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AIMS: Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area and presents a high mortality rate. The aim was to assess prognostic factors for mortality, create a new mortality predictive scale and compare it with previously published scales in patients diagnosed with FG in our Emergency Department. METHODS: Retrospective analysis study between 1998 and 2012. RESULTS: Of the 59 patients, 44 survived (74%) (S) and 15 died (26%) (D). Significant differences were found in peripheral vasculopathy (S 5 [11%]; D 6 [40%]; P=.023), hemoglobin (S 13; D 11; P=.014), hematocrit (S 37; D 31.4; P=.009), white blood cells (S 17,400; D 23,800; P=.023), serum urea (S 58; D 102; P<.001), creatinine (S 1.1; D 1.9; P=.032), potassium (S 3.7; D 4.4; P=.012) and alkaline phosphatase (S 92; D 133; P=.014). Predictive scores: Charlson index (S 1; D 4; P=.013), severe sepsis criteria (S 16 [36%]; D 13 [86%]; P=.001), Fournier's gangrene severity index score (FGSIS) (S 4; D 7; P=.002) and Uludag Fournier's Gangrene Severity Index (UFGSI) (S 9; D 13; P=.004). Independent predictive factors were peripheral vasculopathy, serum potassium and severe sepsis criteria, and a model was created with an area under the ROC curve of 0.850 (0.760-0.973), higher than FGSIS (0.746 [0.601-0.981]) and UFGSI (0.760 [0.617-0.904]). CONCLUSIONS: FG showed a high mortality rate. Independent predictive factors were peripheral vasculopathy, potassium and severe sepsis criteria creating a predictive model that performed better than those previously described.
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Gangrena de Fournier/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos RetrospectivosRESUMO
BACKGROUND: Necrotising fasciitis is a potentially life-threatening soft tissue infection that mainly affects the fascia and deep planes, with a very high mortality rate and severe related complications. AIM: To evaluate clinical and demographic characteristics of patients with necrotising fasciitis in our hospital and to describe their diagnostic and therapeutic management. MATERIAL AND METHODS: Retrospective review of medical records of 21 patients diagnosed with necrotising fasciitis with limb involvement between January 2003 and February 2021 in our hospital. Demographic data, clinical features and details of management and prognosis were collected for each patient. RESULTS: Of 21 patients included, 15 were male (71.43%), with a mean age at diagnosis of 54.38±19.55 years. The most frequent comorbidities were insulin-dependent diabetes mellitus in seven patients (33.33%) and a history of cancer in five patients (23.81%). Infection was monomicrobial in 14 cases (66.66%), with Streptococcus pyogenes being the most frequent microorganism; multiple pathogens were isolated in 2 patients (9.52%) and no microorganism was identified in 5 patients (23.81%). All patients underwent surgery at our hospital, with a mean of 4.14±3.98 surgeries. Only one patient underwent amputation of the affected limb. The mean hospital stay was 23.14±16.44 days, with an overall mortality of 47.62% (10 cases). CONCLUSIONS: Despite being a rare disease, necrotising fasciitis is a very aggressive pathology, with a high mortality rate, especially in immunocompromised patients. Advanced age and oncological disease are potential factors of worse prognosis in the evolution of this condition.
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BACKGROUND AND OBJECTIVE: To assess the usefulness of a risk scale based on serum procalcitonin (PCT) compared to the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scale in the early discrimination between necrotising fasciitis (NF) and cellulitis of the extremities. MATERIALS AND METHODS: Retrospective study of consecutive patients with confirmed diagnosis of NF in one limb (n=11). This study group was compared with 23 consecutive patients with a diagnosis of severe limbs cellulitis during the same period. The clinical data and laboratory parameters were analysed, the main variable was the serum level of PCT upon admission. The capacity for NF diagnosis of the two methods, PCT level and LRINEC scale score, were evaluated by ROC curve and determined by the calculation of the area under the curve (AUC). RESULTS: The AUC was significantly higher with PCT measurement, both as a continuous variable and when the risk was categorised. The cut-off point for the PCT level with the highest AUC under the curve was from 0.87ng/ml (sensitivity 90.9%, specificity 82.6%), whereas it was a score of 5 on the LRINEC scale (sensitivity 72.7%, specificity 82.6%). CONCLUSION: PCT measurement was a more effective method than the LRINEC score for early discrimination between NF and cellulitis of the extremities. A low level of PCT, associated with the patient's clinical status and physical examination is especially useful to rule out an early diagnosis of NF.
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Celulite (Flegmão)/sangue , Celulite (Flegmão)/diagnóstico , Fasciite Necrosante/sangue , Fasciite Necrosante/diagnóstico , Pró-Calcitonina/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Diagnóstico Diferencial , Diagnóstico Precoce , Extremidades , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Adulto JovemRESUMO
An 80 year-old woman with no relevant medical history, consulted for worsening of right palpebral itching and pain after an insect bite. Her eyelids had areas of laceration due to scratching, which rapidly progressed to fibrinoid necrosis over the first 24hours. Lesions were cultivated, revealing Streptococcus pyogenes and Staphylococcus aureus. The patient was admitted to hospital with the diagnosis of periorbital necrotising fasciitis, in order to receive treatment with intravenous ceftriaxone, linezolid, and immediate surgical debridement. She remained in hospital for 17 days. Daily wound management consisted of debridement of necrotic remains, disinfection with chlorhexidine, and wound dressing with mupirocin, sulfadiazine, and miconazole ointments. The patient suffered streptococcal toxic shock syndrome, but she recovered over the first week. Palpebral reconstruction was performed on day 15, consisting of a preauricular total thickness skin graft for the superior eyelid, and lateral malar advancement to cover the lower eyelid. Adequate cosmetic and functional results were obtained.
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Fasciite Necrosante/etiologia , Mordeduras e Picadas de Insetos/complicações , Lacerações/etiologia , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Desbridamento , Fasciite Necrosante/terapia , Feminino , Humanos , Infecções Estafilocócicas/diagnóstico , Staphylococcus aureus/isolamento & purificação , Infecções Estreptocócicas/diagnóstico , Streptococcus pyogenes/isolamento & purificaçãoRESUMO
La fascitis necrosante es una enfermedad rara y potencialmente mortal, que se produce por una infección grave que se disemina desde las fascias superficiales destruyendo el tejido celular subcutáneo y la piel suprayacente. Las formas perioculares de la enfermedad son aún más raras y pueden tener graves consecuencias para el paciente. El objetivo de este estudio fue contrastar los hallazgos clínicos y los resultados terapéuticos en una serie de cuatro casos diagnosticados en el Centro Oftalmológico de Holguín en el curso de cinco años. Entre 2017 y 2022 se diagnosticaron cuatro pacientes con formas perioculares de fascitis necrosante en el Centro Oftalmológico de Holguín. Dos pacientes tuvieron antecedentes de trauma menor. El dolor predominó entre los síntomas locales. Se identificaron dos patrones de lesiones: bilateral con ulceración y afectación de la región palpebral superior y unilateral con extensión en ambos párpados y apariencia oscura de la piel. Los pacientes evolucionaron a la gravedad con deterioro del estado general. El desbridamiento del tejido necrótico y el tratamiento con antibióticos de amplio espectro permitieron detener el progreso de la enfermedad, aunque quedaron secuelas anatómicas y funcionales. Un paciente falleció como consecuencia de una leucemia diagnosticada durante su ingreso. El reconocimiento temprano de la fascitis necrosante periocular y su inmediato tratamiento es indispensable para garantizar resultados óptimos y la supervivencia del paciente. Las formas perioculares pueden tener apariencia clínica diversa, lo que debe ser tenido en cuenta ante la sospecha de este cuadro, sobre todo por la similitud inicial con la celulitis preseptal(AU)
Necrotizing fasciitis is a rare and potentially fatal disease caused by a severe infection that spreads from the superficial fasciae destroying the subcutaneous cellular tissue and overlying skin. Periocular forms of the disease are even rarer and can have serious consequences for the patient. The aim of this study was to contrast clinical findings and therapeutic outcomes in a series of four cases diagnosed at the Holguin Ophthalmology Center over the course of five years. Between 2017 and 2022, four patients with periocular forms of necrotizing fasciitis were diagnosed at the Holguín Ophthalmologic Center. Two patients had a history of minor trauma. Pain predominated among the local symptoms. Two patterns of lesions were identified: bilateral with ulceration and involvement of the upper palpebral region and unilateral with extension in both eyelids and dark appearance of the skin. Patients progressed to severity with deterioration of general condition. Debridement of necrotic tissue and treatment with broad-spectrum antibiotics halted disease progression, although anatomical and functional sequelae remained. One patient died as a result of leukemia diagnosed during his admission. Early recognition of periocular necrotizing fasciitis and its immediate treatment is essential to ensure optimal outcome and patient survival. Periocular forms can have different clinical appearances, which should be taken into account when suspecting this condition, especially due to the initial similarity with preseptal cellulitis(AU)
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Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Fasciite Necrosante/epidemiologia , Desbridamento/métodosRESUMO
We present a case of necrotizing fasciitis in a 66-year-old Caucasian woman with rheumatoid arthritis receiving tocilizumab, and provide a review of published cases. The patient exhibited no systemic symptoms and discreet cutaneous inflammatory signals at presentation. She was successfully treated with broad-spectrum empiric antibiotic therapy and surgical debridement.
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Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Fasciite Necrosante/induzido quimicamente , Idoso , Antibacterianos/uso terapêutico , Anticorpos Monoclonais Humanizados/administração & dosagem , Antirreumáticos/administração & dosagem , Terapia Combinada , Desbridamento , Fasciite Necrosante/tratamento farmacológico , Fasciite Necrosante/cirurgia , Feminino , Humanos , Imunossupressores/uso terapêuticoRESUMO
SUMMARY: Cervical necrotizing fasciitis (NF) is a rare complication of oral cavity infection with high morbi-mortality. Given its low prevalence, adequately reporting cases of NF, its therapeutic management, and associated morphofunctional modifications to the clinical and scientific community is pivotal. To that end, we herein describe a case of cervical NF in a 60-year-old patient with comorbidities and patient presented large, painful cervical swelling associated with a necrotic ulcer lesion in the anterior neck region. Intraoral examination indicated a periodontal abscess in the right mandibular area, while computed tomography indicated the lesion's extension from the right mandibular to the submandibular region. Following empirical intravenous antibiotic treatment, a broad surgical debridement was performed, and the foci of oral infection were removed. Debridement revealed communication between deep and superficial anatomical regions in the submandibular area, where we subsequently placed a Penrose drain. Biopsies showing acute inflammatory infiltrate associated with necrotic and hemorrhagic regions confirmed the diagnosis of NF. When an antibiogram revealed resistance to the empirical treatment, the antibiotic scheme was replaced with an adequate alternative. After a second debridement, we closed the defect with fascio-mucocutaneous advancement flaps with a lateral base while maintaining suction drainage. Having reacted positively, the patient was discharged 10 days after the operation. Despite an extensive morphofunctional change generated in the treated area, the patient showed no difficulties with breathing, phonation, swallowing, or mobilizing the area during control sessions. Altogether, this report contributes to the highly limited literature describing morphological aspects that can facilitate or delay the spread of infection or the morphofunctional disorders associated with the size and depth of surgical interventions for cervical NF, information that is relevant for the comprehensive, long-term prognosis of the treatment of NF.
La fascitis necrosante (FN) cervical es una rara complicación de una infección proveniente de la cavidad bucal asociada a una alta morbimortalidad. Por lo anterior, es fundamental informar a la comunidad clínica y científica los casos de FN, su manejo terapéutico y las modificaciones morfofuncionales asociadas. Se describe un caso de FN cervical en una paciente de 60 años quien presentó una gran tumefacción dolorosa asociada a una lesión ulcerosa necrótica en la región anterior del cuello. El examen intraoral mostró un absceso periodontal en el área mandibular derecha y la tomografía computarizada mostró la extensión de la lesión hacia la región submandibular. Tras el tratamiento antibiótico empírico, se realizó un desbridamiento quirúrgico extenso y se extirparon los focos de infección oral. El desbridamiento reveló comunicación entre las regiones anatómicas profundas y superficiales del área submandibular, donde se colocó un drenaje Penrose. Las biopsias mostraron un infiltrado inflamatorio agudo asociado con regiones necróticas y hemorrágicas, confirmando el diagnóstico de FN. El antibiograma reveló resistencia al tratamiento empírico, por lo que el esquema antibiótico se sustituyó. Tras un segundo desbridamiento, se cerró el defecto con colgajos de avance fascio-mucocutáneos de base lateral manteniendo drenaje aspirativo. El positivo progreso del paciente permitió su alta 10 días después. Aun cuando se generó una gran modificación morfofuncional en el área tratada, la paciente no presentó dificultades para respirar, hablar, deglutir o movilizar el área cervical intervenida durante las sesiones de control. Este informe contribuye a la limitada literatura que describe los aspectos morfológicos que pueden facilitar o retrasar la propagación de la FN y las consecuencias asociadas a los trastornos morfofuncionales provocadas por el tamaño y profundidad de las intervenciones quirúrgicas requeridas por la FN, información relevante para el pronóstico integral a largo plazo del tratamiento de la FN.
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Humanos , Feminino , Pessoa de Meia-Idade , Fasciite Necrosante/cirurgia , Abscesso Periodontal/complicações , Resultado do Tratamento , Fasciite Necrosante/etiologia , Fasciite Necrosante/microbiologia , Fasciite Necrosante/patologia , Recuperação de Função Fisiológica , Desbridamento , Pescoço/cirurgia , Pescoço/patologiaRESUMO
BACKGROUND: Diverticular disease, and the diverticulitis, the main complication of it, are widely studied diseases with multiple chronic cases reported in the literature, but there are no atypical presentations with extra-abdominal symptoms coupled with seemingly unrelated entities, such as necrotising fasciitis. CLINICAL CASE: Female 52 years old, was admitted to the emergency department with back pain of 22 days duration. History of importance: Chronic use of benzodiazepines intramuscularly. Physical examination revealed the presence of a gluteal abscess in right pelvic limb with discoloration, as well as peri-lesional cellulitis and crepitus that stretches across the back of the limb. Fasciotomy was performed with debridement of necrotic tissue. Progression was torpid with crackling in abdomen. Computed tomography showed free air in the cavity, and on being surgically explored was found to be complicated diverticular disease. DISCUSSION: It is unusual for complicated diverticular disease to present with symptoms extra-peritoneal (< 2%) and even more so that a diverticulitis is due to necrotising fasciitis (< 1%). The absence of peritoneal manifestations delayed the timely diagnosis, which was evident with the crackling of the abdomen and abdominal computed tomography scan showing the parietal gaseous process. CONCLUSION: All necrotising fasciitis needs an abdominal computed tomography scan to look for abdominal diseases (in this case diverticulitis), as their overlapping presentation delays the diagnosis and consequently the treatment, making a fatal outcome inevitable.
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Doença Diverticular do Colo/complicações , Fasciite Necrosante/etiologia , Perfuração Intestinal/etiologia , Abscesso/complicações , Nádegas , Celulite (Flegmão)/etiologia , Desbridamento , Doença Diverticular do Colo/cirurgia , Fasciite Necrosante/cirurgia , Fasciite Necrosante/terapia , Fasciotomia , Evolução Fatal , Feminino , Humanos , Perfuração Intestinal/cirurgia , Perna (Membro) , Dor Lombar/etiologia , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Tomografia Computadorizada por Raios XRESUMO
Resumen ANTECEDENTES: La fascitis necrosante es una infección rara del tejido subcutáneo y la fascia que rápidamente puede complicarse y poner en riesgo la vida; por esto siempre debe tenerse en mente la posibilidad de este diagnóstico. OBJETIVO: Describir un caso raro de fascitis necrosante genital aparecida luego de un parto instrumentado. CASO CLÍNICO: Paciente primigesta, de 30 años, con antecedente de infección vaginal por Ureaplasma. El parto instrumentado tuvo lugar a las 39 semanas; se reparó la episiotomía medio-lateral derecha, sin complicaciones, y se dio de alta del hospital a las 48 horas. Al quinto día de puerperio acudió a Urgencias por dolor perineal intenso y fiebre. Durante la auscultación se encontró un hematoma perineal y glúteo derecho, con eritema alrededor, indurado y con crepitación vaginal, con secreción hematopurulenta fétida. Reportes de laboratorio: leucocitosis y anemia. Los cultivos de la herida reportaron infección polimicrobiana. El ultrasonido pélvico evidenció dos colecciones debidamente delimitadas en planos dérmicos y musculares. Se indicó tratamiento con antibióticos de amplio espectro, lavado quirúrgico y desbridamiento quirúrgico diario durante 5 días. Después, se inició la terapia de cierre asistido por vacío (VAC) durante 7 días hasta lograr la granulación. Se continuó con lavados quirúrgicos durante 5 días más. El día 18 posparto se cerró la herida sin complicaciones. A la sexta semana de seguimiento la herida había cicatrizado, sin dolor, ni incontinencia fecal o urinaria: solo hipoestesia de la cicatriz, pero con evolución satisfactoria. CONCLUSIÓN: Lo ideal es establecer el diagnóstico lo más temprano posible para disminuir la morbilidad y mortalidad, ofrecer inmediatamente atención multidisciplanaria que permita conseguir los mejores desenlaces quirúrgicos e incrementar la supervivencia.
Abstract BACKGROUND: Necrotizing fasciitis is a rare infection of the subcutaneous tissue and the fascia that is rapidly progressive and deadly, requiring early and aggressive surgical debridement to decrease mortality. The objective of this study was to describe a rare case of genital necrotizing fasciitis after operative vaginal delivery. CLINICAL CASE: A 30 years old primiparous woman with a history of vaginal infection by Ureaplasma. Instrumented delivery was attended at 39 weeks, repairing right mid-lateral episiotomy without complications and discharge after 48 hours. On the fifth day of the puerperium she went to the emergency department for severe perineal pain and fever, finding perineal hematoma and right gluteus with erythema around, indurated and with vaginal crepitation with fetid hemato-purulent secretion. The laboratories reported leukocytosis and anemia, wound cultures showed polymicrobial infection and pelvic ultrasound diagnosed 2 well-defined collections in dermal and muscular planes. Management was initiated with broad-spectrum antibiotics plus washing and daily surgical debridement for 5 days. Subsequently, it was placed with VAC therapy for 7 days until granulation was achieved; and then, surgical washes were continued for 5 more days. On the 18th day, the wound was closed without complications. In her sixth week of follow-up she has a scarred wound, without pain or fecal or urinary incontinence; only refers to hypoesthesia of the scar, but with satisfactory evolution. CONCLUSION: The ideal is to establish the diagnosis as early as possible to decrease morbidity and mortality, immediately offer multidisciplinary care that allows the best surgical outcomes to be achieved, and increases survival.
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Resumen Introducción: A pesar de la morbilidad significativa asociada a la fascitis necrosante (FN), hay pocas publicaciones al respecto y esta es la serie pediátrica más grande proveniente de Latinoamérica. Objetivo: Describir la epidemiología, características clínicas y microbiología de la FN en niños costarricenses. Pacientes y Métodos: Revisión de registros clínicos y anatomo-patológicos, período abril de 2002 a abril de 2014 en pacientes bajo 13 años de edad. Resultados: Cumplían requisito de inclusión 19/22 pacientes, 12 tenían co-morbilidad: 26% con antecedente de cirugía reciente y 21% eran neonatos. Etiología se documentó en hemocultivos en 26% y mediante cultivo de tejidos en 63% (un tercio de ellos polimicrobianos). Pseudomonas aeruginosa, Escherichia coli y Staphylococcus aureus fueron los agentes etiológicos más comúnmente hallados. La tasa de fatalidad fue de 42%, una de las más altas de la región. Conclusiones: La FN es una patología grave, inusual, asociada frecuentemente a neonatología y pacientes post-quirúrgicos, con etiología mixta que requiere de asociación de antimicrobianos y cirugía precoz. Su letalidad es elevada en nuestro medio, por sobre series previamente publicadas.
Abstract Background: Despite the significant associated morbidity of necrotizing fasciitis (NF), few studies have been published and this is the larger pediatric series in Latin America. Aim: To describe the epidemiology, clinical characteristics and microbiology of NF in Costa Rican children. Methods: Review of clinical and pathological records, period April 2002 to April 2014, in patients under 13 years of age. Results: 19/22 patients met the inclusion requirement, 12 had co-morbidity: 26% with a history of recent surgery and 21% were neonates. Etiology was documented in blood cultures in 26% and by tissue culture in 63% (one third of them polymicrobial). Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus were the three most common etiologic agents. Case fatality rate was 42%, one of the highest in our region. Conclusion: NF is a serious, unusual pathology, frequently associated with neonatology and post-surgical patients, with a mixed etiology that requires the association of antimicrobials and early surgery. Its lethality is high in our setting, over previously published series.
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Humanos , Recém-Nascido , Criança , Fasciite Necrosante/epidemiologia , Pseudomonas aeruginosa , Infecções Estafilocócicas , Staphylococcus aureus , Hospitais PediátricosRESUMO
Resumen ANTECEDENTES: La fascitis necrosante es una infección progresiva poco común, con elevada mortalidad, que puede afectar cualquier parte del cuerpo. En la mayoría de los casos se origina por una infección polimicrobiana, con subsecuente afectación de la fascia superficial, tejido y grasa subcutáneos, nervios, arterias, venas y la fascia profunda. CASO CLÍNICO: Paciente de 28 años, obesa, infectada con VIH, que ingresó al servicio de Obstetricia durante el puerperio, con temperatura de 39 °C, escalofríos y dolor abdominal. En la exploración física se observó una lesión negra-azulada, de bordes definidos, de aproximadamente 40 x 20 cm en el área abdominal, alrededor de la herida quirúrgica, con ampollas y olor fétido. Los estudios de laboratorio reportaron hemoglobina 10 g/L, proteína C reactiva 413 y creatinina 110 mg/dL. Se obtuvo una muestra de las ampollas para cultivo. Al día siguiente se repitieron los exámenes de laboratorio y se encontró hemoglobina 8.5 g/L, proteína C reactiva 516 y creatinina 215 mg/dL; el cultivo resultó positivo para Pseudomonas aeruginosa y Staphylococcus aureus. Se prescribió tratamiento endovenoso con antibióticos y la lesión se intervino quirúrgicamente con debridamiento. La evolución de la paciente fue satisfactoria y no reportó secuelas. CONCLUSIONES: El diagnóstico oportuno de la fascitis necrosante permite su tratamiento temprano y la supervivencia del paciente.
Abstract BACKGROUND: Necrotizing fasciitis is an uncommon progressive infection, with high lethality that can affect any part of the body, caused mostly by a polymicrobial infection affecting the superficial fascia, subcutaneous tissue, subcutaneous fat with nerves, arteries, veins and deep fascia. CLINICAL CASE: A 28-year-old woman with a history of obesity and HIV, admitted to the Obstetrics Service with fever (39° C), chills and abdominal pain. A black-bluish lesion was observed, with defined edges of approximately 40 x 20 cm in the abdominal area, around the surgical wound, with blisters and great stench. Hematological study was carried out Hb: 10 g/L, C-reactive protein: 413, and Creatinine: 110 mg/dL. Culture sample of the ampoules is taken. The next day the complementary ones are repeated and Hb is observed: 8.5 g/L, C-reactive protein: 516, and Creatinine: 215 mg/dL; the result of the culture positive for Pseudomonas aeruginosa y Staphylococcus aureus. Endovenous treatment with antibiotics and surgical treatment was used. We observed satisfactory evolution of the patient without sequelae. CONCLUSIONS: The opportune diagnosis of this pathology allows an early action, with the consequent survival of the patients.
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Las infecciones de piel y tejidos blandos (IPTB) representan la tercera causa de consulta por enfermedad infecciosas a los servicios médicos, después de las infecciones respiratorias y urinarias. Se presenta una guía de práctica clínica (GPC) con 38 recomendaciones basadas en la evidencia, graduadas bajo el sistema SIGN, para el diagnóstico y tratamiento de pacientes adultos con IPTB en el contexto colombiano, posterior a un proceso de adaptación de GPC publicadas y la búsqueda sistemática y síntesis de literatura para la actualización de la evidencia científica. Además, se realizó un consenso de expertos para la evaluación de las potenciales barreras para la implementación de las recomendaciones y la evaluación del grado de recomendación en el contexto local.
Skin and soft tissue infections (SSTI) represent the third leading cause of infectious disease consultation for medical services after respiratory and urinary tract infections. This document generates a clinical practice guideline with 38 recommendations based on evidence, graduated under the SIGN system for the diagnosis and treatment for SSTI infections in adult patients in Colombia, following a process of adaptation of guidelines published, and the systematic search and synthesis of literature for the updating of scientific evidence. In addition, a consensus of experts was made for the evaluation of the potential barriers for the implementation of the recommendations and the evaluation of the degree of recommendation in the local context.
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Humanos , Masculino , Feminino , Adulto , Dermatopatias Infecciosas , Guia de Prática Clínica , Infecções dos Tecidos Moles , Staphylococcus aureus , Colômbia , Fasciite Necrosante , Abscesso , Piomiosite , Terapia de Tecidos Moles , CeluliteRESUMO
Resumen: El síndrome de choque tóxico por Streptococcus se describió por primera vez en 1978 por Todd y su equipo. Éste incluye datos de hipotensión, disoxia celular, aislamiento de Streptococcus pyogenes, así como la inclusión de dos o más de los siguientes criterios: síndrome de dificultad respiratoria aguda, insuficiencia renal, anormalidad hepática, coagulopatía y erupción cutánea con descamación. Es una enfermedad relativamente rara entre niños y adultos; representa una alta mortalidad, la cual oscila de 23 al 70%. En más de la mitad de los casos, se desconoce la causa de entrada de este patógeno al torrente sanguíneo, aunque los pacientes con alcoholismo, en los extremos de la vida, con comorbilidades (como enfermedad renal crónica, insuficiencia hepática y leucemias) y que hayan sido sometidos a esplenectomía son más susceptibles al contagio y a infecciones severas. En los pacientes que desarrollan infecciones de tejidos blandos profundos, como fascitis necrosante o infección intrauterina, el dolor severo es el síntoma inicial más frecuente.
Abstract: Streptococcal toxic shock syndrome was first described by Todd and collaborators in 1978, this syndrome includes hypotension, traces of cellular dysoxia, isolation Streptococcus pyogenes; as well as two or more of the following criteria: acute respiratory distress syndrome, renal failure, liver abnormality, coagulopathy, skin rash with necrosis flaking of soft tissues. It is a relatively rare disease among children and adults, representing a high mortality ranging from 23 to 70%. In more than half of the cases the cause of entry of this pathogen into the bloodstream is unknown, although patients with alcoholism, on the edge of death, with splenectomy, with comorbidities (chronic kidney disease, liver failure, leukemia) are more susceptible to infection, to acquire severe infections and shock. Cutaneous infections usually are followed by minor skin irritations (insect bites), 20% of the cases experience a flu-like syndrome (fever, chills, myalgia and diarrhea). In patients who develop deep soft tissue infections such as necrotizing fasciitis or intrauterine infection, the severe pain is the most common initial symptom of streptococcal TSS.
Resumo: A síndrome do choque tóxico estreptocócico foi descrita pela primeira vez por Todd et al em 1978, incluindo dados sobre hipotensão, disxia celular, isolamento de Streptococcus pyogenes, bem como 2 ou mais dos seguintes critérios: síndrome do desconforto respiratório agudo, insuficiência renal, anormalidade hepática, coagulopatia, erupção cutânea com descamação. É uma doença relativamente rara em crianças e adultos, representa uma alta mortalidade que varia de 23 a 70%. Em mais da metade dos casos, a causa desse patógeno na corrente sanguínea é desconhecida, embora pacientes com alcoolismo, extremos da vida, com esplenectomia e comorbidades (como doença renal crônica, insuficiência hepática, leucemia) sejam mais suscetíveis à infecção e infecções graves. Em pacientes que desenvolvem infecções profundas dos tecidos moles, como fasceíte necrozante ou infecção intra-uterina, a dor intensa é o sintoma inicial mais frequente.
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Introducción: El diagnóstico de fascitis necrosante es muy difícil y precisa un alto grado de sospecha clínica. Debido a la complejidad para diagnosticar esta entidad, en 2004, Wong propone un algoritmo diagnóstico basado en parámetros de laboratorio (escala LRINEC: Laboratory Risk Indicator for Necrotizing Fascitis). Objetivo: Demostrar la utilidad diagnóstica de la escala LRINEC en la fascitis necrosante. Material y Método: Se diseña un estudio prospectivo y descriptivo, tipo serie de casos, en 28 pacientes atendidos en el Servicio de Ortopedia y Traumatología del Hospital General Docente Julio Arístegui Villamil con el diagnóstico de fascitis necrosante, en el período comprendido entre enero de 2000 y junio de 2015. Se calcula el índice LRINEC (Laboratory Risk Indicator for Necrotizing Fascitis), para predecir el riesgo de la enfermedad. Resultado: El índice LRINEC mostró una estratificación de riesgo intermedio (6-7). En los pacientes que sobrevivieron se encontraron menores valores de Proteína C reactiva que los fallecidos (t=9,7). Los pacientes del estudio que fallecieron presentaron niveles de hemoglobina menores que los supervivientes (t=8,5) y valores de creatinina mayores (t=5,5). La media del recuento de leucocitos en ambos grupos se encontró por debajo de 15x109 cels/µl. El área bajo la curva ROC fue de 0,607 (IC95 por ciento=0,47-0,73) para el Score LRINEC de este estudio. El punto de corte tuvo una sensibilidad de 66 por ciento y una especificidad de 75 por ciento. Conclusiones: La escala LRINEC es una herramienta útil cuando se sospecha una fascitis necrosante, pero se suele requerir información adicional para confirmar el diagnóstico(AU)
Introduction: The diagnosis of necrotizing fasciitis is very difficult to make, and requires a high degree of clinical suspicion. Because of the complexity of the diagnosis of this entity, Wong proposed an algorithm based on laboratory parameters in 2004 (LRINEC scale: Laboratory Risk Indicator for Necrotizing Fascitis). Objective: To demonstrate the diagnostic utility of LRINEC scale in necrotizing fasciitis. Material and Method: A descriptive prospective case series study was designed in 28 patients treated in the Department of Orthopedics and Traumatology of the General Teaching Hospital Julio Arístegui Villamil with the diagnosis of necrotizing fasciitis, from January 2000 to June 2015. LRINEC (Laboratory Risk Indicator for Necrotizing Fascitis) score is calculated to predict risk of the disease. Results:LRINEC score showed an intermediate risk stratification (6-7). In the patients that survived, lower C-reactive protein levels than the ones in the deceased patients were found (t=9,7). The patients who were included in the study and died presented lower levels of hemoglobin than the ones who survived (t=8,5), and higher values of creatinine (t=5,5). The average value of leukocytes recount in both groups was below 15x109 cels/µl. The area under the ROC curve was 0,607 (IC95 percent=0,47-0,73) for the LRINEC Score in this study. The cutoff point had a sensitivity of 66 percent and a specificity of 75 percent. Conclusions: LRINEC scale is a useful tool when a necrotizing fasciitis is suspected, but additional information is usually required to confirm the diagnosis(AU)
Assuntos
Humanos , Masculino , Feminino , Algoritmos , Fasciite Necrosante/diagnóstico , Epidemiologia Descritiva , Estudos Prospectivos , Indicadores e Reagentes/métodosRESUMO
Las infecciones necrosantes de tejidos blandos presentan altas tasas de mortalidad. Estas se han relacionado con diferentes causas, incluidas las enfermedades neoplásicas. En la literatura se ha descrito infección necrosante especialmente en pacientes con neoplasias del tracto gastrointestinal bajo. La presentación de este caso clínico tiene como objetivo recordar a los médicos de urgencias la pertinencia de considerar este diagnóstico en pacientes con neoplasias de colon y recto en estadio avanzado y presentar una breve revisión de la literatura.
Necrotizing soft tissue infections have high mortality rates. These infections have been linked to various causes, including those related to neoplastic diseases. The literature has described necrotizing particularly in patients with malignancies of the colon and rectum. The presentation of this case is intended to remind emergency physicians to consider this diagnosis in patients with advanced-stage gastrointestinal tract tumors and to present a brief review of the literature.
Assuntos
Humanos , Masculino , Adulto , Fasciite Necrosante , Neoplasias Retais , Pele/imunologia , Neoplasias do Colo , Infecções dos Tecidos Moles , Serviços Médicos de EmergênciaRESUMO
La gangrena de Fournier es una enfermedad amenazante para la vida, que se caracteriza por fascitis necrosante del área perineal. Afecta con mayor frecuencia a pacientes adultos con inmunosupresión y son pocos los casos reportados en la población pediátrica. El uso de fármacos anti-inflamatorios no esteroideos (AINEs) se ha asociado con fascitis necrosante, probablemente por supresión de la inmunidad durante la infección. Describimos el caso de un paciente con 6 meses de edad sin factores inmu-nosupresores, con gangrena de Fournier, probablemente asociada a la ingesta de AINEs.
Founier's gangrene is a rare but life-threatening disease characterized by necrotizing fasciitis of the perineal area. It mostly affects adult patients with an immunosuppressant factor and there are only a few cases reported in children. Use of nonsteroidal anti-inflammatory drugs has been associated with necrotizing fasciitis probably because of suppressing host immunity during infection. We describe a case of a six month old infant without im-munosuppressant factors, with Founier´s gangrene probably associated with nonsteroidal anti-inflammatory intake.
Assuntos
Humanos , Lactente , Masculino , Anti-Inflamatórios não Esteroides/efeitos adversos , Gangrena de Fournier/induzido quimicamente , Ibuprofeno/efeitos adversos , Infecções por Pseudomonas/induzido quimicamente , Desbridamento , Evolução Fatal , Gangrena de Fournier/diagnóstico , Gangrena de Fournier/cirurgia , Infecções por Pseudomonas/diagnóstico , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa/isolamento & purificaçãoRESUMO
Se presenta el caso de un paciente con gangrena de Fournier o fascitis necrosante. Después de su ingreso en la Unidad de Cuidados Intensivos se le realizó tratamiento quirúrgico precoz (incisión y drenaje amplio de toda la zona afectada así como desbridamiento de la zona de necrosis); se tomó muestra de pus para estudio microbiológico y se comenzó tratamiento antibiótico de inmediato (ceftriaxona, amikacina y metronidazol). Se identificaron como agentes causantes del proceso Pseudomonas aeruginosa y Escherichia coli (sensibles a la ceftriaxona y la amikacina). Como tratamiento coadyuvante, se aplicaron 10 sesiones de cámara hiperbárica y 12 dosis de factor de crecimiento humano recombinante liofilizado, que se infiltraron en el interior de la zona quirúrgica para contribuir al cierre por tercera intención(AU)
This is the case of a patient presenting with Fournier gangrene of necrotizing fasciitis. After admission in Intensive Care Unit (ICU) he undergoes an early surgical treatment (incision and wide drainage of the whole involved zone as well as debridement of necrosis zone); a pus sample was took for microbiologic study and a immediate antibiotic treatment was started (Ceftriaxone, Amikacin and Metronidazole). Pseudomonas aeruginosa and Escherichia coli (sensitive to Ceftriaxone and Amikacin) were identified as the causative agents of process. As adjuvant treatment ten sessions of hyperbaric chamber were applied and twelve dose of lyophilized recombinant human growth factor with infiltration into the surgical zone for the third intention closure(AU)
Assuntos
Humanos , Masculino , Adulto , Fator de Crescimento Epidérmico/efeitos adversos , Fasciite Necrosante/diagnóstico , Gangrena de Fournier/cirurgia , Gangrena de Fournier/diagnóstico , Oxigenoterapia Hiperbárica/métodosRESUMO
Necrotizing fasciitis (NF) is a serious infection that compromises subcutaneous tissue, fascia, and adipose tissue, with high mortality rate and sequelae. Extremities, trunk and pelvis are the most common body sites affected. Periorbital celullitis with necrotizing fasciitis of the eyelid is rare. We report the case of a three years old child with bilateral NF of the eyelids and toxic shock syndrome secondary to Streptococcus pyogenes infection ocurring after a minor skin trauma. Early recognition leading to intensive care treatment and prompt surgical debridement were critical in the favourable outcome of the child.
La fascitis necrosante (FN) es una infección grave de los tejidos subcutáneos, localizada más frecuentemente en extremidades, tronco y pelvis. El compromiso de la cara y la región palpebral es inusual. Reportamos el curso clínico de un niño de tres años, previamente sano, que presentó una FN palpebral bilateral asociado a shock tóxico por Streptococcus pyogenes, secundaria a un trauma localizado. El paciente requirió tratamiento en cuidado intensivo con resucitación enérgica, antimicrobianos, inmunoglobulina intravenosa y desbridamiento quirúrgico precoz, lo que permitió su evolución favorable.
Assuntos
Pré-Escolar , Humanos , Masculino , Doenças Palpebrais/terapia , Fasciite Necrosante/terapia , Streptococcus pyogenes , Choque Séptico/terapia , Infecções Estreptocócicas/tratamento farmacológico , Antibacterianos/uso terapêutico , Terapia Combinada , Desbridamento , Doenças Palpebrais/diagnóstico , Doenças Palpebrais/microbiologia , Fasciite Necrosante/diagnóstico , Fasciite Necrosante/etiologia , Imunoglobulinas Intravenosas/uso terapêutico , Índice de Gravidade de Doença , Choque Séptico/diagnóstico , Choque Séptico/microbiologia , Infecções Estreptocócicas/diagnóstico , Streptococcus pyogenes/isolamento & purificação , Resultado do TratamentoRESUMO
Una paciente de 81 años con insuficiencia cardíaca crónica, fibrilación auricular y tratamiento anticoagulante, ingresó por un cuadro fulminante de dolor y celulitis en la extremidad inferior derecha de 24 horas de evolución. Sobre la zona existía una úlcera crónica de cinco meses de evolución, manejada con curaciones locales. Al ingreso, había una placa necrótica pero sin hipotensión o confusión mental. La paciente estaba febril y con taquicardia (126 por min). La evaluación reveló ausencia de leucocitosis, trombosis venosa profunda en la misma pierna e infiltrados radiológicos pulmonares en el lóbulo inferior izquierdo. En las horas siguientes aumentó el dolor, apareció secreción purulenta por la úlcera y la paciente presentó confusión, hipotensión, falla respiratoria y luego shock. La paciente recibió ciprofloxacino endovenoso y clindamicina y fue intervenida a las 15 horas de ingreso, efectuándose una amputación supracondílea. El sondeo cardíaco demostró un gasto bajo (2,3 L/min) y una resistencia vascular sistémica (2888 din.s.cm"5) y presión capilar pulmonar elevada (17 cm H(2)0), cifras compatibles con un shock cardiogénico. Evolucionó en malas condiciones y falleció de falla orgánica múltiple a las 36 horas de ingreso. Los hemocultivos demostraron crecimiento de Serratia marcescens en dos frascos. No se efectuó una necropsia y los cultivos de la secreción de la úlcera fueron negativos.
An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8°C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest x-ray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm"5) and pulmonary capillary wedge pressure (17 cm H(2)0), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative.