Necrotizing fasciitis associated with malignancy.

Necrotizing fasciitis (NF) is a rare soft-tissue condition with a high mortality rate even with treatment. Diagnosis is challenging due to an absence of specific symptoms at the early stages of clinical presentation. NF is typically associated with traumatic injuries, superficial skin breakdown, and surgical procedures. Diabetes mellitus and immunosuppression also increase the risk of developing NF. NF predominantly occurs in the lower extremities, the peritoneum, and the perineum. Treatments include antimicrobials, supportive care, and surgical source control. It is important for clinicians to recognize the association of spontaneous atraumatic NF caused by Clostridium septicum with malignancy, so they can maintain a high index of suspicion and provide timely interventions to optimize patient outcomes.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics.

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Necrotising fasciitis complicating hand, foot and mouth disease.

A literature search confirmed no previous cases of necrotising fasciitis (NF) complicating hand,foot and mouth disease (HFMD). This report explores the case of a previously well 55-week-old Caucasian boy who attended accident and emergency with an acutely swollen right hand and atypical viral rash affecting the hands and face. He was admitted under plastic surgery and treated with intravenous antibiotics and fluid resuscitation for sepsis secondary to cellulitis. Following dermatological review of the rash, a clinical diagnosis of atypical HFMD was made. He deteriorated over the first 12 hours with progression of cellulitis despite intervention. Emergency exploration and debridement were performed for suspected NF. NF was subsequently confirmed by laboratory testing. He required 5 days in paediatric intensive care but made a full recovery. Recent reports highlight an increase in atypical cases of HFMD. Clinicians should be aware of the potential for superadded necrotising infection in cases of atypical HFMD.

Comparison of Efficacy and Complications Between Negative Pressure Wound Therapy and Conventional Mechanical Fixation in Skin Grafts: A Retrospective Analysis.

INTRODUCTION: Graft fixation is critical for the successful survival of a skin graft. Conventional mechanical fixation may induce inappropriate pressure and increase wound complications. Negative pressure wound therapy (NPWT) could be utilized to secure a skin graft and improve drainage. Limited quantitative data exist on the efficacy of NPWT for skin grafting. OBJECTIVE: This retrospective study compares the efficacy and complications between NPWT and conventional mechanical fixation in skin grafts. MATERIALS AND METHODS: Patients who underwent skin graft surgery from January 2015 to December 2016 at a large university hospital in southwest China were retrospectively analyzed. Characteristics, including wound pattern, skin graft type, surgical procedure, survival rate, and postoperative complication, were statistically analyzed by Pearson chi-square or Fisher's exact test. RESULTS: A total of 186 patients were included in the study; 72 received NPWT and 114 received conventional mechanical dressing fixation after skin grafting. Overall survival rate of full-thickness skin grafts was significantly higher in the NPWT group than the dressing group (P ⟨ .01). The NPWT group showed a higher survival rate than the dressing group for each anatomic site, but only patients who had skin grafts of the hand exhibited statistically significant results. CONCLUSIONS: This study reports a quantitative analysis of the efficacy of NPWT on skin graft fixation with NPWT providing consistent pressure and better drainage than conventional mechanical fixation. In addition, the use of NPWT also could increase graft take on the hand region.

Monomicrobial Klebsiella pneumoniae necrotizing fasciitis: an emerging life-threatening entity.

BACKGROUND AND AIMS: Necrotizing fasciitis (NF) although rare, is a potentially fatal infection. The majority of cases are polymicrobial, although a recent surge has been reported in monomicrobial NF caused by Klebsiella pneumoniae (KP-NF). KP-NF recently accounted for an average of 16% among all pathogens, with highest mortality rate of 60%. This review discusses the important aspects of KP-NF with additional notes on the implications of multidrug resistant infections. SOURCES: The literature was searched using PubMed. Klebsiella pneumoniae isolated monomicrobially in NF cases was used as the selection criteria. CONTENT: KP-NF predominates in East Asia with the majority of cases reported from Taiwan alone. Reports from the Western hemisphere are also gradually rising. This infection has invariably presented with underlying predisposing factors occurring mostly in individuals with compromised host immunity. Diabetes, chronic liver disease, and instrumentation are important risk factors. With haematogenous spread more common, multifocal involvement via metastasis is reported. Clinical presentations are usually aggressive with rapid progression despite antimicrobial therapy. It may even present with severe sepsis. Clinicians must be aware of the differential diagnosis of such severe presentations. Emergency surgical explorations and microbiological investigations clinch the diagnosis. Outcomes are not favourable, with a high mortality rate of 40% even after appropriate interventions. Nosocomial KP-NF cases are more fulminant and multidrug resistant with even higher mortality rates (approx. 70%). IMPLICATIONS: KP-NF with its virulent course and high mortality, is an emerging life threat. Clinicians must be aware of its key features. Further comprehensive studies are needed for better insights into the spectrum of this fatal infection.

The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.

PURPOSE: Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs. METHODS: A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded. RESULTS: There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality. CONCLUSIONS: Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

A successful treatment of necrotizing fasciitis following the surgery of distal radius plate removal: A case report and literature review.

RATIONALE: Necrotizing fasciitis (NF) is defined as a rare, rapidly progressive, and highly lethal skin infection characterized by necrosis of the fascia and subcutaneous tissue. PATIENT CONCERNS: The present study aims to discuss the case of a 35-year-old man who developed NF following a routine sterile right distal radius bone plate removal surgery. DIAGNOSES: The patient was suspected of NF based on his clinical manifestations, laboratory tests, and imaging results. The diagnosis of NF was confirmed by histological examinations. INTERVENTIONS: Serial prompt and extensive debridement was performed during the rapid and aggressive extension of the skin infection, together with antibiotics and supportive treatments. OUTCOMES: The condition of the patient finally improved on the sixth day of disease progression. Skin grafting of his right forearm wound was performed successfully 2 months after the admission. LESSONS: NF can occur during the perioperative period for routine clean radius plate removal operation in patients with no risk factor for NF. The objective is to remind the physicians to stay aware of this disease, especially its early clinical signs and symptoms. Urgent subsequent treatment, including surgical debridement, antibiotic therapy, and supporting management, is the key to ensure the survival and better prognosis of patients.

Postoperative gluteal compartment syndrome following microsurgical free-flap hand reconstruction: the importance of early recognition and treatment.

Compartment syndrome, a surgical emergency, is caused by an increase in pressure within a closed osseofascial space, often due to trauma. This causes a decrease in tissue perfusion and ultimately tissue necrosis and multiorgan failure if not treated in a timely fashion. Gluteal compartment syndrome is a rare variant and often caused by a period of immobilisation secondary to intoxication with alcohol or drugs or during long operations, typically in the supine position. We report on a case of gluteal compartment syndrome developing in a patient postoperatively following a long microsurgical procedure to a hand, which has not been documented before. Although rare, we highlight the clinical course and diagnostic criteria, which are essential for early identification and treatment.

Serratia marcescens Bullous Cellulitis in a Splenectomized Patient: A Case Report and Review of the Literature.

Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.

Liver cirrhosis as a real risk factor for necrotising fasciitis: a three-year population-based follow-up study.

INTRODUCTION: Necrotising fasciitis (NF) is often found in patients with diabetes mellitus, chronic renal failure, alcoholism, malignancy or liver cirrhosis. However, it remains unknown whether liver cirrhosis is an independent risk factor for the occurrence of NF. This study aimed to determine whether liver cirrhosis is an independent risk factor for the occurrence of NF, and to identify the relationship between severity of liver cirrhosis and occurrence of NF. METHODS: The National Health Insurance Research Database, maintained by Taiwan's National Health Insurance programme, was retrospectively analysed, and the hospitalisation data of 40,802 cirrhotic patients and 40,865 randomly selected, age­ and gender­matched non­cirrhotic control patients was collected. The medical records of all patients were individually followed for a three­year period from the patients' first hospitalisation in 2004. RESULTS: During the three­year follow­up period, there were 299 (0.7%) cirrhotic patients with NF and 160 (0.4%) non­cirrhotic patients with NF. Cox regression analysis showed that liver cirrhosis was a risk factor for the occurrence of NF during the study period (hazard ratio 1.982; p < 0.001). Among cirrhotic patients, those with complicated liver cirrhosis had a higher risk for the occurrence of NF than patients with non­complicated liver cirrhosis (hazard ratio 1.320; p = 0.028). CONCLUSION: Cirrhotic patients had a higher risk for the occurrence of NF than non­cirrhotic patients, and the risk for NF was especially high among patients with complicated liver cirrhosis.

A case of fatal necrotizing fasciitis arising from chronic lymphedema.

Chronic lymphedema and lymphangitis are common adverse effects following treatment for gynecological cancer. Because the early symptoms of necrotizing fasciitis are similar to those of lymphangitis, fatal outcome can occur if patients or physicians underestimate this condition. Here, we present a case of necrotizing fasciitis in a patient with chronic lymphedema.

Necrotising fasciitis of the thigh.

Necrotising fasciitis (NF) is an extremely virulent form of infectious fasciitis. It affects skin, subcutaneous fat and superficial and deep muscular fascia by rapidly progressive necrosis. Expeditious diagnosis and radical debridement is necessary to prevent the onset of sepsis, multisystem organ failure and possible death. Perforated rectal cancer resulting in NF can spread to the perineum and genitals known as Fournier gangrene. This case describes an unusual case of NF of the right thigh as first presentation highly suggestive for rectal cancer.

Periorbital necrotising fasciitis following cutaneous herpes zoster.

Necrotising fasciitis is a rare severe infection of the soft tissues and deep fascia, which is associated with a significant level of mortality. Involvement of the head and neck is uncommon, and necrotising fasciitis of the periorbital area even rarer. We present a case of bilateral periorbital necrotising fasciitis following shingles in an otherwise healthy immunocompetent patient.

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.

Necrotizing fasciitis: early detection may save your patient's limb.

Necrotizing fasciitis (NF) is a rapidly spreading infection affecting the subcutaneous soft tissue. Because of its rapid progression and high mortality, it is essential that the patient is diagnosed and treated early. Over the past century and a half, little has changed in the mortality of this disease. The orthopaedic nurse is in a key position to assist with the early detection and treatment of NF. In the following article, the pathophysiology, early disease detection, diagnostic and treatment challenges, and appropriate nursing interventions will be discussed as it relates to improving the care of the patient with NF.

Necrotising fasciitis following anterior cruciate ligament reconstruction. A case report.

Necrotising fasciitis is a rapidly progressive and life threatening soft tissue infection that primarily involves the superficial fascia. It can be a difficult condition to diagnose in its early stages and requires aggressive surgical and supportive management if devastating consequences are to be avoided. We describe a case of necrotising fasciitis following an anterior cruciate ligament (ACL) reconstruction using a hamstring graft. To our knowledge this has not been previously reported. Following radical debridement, reconstructive surgery and intensive physiotherapy our patient has made a satisfactory recovery.

Caloric requirements in patients with necrotizing fasciitis.

Patients with necrotizing fasciitis (NF) and other soft tissue infections are often treated in burn centers due to the extent of wound care and surgical intervention needed. Sepsis and surgery increase metabolic needs and may limit oral intake and necessitate enteral (TEN) or parenteral (TPN) nutrition. We reviewed the records of patients admitted with necrotizing fasciitis or surgical soft tissue infections from January 1993 to June 1998 who had indirect calorimetry (IC) measurements performed. Records were also reviewed for surgical/medical management and nutritional intervention. Twenty-six patients were admitted with 17 of these having IC measurements (133 total IC measurements). The IC group had more surgeries (mean 4.9 versus 2.7) and 82% required mechanical ventilation (mean 17.9 days). Energy expenditure showed a moderate but significant increase in energy needs (mean 23.8 kcal/kg/day, 124% BEE) with large variations (10.7-42.4 kcal/kg/day, 60%-199% BEE) in individual energy requirements. Caloric intake averaged 73% of needs based on IC (range 53%-104%). Nearly all patients (94%) required TEN (82%) and/or TPN (41%) nutrition for a mean of 24 days (range 1-68 days). NF presents a broad range of metabolic and surgical needs. Our data indicates patients with NF have increased energy requirements and suggests provision of calories at 124% basal or 25 kcal/kg actual wt/d; but due to the large individual variation, routine assessment using IC is recommended. Clinicians need to recognize the likely need for nutritional support and possibly lengthy clinical course for these patients.