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.     

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。     

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.     

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.     

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.     

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.     

Streptococcal Necrotizing Myositis: A Case Report and Clinical Review

Background

Streptococcal necrotizing myositis, also known as gangrenous myositis, is a very rare and severe soft tissue infection that predominately involves skeletal muscle and, eventually, superficial fascia and surrounding tissues. The presentation is often nonspecific until the rapidly progressing clinical course becomes apparent. A high morbidity and mortality rate has been reported in the small number of cases since 1900. Despite several attempts to better define the different entities causing necrotizing myositis, no single definitive causal relationship has been defined.

Objectives

A review of the literature is presented here to help clinicians distinguish those with necrotizing myositis from those with nonnecrotizing myositis when the clinician is at all confronted with the suspicion for such an infection.

Case Report

The case presented is that of a 48-year-old woman who had streptococcal necrotizing myositis. She died roughly 72 h after admission. After the patient’s death, the clinical team sought consent for autopsy. Hospital staff made contact with family, and information was obtained from the family that the onset of the patient’s symptoms was allegedly temporally related to her acquisition of a new tattoo on the right back, where the tattoo process allegedly included injection of cremated ashes of a pet dog.

Conclusion

A high level of suspicion for necrotizing myositis must be maintained for a patient with unexplained severe muscle pain and soft tissue swelling accompanied by systemic inflammatory response syndrome.     

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.     

The combined score of quick SOFA and the charlson comorbidity index could be a poor prognostic indicator for in-hospital mortality among patients with necrotizing fasciitis

IntroductionWhile necrotizing fasciitis (NF) is a rare but rapidly progressive devastating soft tissue infectious disease showing a high in-hospital mortality rate of 20–30%, there are no evidence-based predictive tools.Patients and methodsFor the purpose of examining which predictive tools could correctly reflect the severity and prognosis of NF, we retrospectively reviewed all patients who were diagnosed with NF at our institute. The disease severity was evaluated by quick SOFA (qSOFA), SOFA score, SIRS score, APACHE II score, LRINEC score and the combined score of qSOFA and CCI.ResultsA total of 27 patients were enrolled in this study. The median age was 68 years (range 39–96 years). With respect to the predictive values for in-hospital mortality among NF patients, the area under the ROC curve for qSOFA, SOFA score, APACHE II score, the combined score of qSOFA and CCI were 0.653 (p = 0.192), 0.588 (p = 0.12), 0.709 (p = 0.075) and 0.782 (p = 0.016) respectively.A univariate analysis showed that the combined score of qSOFA and CCI≥5 and the initial treatment failure were poor prognostic indicators for the in-hospital death among NF patients. The appropriate cut-offs of qSOFA and CCI were based on the Youden Index.ConclusionWe concluded that the combined score of qSOFA and CCI could reflect the severity and prognosis of NF for in-hospital death.     

嗜酸性筋膜炎2例报道并文献复习

目的：探讨嗜酸性筋膜炎（EF）的临床和病理特点。方法：回顾性分析我院2例确诊为EF的患者的临 床表现、实验室检查、影像学资料及病理检查,并结合文献进行回顾性分析。结果：2例患者中女性和男性各 1例,2例均表现为对称性肢体肿胀僵硬;2例外周血嗜酸性粒细胞增多及血沉增快;1例高丙种球蛋白血症 及C反应蛋白增高;肌肉MRI提示筋膜增厚,T2WI呈高信号;受累区域全层皮肤肌肉活检可见筋膜增厚伴 炎性细胞浸润。检索既往报道的EF患者496例,最常见的表现是对称性肢体肿胀僵硬。实验室检查常显示 外周血嗜酸性粒细胞增多、高丙种球蛋白血症及血沉增快。典型的肌肉MRI表现是T1加权成像显示受累筋 膜增厚,T2加权成像呈高信号,增强扫描增厚的筋膜明显强化。典型的病理改变是筋膜增厚、纤维化并伴炎 性细胞浸润。结论：EF是一种以对称性肢体肿胀硬化、外周血嗜酸性粒细胞增多、高丙种球蛋白血症、血沉 增快等为主要特征的少见病,系统受累较少,激素治疗有效。     

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.     

Case report of open appendectomy in treating acute perforated appendicitis with necrotizing fasciitis of the abdominal wall: A rare complication of a common disease

Acute appendicitis can be associated with uncommon complications such as necrotizing fasciitis. We present a case of a 37‐year‐old woman referred to our hospital with a 1‐week history of significant weakness, anorexia, and mild abdominal pain. According to laboratory and radiographic data, the patient was diagnosed with perforated appendicitis and gangrene.     

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。     

Cardiac Tamponade Due to Group A Streptococcus Descending Necrotizing Mediastinitis: Case Report of an Unusual Presentation

Background

Cardiac tamponade from necrotizing descending mediastinitis is a rare but life-threatening complication of cervicofacial infections.

Case Report

A 49-year-old woman presented in shock with pleuretic chest pain at a small community clinic. She was transferred to our emergency department where cardiac tamponade was diagnosed and drained. Her initial complete blood count and chest radiography suggested a neoplastic process. She, however, was diagnosed with descending necrotizing mediastinitis due to group A Streptococcus. She underwent surgical drainage and recovered uneventfully.

Why Should an Emergency Physician Be Aware of This?

Descending necrotizing mediastinitis can present with cardiac tamponade and a leukemoid reaction mimicking a neoplastic process. Recognizing this entity allows initiation of potentially life-saving treatments.     

Necrotizing fasciitis of the neck due to an odontogenic infection: A case report

Deep fascial space infections of the neck are most frequently odontogenic in origin. We describe a case of odontogenic infection of the mandible which extended to the lateral pharyngeal space and resulted in a severe life-threatening necrotizing fasciitis of the neck. A 69-year-old nondiabetic male complained of dysphagia and a severe toothache of the lower left molar and was transported to the emergency ward. A CT scan revealed swelling of the peritonsillar, lateral pharyngeal and masticator space with narrowing of the airway of the middle pharynx. The patient underwent a tracheotomy with surgical drainage. The strap muscles, including the fascia, of the neck were necrotic. He was treated with a combination of ampicillin and clindamycin-2-P. On the second postoperative day, the patient's platelet count fell to 20,000/mm³. The patient was transfused with platelet concentrate, and given gamma globulin and gabexate mesilate, and his predisseminated intravascular coagulation (DIC) status improved. However, on the eight post operative day, progressive tissue necrosis of the face and neck was observed. Panipenem betamipron was started and continued for 20 days. A second extensive surgical debridement of the neck and face was carried out, and the patient ultimately recovered.Prevotella buccae, Streptococcus intermedius, Lactobacillus fermentum, L. casei, L. catenaforme, L. acidophilus, andBifidobacterium sp. were isolated from either the peritonsillar, submandibular, lateral pharyngeal or carotid space abscesses. We emphasize the importance of proper diagnosis, early surgical intervention and systemic antimicrobial chemotherapy to control this aggressive infectious disease.     

超声引导下经皮置管治疗急性感染性坏死性胰腺炎92例临床分析

目的：评价超声引导下经皮置管治疗急性感染性坏死性胰腺炎的疗效。方法：回顾性分析2002年1月至2012年11月收治的应用超声引导下经皮穿刺置管胰周感染性积液的急性感染性坏死性胰腺炎92例的临床资料。结果：本组82例（89．1％）患者通过经皮置管引流成功,80例（86．9％）治愈出院,2例（2．2％）死于脑出血及呼吸循环衰竭;10例（10．9％）患者引流失败而改行外科手术引流,其中3例（3．3％）术后康复,7例（7．5％）术后死于多器官功能衰竭。本组引流时间7-100d,平均（20．5±3．5）d,引流次数为1—5次,无穿刺并发症发生。结论：在常规治疗的基础上,超声引导下经皮置管治疗急性感染性坏死性胰腺炎是一种简便、安全、有效的治疗方法。     

Mayo评分与Child分级评估肝硬化患者预后

目的:通过研究Mayo评分和Child分级与肝硬化患者预后的关系,比较两种方法预测肝硬化患者预后的价值。方法:回顾分析106例肝炎后肝硬化患者的临床资料,计算入院当天Mayo评分与Child分值,通过ROC曲线及截断值进行比较分析。结果:各组患者生存者与死亡者的Mayo评分与Child分值均有显著差异(P<0.05),3个月与2年生存期的患者两体系ROC曲线下面积有显著差异(P<0.05),而生存期1年的患者两体系ROC曲线下面积无显著差异(P>0.05)。结论:Mayo评分与Child分级均准确评估各生存期预后;Mayo评分适宜评估急、危重患者,而Child分级较适宜评估中长期患者。Mayo评分不仅适用于预测原发性胆汁性肝硬化患者预后,同样适用于肝炎后肝硬化患者。     

Application of Ultrasound in the Assessment of Plantar Fascia in Patients With Plantar Fasciitis: A Systematic Review

Plantar fasciitis (PFS) is one of the most common causes of heel pain, estimated to affect 10% of the general population during their lifetime. Ultrasound (US) imaging technique is increasingly being used to assess plantar fascia (PF) thickness, monitor the effect of different interventions and guide therapeutic interventions in patients with PFS. The purpose of the present study was to systematically review previously published studies concerning the application of US in the assessment of PF in patients with PFS. A literature search was performed for the period 2000–2012 using the Science Direct, Scopus, PubMed, CINAHL, Medline, Embase and Springer databases. The key words used were: ultrasound, sonography, imaging techniques, ultrasonography, interventional ultrasonography, plantar fascia and plantar fasciitis. The literature search yielded 34 relevant studies. Sixteen studies evaluated the effect of different interventions on PF thickness in patients with PFS using US; 12 studies compared PF thickness between patients with and without PFS using US; 6 studies investigated the application of US as a guide for therapeutic intervention in patients with PFS. There were variations among studies in terms of methodology used. The results indicated that US can be considered a reliable imaging technique for assessing PF thickness, monitoring the effect of different interventions and guiding therapeutic interventions in patients with PFS.