Pneumatosis in cervical fascial space and necrotizing fasciitis of neck.

BACKGROUD: Pneumatosis in the cervical fascial space is a common imaging manifestation of cervical necrotizing fasciitis. At present, although there are some literature reports on pneumatosis in the cervical necrotizing fasciitis, there are few comparative reports. OBJECTIVE: To compare the imaging findings of necrotizing fasciitis of the neck and other cervical space infections, and explore the relationship between pneumatosis in cervical fascial space and necrotizing fasciitis of the neck. METHODS: A retrospective study was conducted on 56 cases of cervical fascia space infection in our department from May 2015 to March 2021, including 22 cases of necrotizing fasciitis and 34 cases of non-necrotizing fasciitis. 22 cases underwent incision, debridement and catheter drainage in the necrotizing fasciitis group. 26 cases underwent incision, debridement and catheter drainage, and 8 cases underwent ultrasound-guided puncture biopsy and catheter drainage in the non-necrotizing fasciitis group. All cases were confirmed by operation or pathological biopsy and took purulent secretions for bacterial culture and drug sensitivity test during or after operation. All cases were examined by neck CT or MRI before operation. The previous history of surgical incision or puncture and the rupture of cervical space infection were excluded. RESULTS: In 22 cases of necrotizing fasciitis, there were 19 cases had air accumulation in the fascial space (86.4%); In 34 cases of non necrotizing fasciitis, 2 cases had air accumulation in the fascial space (5.9%). There was significant difference between the two groups (χ2 = 36.9141, p < .01). Bacterial culture results were positive in 18 (81.8%) patients in the necrotizing fasciitis group. In the non necrotizing fasciitis group, 12 (35.3%) patients had positive bacterial culture results. There was significant difference in the positive rate of bacterial culture between the two groups (χ2 = 11.6239, p < .01). Except one death in necrotizing fasciitis group, all other patients were cured. There was no recurrence after follow-up for 3-6 months. CONCLUSIONS AND SIGNIFICANCE: The pneumatosis of necrotizing fasciitis in the neck is dramatically more than that of other infectious diseases. It is suggested that pneumatosis in cervical fascial space is of great significance in the diagnosis of cervical necrosis, the gas production of bacteria may be closely related to the pathogenesis and development of necrotizing fasciitis of the neck, and early measures to block the generation and dissemination of gas is of great significance for treatment.

A necrotising fasciitis: case report.

Necrotizing fasciitis is one of the most common soft tissue infections, with a high risk of major amputation and a mortality ranging from 6 to 33% which has not changed in the past 20 years. Early surgical resection of necrotic tissue plays a key role in determining the prognosis. Nawijn et al. identified an optimal 6 hours window from presentation to surgery. Symptoms of necrotizing fasciitis mimic those of common skin infections, such as erysipelas and cellulitis, making rapid surgical management difficult. In this context, the aid of point-of-care-ultrasound is a valuable tool for early diagnosis, detecting the presence of subcutaneous thickening, gas and perifascial liquid. Other characteristic ultrasound findings include the "cobblestone" appearance of the subcutaneous soft tissues and reverberation artifacts due to hyperechoic outbreaks, defined as "snow globes" due to the presence of heterogeneous swirling material, and "dirty shadowing" due to the foggy shadow created by the gas.

Point-of-care ultrasonography in diagnosing necrotizing fasciitis-a literature review.

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressive necrosis of the fascial layer with a high mortality rate. It is a life-threatening medical emergency that requires urgent treatment. Lack of skin finding in NF made diagnosis difficult and required a high clinical index of suspicion. The use of ultrasound may guide clinicians in improving diagnostic speed and accuracy, thus leading to improved management decisions and patient outcomes. This literature search aims to review the use of point-of-care ultrasonography in diagnosing necrotizing fasciitis. METHOD: We searched relevant electronic databases, including PUBMED, MEDLINE, and SCOPUS, and performed a systematic review. Keywords used were "necrotizing fasciitis" or "necrotising fasciitis" or "necrotizing soft tissue infections" and "point-of-care ultrasonography" "ultrasonography" or "ultrasound". No temporal limitation was set. An additional search was performed via google scholar, and the top 100 entry was screened. RESULTS: Among 540 papers screened, only 21 were related to diagnosing necrotizing fasciitis using ultrasonography. The outcome includes three observational studies, 16 case reports, and two case series, covering the period from 1976 to 2022. CONCLUSION: Although the use of ultrasonography in diagnosing NF was published in several papers with promising results, more studies are required to investigate its diagnostic accuracy and potential to reduce time delay before surgical intervention, morbidity, and mortality.

POINT-OF-CARE ULTRASOUND IN THE EARLY DIAGNOSIS OF NECROTIZING FASCIITIS.

OBJECTIVE: The aim: To detect the ultrasonographic signs of necrotizing fasciitis (NF) suitable for its early diagnosis. PATIENTS AND METHODS: Materials and methods: Eigty two patients with soft tissue infection, including 14 with necrotizing faciitis, were examined by ultrasonography at the admission. Ultrasonografic features were compared to intraoperative findings by the same surgeon. RESULTS: Results: The thickening of subcutaneous tissue had high sensitivity (100%), but low specificity (5.8%). The hypoechoic and hyperechoic zones had the shape of "cobblestone" with sensitivity - 78.5%, specificity - 33.8%. Higher specificity (69.1%) had sign of "cobblestone separation" on two layers. The presence of fluid above the fascia (sensitivity - 71.4%; specificity - 69.1%), thickening of the fascia (sensitivity - 85.7%; specificity - 58.8%), indistinctness of the fascia edges (sensitivity - 85.7%; specificity - 66.1%) and loss of fascial homogeneity (sensitivity - 71.4%, specificity - 66.1%) were noted in early stages of NF. Advanced cases of NF were accompanied by the dissection of thick¬ened fascia with a strip of fluid (sensitivity - 57.1%, specificity - 92.6%) and accumulation of a fluid under the fascia (sensitivity - 28.5%, specificity - 95.5%). The muscles thickening (sensitivity - 28.5%; specificity - 67.6%), skin thickening (sensitivity - 57.1%; specificity - 58.8%), and loss of the skin's lower edge clarity (sensitivity - 57.1%; specificity - 63.2%) don't have diagnostic value without other signs of NF. CONCLUSION: Conclusions: Point-of-care ultrasonography allows visualization of soft tissue changes that may be hidden in the initial stages of necrotizing fasciitis and should be recommended for implementation as mandatory method of examination in patients with suspected surgical soft tissue infection.

Pyoderma Gangrenosum Mimicking Necrotizing Fasciitis on Magnetic Resonance Imaging: A Case Report and Literature Review.

BACKGROUND Pyoderma gangrenosum (PG) is a sterile neutrophilic dermatosis that can be associated with systemic diseases, such as ulcerative colitis, polyarthritis, diabetes mellitus, myelodysplastic syndrome, and/or myeloid leukemia, and is often misdiagnosed as a necrotizing infection. Few reports have described imaging studies of PG; however, necrotizing fasciitis (NF) exhibits distinct imaging characteristics. If deep fascial involvement is not demonstrated on magnetic resonance imaging (MRI), NF is excluded. CASE REPORT We present a case of PG mimicking NF on MRI in a 67-year-old woman with acute myeloblastic leukemia. After undergoing a second cycle of decitabine therapy, she was admitted for pain in her lower left leg. The condition was initially misdiagnosed as NF because MRI findings demonstrated signal intensity in the fascia. MRI revealed fasciitis that exhibited linear fluid signal intensity in the fascia of lower left leg. Despite broad-spectrum antibiotics, the lesion rapidly progressed to a swollen hemorrhagic patch with bullae and an ulcer. Skin biopsy results ultimately led to the diagnosis of PG, based on histopathological findings. The patient was treated with intravenous steroids and regular wound dressing. The skin lesion on the lower left leg exhibited a good response. CONCLUSIONS Despite the presence of a lesion that invaded the fascia on MRI, our patient was diagnosed with PG following a skin biopsy and completely recovered with steroid treatment. To distinguish PG from NF, it is more important to identify the characteristic clinical features than to rely solely on imaging findings.

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection requiring prompt diagnosis and immediate surgical debridement. Imaging, including a computed tomography (CT) scan, can often aid in the diagnosis, though it can prolong time to treatment and diagnosis. Point-of-care ultrasound (POCUS) is often used in the ED to identify soft tissue infections. The objective of this study is to evaluate the use of POCUS to identify NF in patients presenting to the emergency department. METHODS: We prospectively enrolled patients who presented to the emergency department (ED) with suspected soft tissue infection who received a computed tomography and/or surgical consult. POCUS images of the suspected site of infection were obtained by the emergency medicine physician and interpreted based on sonographic findings of NF. These findings were compared with CT scan or surgical impression. RESULTS: We enrolled 64 patients in this study. Eight were determined to be at high risk of having NF based on CT scan and/or surgical impression. All of these patients also had POCUS images interpreted as concerning for NF. Furthermore, 56 patients were classified as being low risk for having NF based on CT scan and/or surgical impression. All but one of these patients had POCUS images interpreted as not concerning for NF. CONCLUSIONS: Our data indicates that POCUS can be used to identify NF with a high sensitivity and specificity.

Neonatal Fournier's Gangrene: Avoiding Extensive Debridement.

Fournier's gangrene is a necrotizing fasciitis of the scrotal and inguinal region, associating high mortality and complication rates. It is extremely rare in the neonatal period and may be life threatening. We present an exceptional case of a 24-day-old boy who consulted to the emergency department for fever (39 °C) and an indurated, fluctuating and painful erythema in both groins, left hemiscrotum, left anterior femoral region and perineum for the last 6 hours. Blood analysis showed increased acute phase reactants without leukocytosis. Ultrasound revealed significant soft-tissue involvement. Due to high clinical suspicion and hemodynamic instability (tachycardia and prolonged capillary filling), urgent fasciotomy, placement of Penrose drains and intensive irrigation was performed. Wound care with irrigations was performed 3 times a day. During the 12 days neonatal intensive care unit admission, he required hemodynamic support and orotracheal intubation and sedation for pain control. Broad-spectrum antibiotic therapy (with cefotaxime, clindamycin and cloxacillin) was administered for 2 weeks. Ampicillin-sensitive Streptococcus pyogenes (Group A) was isolated in blood culture at 4th day of admission allowing antibiotic de-escalation. He was discharged on postoperative day 24. He has minimal, inconspicuous scars and no functional sequelae. Fever in neonates requires close observation considering the use of empirical broad-spectrum antibiotics and hospitalization. Early diagnosis, prompt surgical management and broad-spectrum antibiotic therapy are essential to prevent complication. Early fasciotomy with intensive irrigation and close survey may avoid extensive skin debridement.

[Necrotizing Fasciitis of the Right Thigh Caused by Emphysematous Pyelonephritis Due to a Staghorn Stone : A Case Report].

We report a rare case of necrotizing fasciitis in the thigh induced by emphysematous pyelonephritis due to a staghorn stone. A 60-year-old female was diagnosed with a staghorn stone in the right kidney at another clinic. We referred her to another hospital for indication of percutaneous nephrolithotripsy. However, she chose not to visit the hospital. One year and three months later, she was transported to the emergencyward of our hospital because of a high fever and right hip joint pain. The diagnosis of right emphysematous pyelonephritis with a perinephric abscess was diagnosed by computed tomography. Transurethral ureteral stenting and percutaneous abscess drainage were performed and her condition improved. However, two weeks after the initial treatment, she developed swelling and pain in the right thigh. Computed tomographyrevealed multiple areas of gas in the right thigh and urgent debridement was performed. Escherichia coli was isolated from the cultures of urine and debrided tissues. The patient received several treatments, including two additional debridements, negative pressure wound therapy, and antimicrobial chemotherapy. Three months after the first debridement, the open wound of the right thigh was completely closed. Necrotizing fasciitis in the thigh due to emphysematous pyelonephritis is very rare. A favorable outcome was obtained byprompt debridement and negative pressure wound therapyin this case.

CT in necrotizing soft tissue infection: diagnostic criteria and comparison with LRINEC score.

OBJECTIVE: To investigate which computed tomography (CT) criteria are most useful in diagnosing necrotizing soft tissue infection (NSTI) and how CT performs with respect to the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. METHODS: Patients who underwent CT for suspected NSTI were eligible for inclusion. LRINEC score was assessed. CT scans were evaluated for subcutaneous edema, fluid along superficial fascia, fluid along deep fascia, blurring of intermuscular fat planes, fluid collection, and air in the soft tissues. Surgical findings or clinical follow-up served as reference standard. RESULTS: Fourteen patients with NSTI and 34 patients with non-NSTI were included. LRINEC score was significantly higher in patients with NSTI (median of 7.5 vs. 6, p = 0.039). Fluid along the deep fascia was significantly more frequently present in patients with NSTI (46.2% vs. 5.9%, p = 0.001). In multiple logistic regression analysis, presence of fluid along the deep fascia was significantly associated with NSTI (odds ratio [OR] = 10.28, 95% CI: 1.57 to 67.18, p = 0.015), whereas the LRINEC score was not significantly associated with NSTI (OR = 1.27, 95% CI: 0.92 to 1.74, p = 0.146). Using presence of fluid along the deep fascia as diagnostic criterion for NSTI, sensitivity was 46.2% (95% CI, 23.2 to 70.9%) and specificity was 94.1% (95% CI, 80.9 to 98.4%). CONCLUSION: Fluid along the deep fascia was the only CT criterion which was significantly associated with NSTI and appeared more useful than the LRINEC score. In the right clinical setting, presence of this CT finding is highly suggestive for NSTI. Its absence, however, does not rule out NSTI. KEY POINTS: • The presence of fluid along the deep fascia at CT is highly suggestive for NSTI in suspected patients. Its absence, however, does not rule out NSTI. `• The use of fluid along the deep fascia as a criterion appears to be more useful than the LRINEC score in diagnosing NSTI.

Emergency amputation necessitated within 24 hours by a human bite: a case report.

We herein review and analyze the diagnosis, treatment, and outcome of a severe infection caused by a human bite. A 68-year-old man was bitten on the forearm by a 3-year-old child. Rapid progression of infection, severe local and systemic poisoning, and diverse clinical manifestations were observed at presentation. Based on the medical history, physical signs, imaging examinations (X-ray films, color Doppler ultrasound, and computed tomography), laboratory examinations, and multidisciplinary consultation, the patient was diagnosed with gas gangrene or gas gangrene-like changes. Twenty-four hours after the injury, an emergency amputation was performed (open amputation with wound closure after 1 week). After the operation, the patient was sent to the intensive care unit for isolation and further anti-infection and anti-shock treatments. His condition gradually improved after treatment and he was discharged without further complications. Bacteriological and pathological examinations indicated Aeromonas hydrophila infection leading to extensive necrotizing fasciitis of the limb and severe systemic poisoning. In addition, pre-existing myelodysplastic syndrome progressing to acute myeloid leukemia was identified as a possible predisposing factor. Human bites can cause serious infections requiring timely treatment, particularly in patients with predisposing comorbidities.

Rectal Perforation by an Intrauterine Device Leading to Fatal Intra-Abdominal Sepsis and Necrotizing Fasciitis.

BACKGROUND: Colorectal injury from an intrauterine device (IUD) is rare but may lead to major complications. CASE: A 55-year-old woman presented to a tertiary care hospital with 4 days of generalized weakness, confusion, dysuria, and lower back pain. She provided a vague history of an unsuccessful attempt to remove an IUD 30 years prior. A computed tomography scan demonstrated an IUD in the rectal lumen, with gluteal and pelvic gas and fluid collections. Emergency surgery found necrotizing fasciitis. Despite multiple debridements, sigmoidoscopic IUD removal, and long-term intravenous antibiotics, the patient died from sepsis and multiorgan failure. CONCLUSION: IUDs require proper monitoring and timely removal to prevent potential complications associated with organ perforation.

Imaging and Laboratory Workup for Hand Infections.

Hand infections can lead to significant morbidity if not treated promptly. Most of these infections, such as abscesses, tenosynovitis, cellulitis, and necrotizing fasciitis, can be diagnosed clinically. Laboratory values, such as white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and recently, procalcitonin and interleukin-6, are helpful in supporting the diagnosis and trending disease progression. Radiographs should be obtained in all cases of infection. Ultrasound is a dynamic study that can provide quick evaluation of deeper structures but is operator dependent. Computed tomographic and MRI studies are useful for evaluating deep space or bony infections and preoperative surgical planning.

Air entrapment resembling necrotising fasciitis as a frequent incident following total hip arthroplasty.

In combination with pain and elevated inflammatory parameters that are frequently observed following elective total hip arthroplasty (THA), air entrapment on radiographic images could be indicative of necrotising fasciitis. The aim of the present study was to analyse presence/extent of air entrapment following THA, and to correlate radiological with clinical findings. One-hundred patients undergoing short-stem elective THA (ANA NOVA Alpha Proxy-system) were prospectively included. Patients received pre- and postoperative x-rays (day 1 + discharge) of the affected hip, together with a CT-scan of the lower extremity (discharge). C-reactive-protein-(CRP), leukocyte, haemoglobin-, creatinine-, glucose-, sodium-levels - and based on these the LRINEC score- as well as pain-scores (numeral-rating-scale, NRS) at postoperative days 1, 3 and 5 were documented. Air entrapment was visible in 98% of x-rays taken postoperatively and in 93% of CT-scans at discharge. Leukocyte-levels significantly decreased from postoperative day 1 to 5. CRP-levels had a peak at the 3rd postoperative day (p < 0.001). On discharge-x-rays of patients with low body-mass-indexes, air entrapment was significantly more often visible (p = 0.040). Neither implant-related nor laboratory parameters, LRINEC- or NRS-scores significantly correlated with presence/extent of air entrapment (p > 0.05). Considering the high rate of air entrapment following elective THA postoperatively and at discharge, suspicion of an infection with gas-producing bacteria may only be raised in case of persistent inflammatory parameters, deteriorating general condition and signs of local infection.