A case of necrotizing fasciitis caused by coagulase-negative staphylococcus: utility of magnetic resonance imaging for the preoperative diagnosis of necrotizing fasciitis

A 70-year-old woman presented with fever and pain in the right lower extremity. Fat-suppressed gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI) showed contrast-enhanced fascia, fluid accumulation, and hypointense signals in the muscles. Surgical interventions including incisions and insertion of drainage tubes were performed on the basis of the MRI findings. The histopathological examinations of surgically obtained biopsy specimens demonstrated suppurative fasciitis, widespread myonecrosis, and thromboses of the vessels, all of which were compatible with a diagnosis of necrotizing fasciitis. The bacterial cultures were positive for a coagulase-negative staphylococcus. Following the surgical interventions, the patient was successfully treated by aggressive antimicrobial therapy. MRI can thus be useful for differentiating necrotizing fasciitis from nonnecrotizing soft tissue infection and for planning the treatment of necrotizing fasciitis.     

Dermohypodermites bactériennes nécrosantes et fasciites nécrosantes : chez l’enfant aussi !

Necrotizing soft tissue infection in children with or without necrotizing fasciitis is a rare bacterial infection. Varicella and trauma represent the most frequent predisposing factors. These infections must be early diagnosed, before the occurrence of any complication, including extension necrosis of soft tissue and septic shock. Magnetic resonance imaging and computed tomography-scan are helpful to delimit necrosis extent in deeper tissues. However, indications should be discussed according to infection localisation and imaging timing should not delay appropriate care. Group A β-hemolytic streptococcus is the most common microorganism associated with these infections, although incidence of Staphylococcus aureus is increasing. Death occurs in 5–20% of patients. Good prognosis is related to early diagnosis, antibiotic treatment and surgery. This emergent multidisciplinary approach is sometimes difficult to manage in paediatrics because of the rarity of these infections.     

Necrotizing fasciitis of cryptoglandular infection treated with multiple incisions and thread-dragging therapy: A case report

BACKGROUNDNecrotizing fasciitis is a fulminant necrotizing soft tissue disease with a high fatality rate. It always starts with impact on the deep fascia rapidly and might result in secondary necrosis of the subcutaneous tissue, fascia, and muscle. Thus, timely and multiple surgical operations are needed for the treatment. Meanwhile, the damage of skin and soft tissue caused by multiple surgical operations may require dermatoplasty and other treatments as a consequence. CASE SUMMARYHere, we report a case of 50-year-old male patient who was admitted to our hospital with symptoms of necrotizing fasciitis caused by cryptoglandular infection in the perianal and perineal region. The symptoms of necrotizing fasciitis, also known as the cardinal features, include hyperpyrexia, excruciatingly painful lesions, demonstration gas in the tissue, an obnoxious foul odor and uroschesis. The results of postoperative pathology met the diagnosis. Based on the premise of complete debridement, multiple incisions combined with thread-dragging therapy (a traditional Chinese medicine therapy) and intensive supportive therapies including comprising antibiotics, nutrition and fluids were given. The outcome of the treatment was satisfactory. The patient recovered quickly and achieved ideal anal function and morphology. CONCLUSIONTimely and effective debridement and multiple incisions combined with thread-dragging therapy are an integrated treatment for necrotizing fasciitis.     

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: 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.     

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.     

Necrotizing fasciitis

Necrotizing fasciitis is a synergistic infection caused by aerobic and anaerobic organisms, resulting in liquefaction and necrosis of the fascia. Clinical findings typically include septicemia, anemia and radiographic evidence of gas in the soft tissue. Most patients have a history of diabetes or atherosclerosis. Morbidity and mortality can be reduced by early diagnosis, extensive surgical debridement and aggressive nutritional support.     

Diagnosis of necrotizing fasciitis in children.

Necrotizing fasciitis is a rare but progressive soft tissue infection. This condition is difficult to recognize in the early phase, when it is often confused with cellulitis. We report the cases of four children with necrotizing fasciitis. The initial presentation in these cases was cellulitis. Fever and soft tissue swelling occurred within 24 h and spreading erythema within 4 to 12 h. Radiologic studies of the lesions showed soft tissue thickening. Ultrasonography of the lesions demonstrated distorted, thickened fascia with fluid accumulation. Well-defined, loculated abscesses were demonstrated in two cases. Although typical dusky skin and purplish patches were not found in our cases, necrotizing fasciitis was strongly suspected on the basis of the clinical course and sonographic findings. Ultrasonography also was used as a guide for aspiration of pus. Gram-stained smears and bacterial cultures yielded the pathogens. The choice of antibiotic therapy was made on the results of smears and culture. All patients survived after immediate surgical debridement, intensive antibiotic therapy, and aggressive wound care. In conclusion, ultrasonography provides a rapid and valuable diagnostic modality for necrotizing fasciitis. The pus obtained through sonographically guided aspiration for bacterial culture can allow identification of the pathogenic organisms.     

Necrotizing soft tissue infections

PURPOSE OF REVIEW: The purpose of this review is to consider recent advances in the definition, pathogenesis, diagnostic criteria, and treatment of necrotizing soft tissue infections. RECENT FINDINGS: The efficacy of early surgical debridement combined with antimicrobial therapy, close monitoring and physiologic support is strongly demonstrated. Novel therapeutic strategies including vacuum-assisted wound-closure therapy and intravenous immunoglobulin have been described. SUMMARY: Necrotizing soft-tissue infection is a rare infection of the subcutaneous tissue and fascia that is often associated with sepsis and can progress rapidly with a possible fatal outcome. Although the cause is not yet understood fully, patients often have a prior history of a small, trivial trauma, wound, or scratch. Establishing the diagnosis can be the main challenge in treating patients, and knowledge of all available tools is key for early and accurate diagnosis.     

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 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.     

Necrotizing fasciitis: pathogenesis and treatment

Necrotizing fasciitis is a rapidly progressive, life-threatening infection and a true infectious disease emergency. Despite much clinical experience, the management of this disease remains suboptimal, with mortality rates remaining approximately 30%. Necrotizing fasciitis rarely presents with obvious signs and symptoms and delays in diagnosis enhance mortality. Therefore, successful patient care depends on the physician's acumen and index of suspicion. Prompt surgical debridement, intravenous antibiotics, fluid and electrolyte management, and analgesia are mainstays of therapy. Adjunctive clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulin are frequently employed in the treatment of necrotizing fasciitis, but their efficacy has not been rigorously established. Improved understanding of the pathogenesis of necrotizing fasciitis has revealed new targets for rationally designed therapies to improve morbidity and mortality.     

A fatal case of necrotizing Aeromonas schubertii fasciitis after penetrating injury

Necrotizing fasciitis is an uncommon but life-threatening condition with a high associated mortality and morbidity. Most infections are polymicrobial, another distinct form of necrotizing fasciitis that occurred by penetrating freshwater trauma, such as fishing or wading in wet fields. Aeromonas species are responsible. The rapidity of the infectious process is similar to that of clostridial infection, but gas production is not a consistent feature. We report a patient who presented with fever, chills, and bullae on left forearm, despite antibiotics and wound debridement; the infection extend to mid humerus with a rapid onset of skin necrosis and progressive sepsis. Aeromonas schubertii fasciitis is particularly virulent. An apparent superficial cellulitis that fails to respond to standard therapy must raise suspicion of a more extensive underlying subcutaneous infection. Aggressive surgical debridement and antibiotic coverage for gram-negative rods are the essential features of treatment. Delay caused by a mistaken diagnosis of cellulitis and subsequent inadequate debridement would likely prove fatal.     

Use of drotrecogin alfa in necrotizing fasciitis: a case report and pharmacologic review

Necrotizing fasciitis (NF) is a devastating subset of necrotizing soft tissue infections that requires prompt diagnosis and treatment. Although often occurring in patients with impaired host defense mechanisms (diabetes mellitus, systemic immunosuppression, malignancy, etc.), NF may also present in the immunocompetent following a cutaneous lesion or break. Patients with NF often progress to a systemic inflammatory response syndrome or multiorgan system failure that demands advanced critical care practices. We present a case of NF in an immunocompetent patient and the subsequent use of drotrecogin alfa (Xigris). A review of the pharmacologic treatment of streptococcal NF is included. The addition of drotrecogin alfa to operative debridement and penicillin G/clindamycin therapy may be a useful adjunct in the treatment of necrotizing fasciitis due to group A streptococcus.     

Community-acquired necrotizing fasciitis caused by Acinetobacter calcoaceticus: A case report and literature review

A 61-year-old man presented with pain in the abdomen and right lower limb. He had a history of hepatitis B virus-induced liver cirrhosis, but had not been visiting the outpatient clinic and did not receive any medication. Cutaneous necrosis and bulla were observed on his abdomen and right lower limb. The necrotic skin was incised, and he was diagnosed with necrotizing fasciitis. A nonfermentative Gram-negative bacillus infection was confirmed from aspirated fluid and blood cultures. Therefore, meropenem and immunoglobulins were administered. Because necrosis was widespread, surgical debridement was performed. Thereafter, Acinetobacter calcoaceticus infection was confirmed by semi-quantitative PCR using the bullous fluid and blood cultures. Meropenem was administered for 3 weeks, followed by levofloxacin alone for 1 week. The patient's condition improved; therefore, skin grafting was performed as planned and yielded a favorable response. After rehabilitation, the patient could walk without support and infection did not recur. However, he had severe liver cirrhosis and large esophageal varices, and he eventually died from sudden varix rupture.Necrotizing fasciitis is an uncommon soft tissue infection, associated with high morbidity and mortality, and early recognition and treatment are crucial for survival. Acinetobacter is rarely associated with necrotizing fasciitis. Although this is a very rare case of the occurrence of necrotizing fasciitis due to A. calcoaceticus infection, we believe that this organism can be pathogenic in immunocompromised patients such as those with liver cirrhosis by reporting this case.     

Experience with necrotizing fasciitis at a burn care center

Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated at the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered at a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0-60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died, with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.     

A case of fatal necrotizing fasciitis after intramuscular administration of diclofenac.

Necrotizing fasciitis is a rapidly progressive soft tissue infection that involves subcutaneous fat and spreads along the fascial planes. This disease has a potentially fatal outcome if not recognized in early. Several cases have been reported of a possible association between the use of non-steroidal anti-inflammatory drugs (NSAIDs) and the development or aggravation of necrotizing fasciitis. This association is still a subject of controversy. In this article we present a case of fatal necrotizing fasciitis occurring in association with intramuscular injections of diclofenac in a patient who was admitted for the symptoms of a urinary stone. Our opinion is that the intramuscular injections caused a locally aseptic necrosis, which was secondarily invaded by. Since this incident, our policy is to avoid the use of intramuscular injections of diclofenac and other NSAIDs in cases of potentially infectious diseases.     

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 soft tissue infections: a guide to early diagnosis and initial therapy

Necrotizing skin and soft tissue infections are caused by many different bacteria, are frequently polymicrobial, and may have a deceptively innocent early clinical presentation. Clostridial and nonclostridial necrotizing infections are frequently similar in their early presentation. The initial presentation of these infections can be insidious, which results in delay in diagnosis and the start of therapy. The clinician must use sound medical principles of clinical history and meticulous examination in each patient, combined with constant suspicion, to establish a timely diagnosis. This group of infectious diseases is associated with frequent morbidity and significant mortality rates, which increase with any delay in the diagnosis and the initiation of medical and surgical therapy. Also associated with these necrotizing infections is an excessive index of litigation. This review is intended as a guide for the clinician in making an early diagnosis of any necrotizing skin and soft tissue infection and initiating effective medical and surgical therapy.