Reconstruction of a large abdominal wall defect resulting after necrotizing fasciitis with free latissimus dorsi flap

Necrotizing fasciitis is a severe, life-threatening infection. When it occurs, rapid and wide debridement of all affected tissues is the mainstay of treatment. We present a case in which a large, full-thickness abdominal wall defect occurred after debridement of a necrotizing fasciitis. The defect was reconstructed using a free latissimus dorsi myocutaneous flap. This large and versatile innervated flap seems to be a promising choice for reconstruction of full thickness abdominal wall defects. Received: 21 April 1999 / Accepted: 29 September 1999     

Necrotizing fasciitis developing from a brown recluse spider bite

A 20-year retrospective case series was analyzed to identify the brown recluse spider bite as a cause of necrotizing fasciitis. Data from 31 consecutive patients with necrotizing fasciitis were analyzed. Of the 31 patients with necrotizing fasciitis a brown recluse spider bite was found to be the initial cause in two patients. Both patients with spider bites delayed in obtaining medical treatment, and secondary infection of the necrotic tissue occurred. One patient was diagnosed by frozen section tissue biopsy, and the second patient was diagnosed by clinical examination. All patients in this series had immediate aggressive operative debridement. Both patients survived with functional limbs. There were no deaths in this large series. Necrotizing fasciitis can be caused by a secondarily infected brown recluse spider bite. Successful treatment of necrotizing fasciitis from any cause is associated with early diagnosis, immediate surgical debridement, and supplemental enteral or parenteral nutrition.     

The successful use of maggots in necrotizing fasciitis of the neck: a case report

BACKGROUND: The use of maggots to digest necrotic tissue as a form of wound debridement has a long history in medicine. Necrotizing fasciitis of the neck has a high mortality rate despite aggressive surgical and medical intervention. The use of maggots in this disease has been reported only once before. METHODS: We report the case of a 73-year-old woman, who underwent neck dissection and had necrotizing fasciitis of the neck develop shortly after. After initial surgical wound debridement, we used maggots as a biosurgical method for further debridement. A net containing 100 maggots (Biobag; BioMonde, Germany) was used. RESULTS: Daily wound dressing showed rapid improvement of the wound; 4 days after beginning treatment, the wound was free of necroses. CONCLUSION: In this case, we could avoid repeated surgical wound debridement with the use of sterile maggots. The frequently rapid progression of necrotizing fasciitis could be well controlled.     

急性坏死性筋膜炎的综合治疗

目的：探讨急性坏死性筋膜炎的综合治疗。方法：回顾2003年7月～2013年7月我院收治的7例急性坏死性筋膜炎患者的,临床特点及综合治疗临床资料进行分析。结果：7例患者均治愈,经过1月～3年的随访,患者愈合后功能恢复良好,生活均能自理,部分患者恢复劳动能力。结论：明确诊断及时切开减压,扩大清创引流,必要时反复清创,延期修复创面并结合全身支持的综合治疗是治疗急性坏死性筋膜炎的关键。     

An aggressive group a streptococcal cellulitis of the hand and forearm requiring surgical debridement

Group A streptococcus is responsible for a diverse range of soft tissue infections. Manifestations range from minor oropharyngeal and cellulitic skin infections to more severe conditions such as necrotizing fasciitis and septic shock. Troubling increases in the incidence and the severity of streptococcal infections have been reported over the past 25 years. Cases of streptococcal necrotizing fasciitis have received significant attention in the literature, with prompt surgical debridement being the mainstay of treatment. However, cases of rapidly progressing upper extremity streptococcal cellulitis leading to shock and a subsequent surgical intervention have not been well described. This article presents a case of an 85-year-old woman with a rapidly progressing, erythematous, painful, swollen hand associated with fever, hypotension, and mental status change. Due to a high clinical suspicion for necrotizing fasciitis, the patient was rapidly resuscitated and underwent immediate surgical irrigation and debridement. All intraoperative fascial pathology specimens were negative for necrotizing fasciitis, leading to a final diagnosis of Group A streptococcal cellulitis. Although surgical intervention is not commonly considered in patients with cellulitis, our patient benefited from irrigation and debridement with soft tissue decompression. In cases of necrotizing fasciitis as well as rapidly progressive cellulitis, prompt diagnosis and aggressive treatment may help patients avoid the catastrophic consequences of rapidly progressive group A streptococcal infections.     

Necrotising fasciitis: a new management algorithm based on clinical classification

Necrotising fasciitis is a rare infection of the subcutaneous tissues. If untreated, it is invariably fatal, and thus a high index of suspicion for the diagnosis is required. The disease's manifestation can range from a fulminant presentation to a subtle and insidious development. The priority in every case is to proceed to radical surgical debridement. On review of the literature and based on our clinical experience, we propose a new classification based on clinical presentation and suggest an algorithm to facilitate the management of this devastating condition. Increasing awareness should be given to the management of the large wounds resulting from the surgical debridement of necrotising fasciitis.     

An Atypical Case of Necrotizing Fasciitis of the Breast

Necrotizing fasciitis is a rare and aggressive soft tissue infection involving the fascia and subcutaneous tissues. It carries a high mortality and morbidity rate.

In literature, the few case reports on necrotizing fasciitis of the breast, describe the need for a mastectomy in 90% of the cases.

We report on a case of a 72-year old Caucasian women with an atypical presentation of necrotizing fasciitis of the breast in combination with an acute abdomen, successfully treated with breast-conserving debridement and secondary wound closure.     

Necrotizing fasciitis with no mortality or limb loss

Necrotizing fasciitis is a potentially lethal invasive soft tissue infection. Early aggressive antibiotic therapy and surgical debridement have been the hallmark of successful therapy. It is commonly held that delays in surgical debridement significantly increase the mortality rate and rate of limb loss. A mortality rate of 20 per cent or greater has been reported throughout the last 80 years. We recently reviewed the cases of 20 consecutive patients admitted to our hospital in various stages of necrotizing fasciitis progression. Treatment of all 20 patients consisted of antibiotic therapy and surgical debridement, with frequent follow-up serial debridement. Topical negative pressure was achieved with the use of the Vacuum Assisted Closure system. An aggressive surgical approach, (including the frequency of debridement, appropriate antibiotic utilization, and use of the Vacuum Assisted Closure system), significantly impacted our results, despite delays in treatment and progression of the infection.     

Scrotal reconstruction using a superficial circumflex iliac artery perforator flap following Fournier's gangrene

Fournier's gangrene is a type of necrotising fasciitis around the scrotum and perineum. Because of its aggressive nature, patients should be treated with broad‐spectrum antibiotics and emergency, radical debridement during the acute phase. After recovering from the acute phase, reconstruction of the scrotal and perineal soft tissue defects is needed and is often challenging. Traditionally, various reconstruction methods have been used, including skin grafts, fasciocutaneous flaps and musculocutaneous flaps, each with its pros and cons. We successfully covered a wide scrotal defect using a superficial circumflex iliac artery perforator flap, which has not been previously reported for this indication. The design and operative technique are introduced in this study.     

A rare case of primary necrotising fasciitis of the breast: combined use of hyperbaric oxygen and negative pressure wound therapy to conserve the breast. Review of literature

Necrotising fasciitis is a rare but potentially fatal disease. It is even more unusual as a primary disease of the breast. Surgical treatment is required in order to gain control over the spreading infection and mastectomy is reported to be the most common procedure. We report the first case of an otherwise healthy woman exhibiting a primary necrotising fasciitis of the breast, which was treated combining conservative surgery with hyperbaric oxygen (HO) and negative pressure wound therapy (NPWT). A 39‐year‐old woman presented to the emergency room with fever and swelling of her right breast. The physical examination showed oedema and erythema of the breast, with bluish blisters on the lower quadrant. Ultrasound and CT scans showed diffuse oedema of the entire right breast, with subdermal gas bubbles extending to the fascial planes. Few hours later the necrotic area extended regardless an IV antibiotic therapy; a selective debridement of all breast necrotic tissue was performed and repeated 7 days later. The HO was started immediately after the first surgery and repeated daily (2·8 Bar, 120 min) for 18 days and then a NPWT (120–135 mmHg) was applied. Forty‐five days after the last debridement, the breast wound was covered with a full‐thickness skin graft. Several months later, an excellent cosmetic result was observed. This is the first case of primary necrotising fasciitis of the breast treated associating HO and NPWT to surgical debridement only; this combination resulted in a complete recovery with the additional benefit of breast conservation. Such result is discussed in light of the available literature on the treatment of primary necrotising fasciitis of the breast.     

„Banale“ Rückenschmerzen als erstes Symptom einer nekrotisierenden Fasziitis

Necrotizing fasciitis is a life-threatening disease which can only be successfully treated by an interdisciplinary team. An immediate and radical debridement with opening of all compartments and debridement of the affected fascia is the basis for a successful therapy. We report about the treatment of a 21-year-old man who was taken to hospital due to ?banal“ back pain which was caused by a perforated appendicitis. In only 2 days necrotizing fasciitis developed which spread out over the complete right leg.     

四肢坏死性筋膜炎的诊断与治疗

目的：探讨四肢坏死性筋膜炎的早期诊断与治疗方法。方法：2000年1月—2008年1月间收治11例四肢坏死性筋膜炎患者,男8例,女3例;平均年龄32.9岁。所有患者予以急诊清创、抗感染、对症支持治疗,后期行康复锻炼。结果：11例患者均获治愈且肢体功能恢复良好,住院时间27～61d,平均43d。结论：对四肢坏死性筋膜炎进行早期诊断、彻底清创、合理用药、积极支持治疗与及时康复锻炼,能取得较好的治疗效果。     

Abdominoplasty as an adjunct to the management of peri-Caesarian section necrotising fasciitis.

Necrotising fasciitis is a rare but potentially lethal condition, often requiring extensive soft tissue debridement and complex reconstructive surgery. The disease has been noted to complicate Caesarian section wounds, and our department has recently managed three such patients. They all required extensive abdominal wall debridements which would traditionally be closed initially by split skin grafting. We report on the clinical course of three patients, two of whom had their defects closed successfully by abdominoplasty without recourse to initial skin grafting.     

Necrotising fasciitis in an infant with congenital insensitivity to pain syndrome.

We present a rare case of necrotising fasciitis in an infant with congenital insensitivity to pain syndrome. The aetiology, diagnosis and management of necrotising fasciitis in children are compared with those in adults. In contrast to adults, children affected by necrotising fasciitis are usually previously healthy and have no predisposing factors. Early diagnosis, intravenous antibiotics and aggressive surgical debridement are mandatory for an optimal outcome.     

Necrotizing Fasciitis of the Abdominal Wall Following an Emergency Colostomy: a Case Report

Necrotizing soft-tissue infections (NSTIs) are acute surgical conditions that demand prompt and multi-faceted treatment. Early recognition, appropriate resuscitation measures, aggressive surgical debridement, and targeted antimicrobial therapy significantly affect the overall outcome and survival of NSTI patients. Necrotizing fasciitis refers to a particular type of NSTI, where necrosis of the skin, subcutaneous tissue and fascia is predominant and there is very little muscle involvement.

A 51-year-old woman presented with necrotizing fasciitis of the abdominal wall following colostomy for obstructive colon carcinoma. In this particular case, stoma relocation was necessary because of the need for large parietal surgical debridement.     

Eikenella corrodens causing necrotizing fasciitis after an elective inguinal hernia repair in an adult: a case report and literature review

We report an unusual case of necrotizing fasciitis in a 43-year-old man after elective inguinal hernia repair. The patient presented to the emergency department 9 days postoperatively with high fevers, tachycardia, and crepitus along his abdominal wall. He was treated with broad-spectrum antibiotics and underwent a diagnostic laparoscopy as well as a wide debridement of all necrotic tissue. Cultures grew out Eikenella corrodens, which, to our knowledge, has only been reported in one other case as a cause of necrotizing fasciitis. Patients can develop necrotizing fasciitis after elective, clean procedures and should be adequately resuscitated, undergo immediate surgical debridement, and receive antibiotics. Laparoscopy can be useful in determining if intraabdominal pathology is the cause of the infection and a wound vacuum-assisted device is a cost-effective way to decrease healing times.     

Approach to debridement in necrotizing fasciitis

Aggressive debridement is a cornerstone intervention in necrotizing fasciitis. Our approach consists of 4 steps: (1) confirming the diagnosis and isolate the causative organism; (2) defining the extent of fasciitis; (3) surgical excision; and (4) post-excision wound care. The extent of the infection is defined by probing the wound bluntly. Systematic excision follows. Fascial excision must be complete and uncompromising with the full extent of the involved wound laid open. We classify the infected skin into zones 1, 2, and 3. Zone 1 is necrotic tissue. Zone 2 is infected but potentially salvageable soft tissue, and zone 3 is non-infected skin. Zone 1 is completely excised. Zone 2 is meticulously assessed and cut back as necessary to remove nonviable tissue while maximally preserving salvageable tissue. Zone 3 is left alone. The aim of surgical debridement is to remove all infected tissue in a single operation. This halts the progression of the fasciitis and minimizes unnecessary returns to the operating room.     

Necrotizing fasciitis of the extremities.

Necrotizing fasciitis is a limb- and life-threatening soft-tissue infection. Eighteen patients with necrotizing fasciitis of the extremities were reviewed. These infections occurred most commonly after minor trauma. Associated chronic debilitating diseases were present in 13 patients. All but two infections were polymicrobial. The overall mortality rate was 33%. Death was caused by persistent wound sepsis in three and systemic septic complications in spite of apparent local infection control in three. At the admission physical examination the condition may resemble a benign, low-grade cellulitis. Three of four patients died because of a delay in surgical debridement for more than 24 hours after admission. Multiple radial debridements of the involved skin, fat, and fascia are essential to control progressive necrosis. Our results suggest that early diagnosis and prompt surgical debridement of necrotizing fasciitis are essential for survival.     

Massive soft tissue infections: necrotizing fasciitis and purpura fulminans

Necrotizing fasciitis and purpura fulminans are two destructive infections that involve both skin and soft tissue. Necrotizing fasciitis is characterized by widespread necrosis of subcutaneous tissue and the fascia. Historically, group A beta-hemolytic streptococcus has been identified as a major cause of this infection. However, this monomicrobial infection is usually associated with some underlying cause, such as diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is polymicrobial. The diagnosis of necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous antibiotic therapy is one of the cornerstones of managing this life-threatening skin infection. Surgery is the primary treatment for necrotizing fasciitis, with early surgical fasciotomy and debridement. Following debridement, skin coverage by either Integra Dermal Regeneration Template or AlloDerm should be undertaken. Hyperbaric oxygen therapy complemented by intravenous polyspecific immunoglobulin are useful adjunctive therapies. Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of purpura fulminans: neonatal purpura fulminans, idiopathic or chronic purpura fulminans, and acute infectious purpura fulminans. Clinical presentation of purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with fever, shock, and disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of multiple organ failure can be conducted with aggressive debridement and fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal purpura fulminans is the use of activated protein C.     

Necrotizing fasciitis secondary to chickenpox infection in children.

BACKGROUND: Necrotizing fasciitis is an uncommon but serious complication of chickenpox infection in young children. Because many of these infections affect the musculoskeletal tissues, orthopedic surgeons are often the first caregivers to be involved in diagnosis and treatment. Our objective was to review the diagnostic features of necrotizing fasciitis and analyze treatment methods to control and eradicate the musculoskeletal infection. DESIGN: A review. SETTING: The Children's Hospital of Eastern Ontario, Ottawa, a major Canadian pediatric trauma and referral centre. PATIENTS: Five children who presented with necrotizing fasciitis secondary to chickenpox infection. INTERVENTION: Surgical debridement of the involved area of necrotizing fasciitis and intravenous antibiotic treatment with clindamycin and penicillin. MAIN OUTCOME MEASURES: Complications outcome. RESULTS: The average age of the 5 children at presentation was 3.8 years (range from 2.9-5.8 yr). The necrotizing fasciitis involved the lower extremity in 5 children, the upper extremity in 3, and the abdomen, chest, neck and back in 1 child each. One child presented with involvement of all 4 extremities. In 4 children, culture specimens grew group A beta-hemolytic Streptococcus. They all survived and all limbs were salvaged, although secondary closure and skin grafting were required. At an average follow-up of 1 year, each child had fully recovered with no loss of muscle function. CONCLUSIONS: Necrotizing fasciitis should be suspected in any child with a history of varicella infection and an increasing complaint of pain and swelling in an extremity or other body area associated with increasing fever, erythema, lethargy and irritability. Emergent surgical debridement and intensive antibiotic therapy are essential to prevent muscle necrosis, major limb dysfunction and death.