜炎患者中的应用及临床效果。方法:对28例糖尿病坏死性筋膜炎患者采取心理护理、健康教育、创面观察及护理、负压封闭引流(VSD)护理、血糖监控等综合护理干预措施。结果:本组21例行清创植皮术,3例行带蒂皮瓣修复术,4例行清创术。均治愈出院,住院时间24～72 d。结论:综合护理干预有助于提高糖尿病坏死性筋膜炎患者的治疗效果,改善预后,值得临床推广应用。     

Necrotizing fasciitis of the upper extremity resulting from a water moccasin bite

Aeromonas hydrophila infection has been described as the cause of necrotizing fasciitis in patients with suppressed immune systems, burns, or trauma in an aquatic setting. We report a case in which severe necrotizing fasciitis involving hand, arm, chest, and lateral side of trunk, along with toxic shock, developed after the patient was bitten by a venomous snake. Mixed aerobic and anaerobic bacteria, including A hydrophila, were isolated from the wound culture. The patient was treated with antivenom, a diuretic regimen, broad spectrum antibiotics, and 18 separate surgical procedures. After the application of skin grafts, the wound completely healed. This case illustrates that a venomous snakebite may result in infection with A hydrophila and can cause severe necrotizing fasciitis. Early and aggressive surgical intervention should be implemented as soon as the necrotizing fasciitis is diagnosed.     

The Relationship Between Fluid Accumulation in Ultrasonography and the Diagnosis and Prognosis of Patients with Necrotizing Fasciitis

Necrotizing fasciitis is a severe soft-tissue infection with a high mortality rate. There is little literature on the relationship between the ultrasonographic finding of fluid accumulation along the deep fascia and the diagnosis and prognosis of necrotizing fasciitis. This retrospective study showed that when fluid accumulation was present along the deep fascia, patients with clinically suspected necrotizing fasciitis had a higher probability of having necrotizing fasciitis. The ultrasonographic finding of fluid accumulation with a cutoff point of more than 2 mm of depth had the best accuracy (72.7%) for diagnosing necrotizing fasciitis. In regard to the prognosis of necrotizing fasciitis, when fluid accumulation was present along the deep fascia, patients with necrotizing fasciitis had a longer length of hospital stay and were at risk of amputation or mortality. Ultrasonography is a point-of-care imaging tool that facilitates the diagnosis and prognosis of necrotizing fasciitis.     

Necrotizing fasciitis: a model nursing care plan.

Accurate assessment and timely interventions are critical in caring for patients diagnosed with necrotizing fasciitis. A case example helps nurses assess and intervene the numerous problems commonly experienced by patients with necrotic fasciitis.     

Group C streptococcal sepsis complicating Fournier gangrene

Fournier gangrene is a life-threatening necrotizing fasciitis of the perineal-scrotal area that occurs in diabetic males. Patients typically present with systemic toxicity and significant inflammatory changes in the scrotum and perineum. Most cases of Fournier gangrene are polymicrobic and require urgent surgical debridement and broad-spectrum antibiotic therapy. We describe a case of Fournier gangrene in a young diabetic man that was associated with group C streptococcal bacteremia, an association previously unreported in the literature to our knowledge.     

Burn center management of necrotizing fasciitis

Necrotizing fasciitis is a rapidly progressive soft-tissue infection associated with significant morbidity and mortality. Necrotizing fasciitis is similar to invasive burn wound infection in that diagnosis requires histologic examination of affected tissue and treatment requires aggressive surgical debridement followed by skin autograft. Transfer to a burn center facilitates the management of necrotizing fasciitis, where requisite surgical and nursing expertise is available. We reviewed the experience of one burn center in the management of necrotizing fasciitis over a 5-year period. Ten patients were transferred to the burn center from other medical facilities for care, arriving a mean of 8.9 days after initial hospital admission. The diagnosis was made by a surgical service or consultation before transfer in all cases; initial admission to a medical rather than a surgical service delayed surgery in five cases. All patients had surgical debridement before transfer but required a mean of 5.1 additional operations at the burn center. Although the mean extent of involvement was 14.8% body surface area, the mean length of burn center stay was 34.9 days. Complications were frequent, including pulmonary failure requiring mechanical ventilation (n = 6), renal insufficiency or failure (n = 5), hypotension requiring pressers (n = 4), deep venous thrombosis (n = 3), and pulmonary emboli (n = 1). Overall mortality was 2 of 10 patients (20%). Both fatalities were associated with delay in initial surgical procedure and in transfer to the burn center. The similarity of necrotizing fasciitis and invasive burn wound infection makes the burn center the ideal setting for the treatment of this disease. We advocate the addition of necrotizing fasciitis to the list of conditions currently recognized by the American Burn Association as appropriate for burn center transfer and care.     

Ultrasonographic Screening of Clinically-suspected Necrotizing Fasciitis

OBJECTIVE: To determine the accuracy of ultrasonography for the diagnosis of necrotizing fasciitis. METHODS: This study was a prospective observational review of patients with clinically-suspected necrotizing fasciitis presenting to the emergency department of an urban (Taipei) medical center between October 1996 and May 1998. All patients underwent ultrasonographic examination, with the ultrasonographic diagnosis of necrotizing fasciitis based on the criterion of a diffuse thickening of the subcutaneous tissue accompanied by a layer of fluid accumulation more than 4 millimeters in depth along the deep fascial layer, when compared with the contralateral position on the corresponding normal limb. The final diagnosis of necrotizing fasciitis was determined by pathological findings for patients who underwent fasciotomy or biopsy results for patients managed nonoperatively. RESULTS: Data were collected for 62 patients, of whom 17 (27.4%) were considered to suffer from necrotizing fasciitis. Ultrasonography revealed a sensitivity of 88.2%, a specificity of 93.3%, a positive predictive value of 83.3%, a negative predictive value of 95.4%, and an accuracy of 91.9% as regards the diagnosis of necrotizing fasciitis. CONCLUSIONS: Ultrasonography can provide accurate information for emergency physicians for the diagnosis of necrotizing fasciitis.     

胆道术后肠瘘胆瘘合并坏死性筋膜炎患者的护理

目的总结胆道术后十二指肠瘘、胆瘘合并右侧胸腹壁坏死性筋膜炎患者的护理方法。方法回顾性分析2012年3月在扬州大学临床医学院普外科治疗的1例胆道术后肠瘘、胆瘘合并坏死性筋膜炎患者的临床资料,并总结其护理措施。结果经治疗,患者恢复全肠内营养,好转出院。结论早期清除坏死性筋膜炎创面,并密切观察创面情况,实施有针对性地护理,能有效促进营养物质的吸收、坏死性筋膜炎的恢复和瘘口的愈合。     

负压封闭引流技术治疗糖尿病并发坏死性筋膜炎的护理

目的探讨应用负压封闭引流技术(vacuum sealing drainage,VSD)治疗糖尿病并发坏死性筋膜炎的护理。方法对我科收治的13例2型糖尿病并发坏死性筋膜炎患者应用VSD治疗,探讨应用VSD治疗2型糖尿病并发坏死性筋膜炎患者的护理对策及其方法。结果 VSD治疗坏死性筋膜炎创面有较好的效果,可以促进创面肉芽组织生长,防止创面感染加重,减轻创面渗出,创面一期手术植皮均成活。12例患者创面全部愈合后出院;1例患者因坏死性筋膜炎创面较大,治疗过程中因并发大面积脑梗死而病死。结论 VSD治疗糖尿病并发坏死性筋膜炎患者的效果较好,值得推广。     

房树人绘画测验疗法在一例糖尿病合并坏死性筋膜炎伴重度焦虑患者中的心理干预实践

目的：探讨房树人绘画测验疗法在一例糖尿病合并坏死性筋膜炎伴严重焦虑患者的心理评估与干预效果。方法：在患者治疗前期、中期、后期分别进行焦虑自评（SAS）,并进行房树人绘画测试疗法。结果：在患者治疗前中后期使用焦虑自评量表进行评估,得分依次为：重度焦虑（70分）、中度焦虑（64分）和无焦虑（49分）,三次绘画测试疗法显示患者的焦虑情绪得到了极大的改善。结论：针对该糖尿病合并坏死性筋膜炎伴严重焦虑的患者,房树人绘画测试疗法是一种行之有效的心理评估与干预方法。     

Sonographic findings of necrotizing fasciitis in the breast

Necrotizsing fasciitis is a rapidly developing, fatal bacterial infection of deep subcutaneous tissues. It may occur at any site in the body. We describe a case of necrotizing fasciitis in the breast that was diagnosed on the basis of sonographic findings. Sonographic examination revealed fluid collection in deep tissues with bright echoes likely to represent gas microbubbles. The diagnosis of necrotizing fasciitis was subsequently confirmed on surgical exploration.     

Necrotizing fasciitis: a challenging diagnosis.

The objective of the study was to evaluate our recent experience in diagnosis and management of necrotizing fasciitis. Records of patients who were diagnosed as having necrotizing fasciitis at Al-Ain Hospital in the period between March 2003 and August 2005 were studied retrospectively with regard to clinical features, risk factors, diagnosis, causative organisms, treatment, and outcome. Eleven patients, eight of whom were men of low socio-economic status, were studied. The median age (range) was 46 (8-65) years. The main risk factor was diabetes mellitus in seven patients (64%). The provisional clinical diagnosis was incorrect in seven patients (64%). Pure beta-hemolytic streptococcus group A or B was the causative organism in five patients (46%). Most of our patients underwent multiple surgical debridements with a median range of two (1-11) operations. Two patients died (overall mortality rate 18%). High clinical suspicion is essential for the diagnosis of necrotizing fasciitis. Accurate early diagnosis, aggressive resuscitation, using proper antibiotics, and extensive surgical debridement are essential for a favorable outcome.     

Eyelid Necrotizing Fasciitis: What Were the Early Signs?

Background

Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction.

Objectives

To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis.

Case Report

A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis.

Conclusion

In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis.     

Group A Streptococcal Necrotizing Fasciitis in the Emergency Department

Background

Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients.

Objective

An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED.

Methods

Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group.

Results

During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002−0.16; p < 0.001).

Conclusions

A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis.     

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections

OBJECTIVE: Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. DESIGN: Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140) SETTING: Two teaching tertiary care hospitals. PATIENTS: One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively. CONCLUSIONS: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.     

Necrotizing fasciitis and toxic shock-like syndrome caused by group B streptococcus

A recent increase in reports of necrotizing fasciitis resulting from group B streptococcus has alerted physicians to a possible concomitant increase of toxic shock-like syndrome. We report the second case of group B streptococcus causing necrotizing fasciitis and toxic shock-like syndrome. A black woman, aged 52 years, with newly diagnosed diabetes mellitus had necrotizing fasciitis type II of the left groin. Hypotension, elevated bilirubin and liver enzymes, and adult respiratory distress syndrome rapidly developed. Because group B streptococcus was isolated from a normally sterile site, the patient's condition met the criteria for toxic shock-like syndrome. Extensive surgical debridement, hyperbaric oxygen therapy, and intravenous antibiotic therapy (including clindamycin) were required for complete recovery. The antitoxin effects of hyperbaric oxygen therapy and clindamycin should be further investigated for the treatment of such patients.     

Necrotizing fasciitis in the pediatric age group: report of a case

Necrotizing fasciitis is a rapidly progressive invasive soft tissue infection that is rarely seen in the pediatric population. In the majority of cases described in the medical literature, there has been an identifiable initiating event such as instrumentation or other trauma to the skin. Because of the rapid progression of the infection, the key to a successful outcome is early recognition and rapid initiation of definitive surgical management. A case is presented in which necrotizing fasciitis was seen in a child with no precipitating skin trauma.     

Necrotizing fasciitis in a renal transplant patient

We have described a 28-year-old diabetic woman who had necrotizing fasciitis of the perineum three years after receiving a living related renal transplant. The diagnosis of necrotizing fasciitis was made early and she was referred to a tertiary care center where she received radical perineal debridement and aggressive medical and surgical follow-up. Necrotizing fasciitis in a transplant patient is rare; review of the literature shows few cases and no survivors. Our patient has returned to a normal life despite continuation of all immunosuppressive therapy throughout the entire hospital course. In addition, she had a good cosmetic result despite the large necrotic perineal infection. Her survival can be attributed to early diagnosis and referral, immediate and extensive debridement, and aggressive protein replacement.     

Rapidly progressive septic shock,associated with necrotizing fasciitis

A case is presented of a 59-year-old male with rapidly progressive septic shock and necrotizing fasciitis. The patient was admitted in shock with an extensive skin lesion on the anterior chest wall. The history was relatively short and there was only a questionable history of preceding trauma. Necrotizing fasciitis was suspected from the appearance of the lesion. Antibiotics and anti-shock therapy were given but despite this, his condition deteriorated and he died from septic shock. At autopsy, the diagnosis of necrotizing fasciitis was confirmed. The importance of rapid diagnosis and primary surgical therapy is emphasized.