Retroperitoneal and Cutaneous Necrotizing Fasciitis Secondary to Necrotizing Pancreatitis

Background

Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10–25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess.

Case Report

We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome.

Why Should An Emergency Physician Be Aware of This?

Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course.     

Sonographic Findings in Necrotizing Fasciitis

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.     

“Synchronous” Multifocal Necrotizing Fasciitis

Background

Necrotizing fasciitis (NF) is an infection of the soft tissue, and is fatal if not promptly and aggressively treated. Although it is rare, it is not exceptional; nevertheless, its presentation may be misleading and may delay the diagnosis. We highlight the possible synchronous development of NF in multiple noncontiguous areas.

Case Report

A 44-year-old diabetic man with no history of trauma complained of nonspecific lower back pain, which he treated with analgesics and oral antibiotics. Erythema at the left arm appeared, and the general condition worsened. The patient was admitted to the Emergency Department, and NF was diagnosed at the right gluteus and left arm.

Conclusion

“Synchronous” multifocality is not an expected presentation of NF, and it complicates the diagnosis and delays treatment, with a potentially negative impact on outcome.     

Point-of-Care Ultrasound Diagnosis of Necrotizing Fasciitis Missed By Computed Tomography and Magnetic Resonance Imaging

Background

Necrotizing fasciitis (NF) is a rare but deadly disease. Diagnosis of necrotizing soft tissue infections can be challenging for a variety of reasons. Point-of-care (POC) ultrasound (US) has been described as a diagnostic tool to help the acute care clinician make the early diagnosis that is imperative to optimize outcomes.

Objective

To report a case of Group A Streptococcus NF recognized with POC US, and subsequent negative findings on computed tomography (CT) and magnetic resonance imaging (MRI).

Case Report

A 54-year-old diabetic woman presented to the Emergency Department with atraumatic right foot and lower leg pain associated with fever. Examination was concerning for NF, and a POC US was performed, which showed thickened deep fascia and fluid tracking along the deep fascial plane, with fluid pockets measuring 6 mm in depth, consistent with NF. Surgical consultation was obtained. Per request, CT and MRI of the patient's lower extremity were performed; both were interpreted by the radiologist as showing changes consistent with cellulitis. Septic shock and multisystem organ failure ensued; the patient was eventually taken to the operating room, where operative findings were consistent with NF. Operative cultures grew Streptococcus pyogenes.

Conclusion

NF is a surgical emergency. Early and accurate diagnosis is critical to ensure the necessary aggressive management needed to optimize outcomes. This case illustrates the utility of POC US to make the prompt diagnosis of NF, particularly in light of subsequently negative CT and MRI.     

Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. Objectives: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. Discussion: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. Conclusion: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.     

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。     

Necrotizing Fasciitis in the Adult Patient: Implications for Nurse Practitioners

Necrotizing fasciitis is a life-threatening skin and soft tissue infection associated with high morbidity and mortality in adult patients. Nurse practitioners in both outpatient and inpatient settings should be vigilant for the hallmark signs and symptoms, such as pain out of proportion to the wound appearance and gray or “dishwasher”-colored discharge from the wound. Prompt recognition of these signs and symptoms, rapid surgical debridement, and early initiation of broad-spectrum antimicrobial management are necessary for optimizing patient outcomes and reducing hospital length of stay, cost, morbidity, and mortality.     

Necrotizing fasciitis: early sonographic diagnosis

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.     

Orbital Compressed Air and Petroleum Injury Mimicking Necrotizing Fasciitis

Background

Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis.

Case Report

A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery.

Why should an emergency physician be aware of this?

Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management.     

A Case of Necrotizing Fasciitis with a LRINEC Score of Zero: Clinical Suspicion Should Trump Scoring Systems

Background

Necrotizing fasciitis (NF) is a potentially lethal infection involving the skin, subcutaneous tissue, and fascia. The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score has been proposed as a way of using abnormal laboratory values to distinguish between severe cellulitis and necrotizing fasciitis.

Objectives

The utility of the LRINEC system, including a review of current literature on this scoring system, is discussed.

Case Report

A case of a 37-year-old man is presented. As part of the diagnostic work-up, appropriate laboratory tests necessary to calculate a LRINEC score were obtained. Despite a LRINEC score of 0, NF was later confirmed at surgery.

Conclusions

Although the LRINEC score has been proposed as a robust way of identifying patients with early NF, it failed to detect NF in the patient reported here. NF should thus remain primarily a disease of clinical suspicion, and this suspicion should trump the LRINEC score.     

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.     

Necrotizing fasciitis and gangrene associated with topical herbs in an infant

A 4-mo-old Chinese infant developed necrotizing fasciitis and gangrene from a small skin infection on his buttock that was treated with topical herbs. Sequential cultures revealed a number of organisms:Enterococcus species, sensitive to ampicillin, were isolated throughout the course, and coagulasenegative staphylococci replaced gram-negative rods during the later phase of the illness. The infant required prolonged intravenous antibiotic treatment and underwent multiple surgical procedures for debridement and reconstruction. This report serves to alert the public of the importance of avoiding application of unknown topical herbs in children with skin disease. A seemingly small wound, if inappropriately treated, may result in extensive tissue destruction and require extensive surgery.     

Necrotizing fasciitis as the clinical presentation of a retroperitoneal abscess

Infections of the retroperitoneal space may present with insidiously vague symptoms and non-specific clinical signs. We report a case of a retroperitoneal abscess presenting as necrotizing fasciitis of the thigh from direct spread over the iliac crest. In cases of necrotizing fasciitis of the thigh with no obvious source, an intra-abdominal nidus of infection may be considered.     

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。     

Necrotizing fasciitis due to acute perforated appendicitis: case report

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in treatment increases the likelihood of complications such as perforation, which is associated with an increase in morbidity and mortality rates. We herein present the case of a 76-year-old woman presenting with necrotizing fasciitis of the abdominal wall and right flank regions due to a perforated appendix. Such complication is extremely rare but life-threatening. It may be confused with cellulitis, causing a delay in aggressive treatment. This case represents an unusual complication of a common disease. Also, acute appendicitis or intra-abdominal pathologies should be taken into consideration in determining the cause of necrotizing fasciitis presenting over abdominal, flank, or perineal regions.     

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.     

结节性筋膜炎201例临床病理分析

目的 探讨结节性筋膜炎的临床和病理特征。方法 对201例结节性筋膜炎会诊病例进行总结分析并结合文献进行讨论。结果 结节性筋膜炎的好发部位为上肢,尤其是前臂;发病高峰年龄为20－29岁;大多数（82.4％）病变最大径小于3cm;病程大多数（81.6%)不超过3个月。具诊断意义的4个主要的组织学特征为细胞整体排列方式呈长束状S形轻度弯曲;小裂隙空间;血管外红细胞及黏液样间质基质。常常可以见到正常核分裂象。结论 诊断结节性筋膜炎应紧密结合其快速生长的临床特点,抓住4个主要的组织学特征及常见正常核分裂象的特点。注意防止过度诊断肉瘤。     

Necrotizing Soft Tissue Infections: A Review of Diagnosis,Management, and Implications for NP Practice

Skin and soft tissue infections are among the most common diagnoses seen by nurse practitioners practicing in all settings. These infections range from mild, uncomplicated cellulitis to the more severe, complicated diagnosis of necrotizing soft tissue infections (NSTI). For patients presenting with symptoms of skin and soft tissue infections, differentiating NSTIs from less insidious infections is of paramount importance. NSTIs can be difficult to diagnose because the early presentation may be misleadingly straightforward; however, it is essential that NPs carefully consider NSTIs when a patient presents with the following cardinal skin signs: erythema, swelling, and warmth.