Aeromonas hydrophila induced necrotizing fasciitis following laparoscopic cholecystectomy.

Necrotizi ng fasciit is [NF] i s a m ultifaceted disease of the muscle fascia and body tissues which demands the earliest intervention. Past reviews have documented ver y few cases of Aeromonas Hydroph ila [AH] induced N F fol lo wing abdominal surgery. AH can cause fatal NF as seen in a 72 year old female patient reported at Liaquat National Hospital &Medical College; a ter tiary care center in Karachi, Pakistan on 2nd April, 2022. She had a k nown comorbidity of hypertension and presented with the chief complaint of symptomatic gallstones for which she unde rwent Laparoscopic Cholecystectomy (LAPCHOL). She developed NF of the lower ab domen post- oper atively. Following uneventful Laparoscopic Cholecystectomy our pati ent presented to the ER two days later with severe lower abdo minal pain and overlyi ng celluliti s. Fasc io to my revealed extensive myonecrosis with necrotizing soft tissue in fe ction. Despite u ndergoing extensive surgical debr idement and broad spectr um antibi ot ic administration; the patient died in the ICU on the fifth postoperat ive day followi ng septic complications. Histopathologica l an alysis, confirmed i nflammat ion and necrosis. Culture sensitivity of the debrided tissue revealed AH. Approach should lie towards analyzing the behaviour of such microbes in high risk patients through collective case studies. This is the first clinical case showcasing such parameters e ncountered in the General Surger y Department.

[Hand infections]. / Infections de la main.

HAND INFECTIONS. Hand and finger infections are very common. They result from the inoculation of a germ through the skin barrier. They can range from simple paronychia to extremely serious necrotizing fasciitis. Certain infections, such as those resulting from bites, have their own specific characteristics, which will determine how they are managed. While management can be medical in the early stages, it is important not to ignore the need for surgical treatment, otherwise serious complications may arise, leading to functional and aesthetic sequelae. Delays in treatment cannot be made up. Any infectious lesion can be potentially serious and must be treated in an appropriate department if there is the slightest doubt.

INFECTIONS DE LA MAIN. Les infections de la main et des doigts sont très fréquentes. Elles résultent de l'inoculation d'un germe à travers la barrière cutanée. Elles vont du simple panaris à la gravissime fasciite nécrosante. Certaines infections, comme celles faisant suite aux morsures, ont des caractéristiques propres dont dépend la prise en charge. Si elle peut être médicale au stade initial, il est important de ne pas méconnaître le moment du traitement chirurgical sous peine de voir survenir des complications graves responsables de séquelles fonctionnelles et esthétiques. Le retard à la prise en charge ne peut être rattrapé. Toute lésion infectieuse peut être potentiellement grave et, au moindre doute, doit être prise en charge dans un service adapté.

A case of necrotizing fasciitis of the breast following lumpectomy and oncoplastic closure.

BACKGROUND: NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. CASE REPORT: The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. CONCLUSION: This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.

Cervical Necrotizing Fasciitis: A Severe Sequela of Open Mandibular Fracture and Delay in Treatment.

Cervical necrotizing fasciitis (CNF) is a rare condition in the United States, with very few cases reported as a sequela of mandibular fracture. The authors describe the case of a 40-year-old man with poor oral health and no significant past medical history who developed CNF following delayed treatment of an open mandibular fracture, leading to life-threatening septic shock, thrombophlebitis of the internal jugular vein, and septic emboli to the lungs. Successful management of this patient was accomplished by serial surgical debridement, the administration of broad-spectrum antibiotics, and hemodynamic support. Eventual reconstruction was performed with external fixation of the mandible fracture and split-thickness skin grafting for the left neck and chest wound. The authors recommend early treatment of open mandibular fractures for immunocompromised patients or patients with poor oral hygiene to avoid the rare but potentially fatal complication of CNF and highlight external fixation as a useful technique in select cases of complex mandibular fractures.

A rare case of the axillary necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection that needs acute surgical intervention and other types of supportive care. The upper extremities are a less frequent site for this infection than the lower extremities. Axillary necrotizing fasciitis is quite rare and bears a high risk of iatrogenic neurovascular injuries. We report a severe case of a 39-year-old man with a right axillary necrotizing fasciitis caused by Streptococcus pyogenes. While dealing with important nerves and blood vessels at the initial emergency surgery, we marked and preserved them with vascular tapes. The patient underwent several surgical interventions for infection control in addition to supportive care to avoid limb loss and to survive. Intraoperatively, the locations of nerves and vessels could be easily found by checking the vessel tapes. Twelve months after the initial admission, the patient had no symptoms of nerve injuries and resumed work. With necrotizing fasciitis, the risk of an iatrogenic nerve injury exists even if limb amputation is avoided due to repeated debridement. We report that marking and preserving nerves and blood vessels with vascular tapes at the initial surgery may make the subsequent ones easier and may reduce iatrogenic neurovascular injury.

Massive dermal ulcerative lesions due to brown recluse spider bite: a rare case report and review of literature.

A brown recluse spider (BRS) bite is challenging to confirm, but may be clinically diagnosed by considering the location, the season of the year, and the clinical manifestations. Here, the case of a 26-year-old male who presented after an insect bite with a skin lesion, bruising, severe swelling, and diffuse blisters on the right lower extremity after three days, is described. Following clinical examination, patient history assessment, and consideration of other relevant factors, the patient received a differential diagnosis of necrotizing fasciitis caused by BRS bite. Although spider bite poisoning is rare, proper diagnosis and management are important because, in some cases, the outcomes may be devastating.

Necrotizing fasciitis after total abdominal hysterectomy: A case report.

RATIONALE: Necrotizing fasciitis is rapidly progressive infection with high mortality rate. This study aimed to summarize the clinical and pathological presentation of this case. PATIENT CONCERNS: A 46-year-old woman patient presented to our emergency department of an obstetric and gynecology clinic on the 8th day after total abdominal hysterectomy. The abdominal wall showed pronounced signs of inflammation. Abundant purulent content was oozing from the abdominal wound. DIAGNOSES: The patient underwent surgery. Areas of necrosis were observed on the skin around the wound, the subcutaneous fatty tissue was necrotic around the incision site, and the fascia was completely dehisced. INTERVENTIONS: Wound debridement and flap cutting of the anterior abdominal wall were performed. Metronidazole, ceftriaxone, and vancomycin were administered intravenously. A plastic surgeon suggested daily debridement and toileting of the wound in the operating room. Swabs of the abdominal cavity, abscess cavity, and abdominal wound were obtained, and Enterococcus faecalis was isolated. After the negativism of microbiological swabs, excochleation of granulation tissue was performed by a plastic surgeon. OUTCOMES: Nineteen days after the relaparotomy, the patient was discharged in good general condition with advice for further monitoring and therapy. LESSONS: Successful treatment of necrotizing fasciitis can be achieved through an initial diagnosis, adequate debridement, empirical broad-spectrum antibiotic coverage, and multidisciplinary treatment.

Serratia marcescens Necrotizing Fasciitis of the Ankle: A Case Report.

Necrotizing fasciitis is a devastating inflammatory infection requiring emergent medical treatment and surgical intervention. Even with timely management, the mortality rate of necrotizing fasciitis approaches 25%. The causative bacteria invade fascial planes and express toxins that advance rapidly. Here, we document a rare case of necrotizing fasciitis from Serratia marcescens infection. Serratia marcescens is capable of inducing a necrotizing inflammatory cascade mediated by extracellular cytotoxin and lipase. In this case report, a 90-year-old man presented to our emergency department from a long-term care facility with a relatively benign-appearing ulcer with surrounding cellulitis on the right ankle. Blood cultures and wound cultures confirmed the organism to be S marcescens. A multidisciplinary team was consulted for management. The patient received antibiotic therapy and medical support, but because of his comorbid conditions and social situation, the designated medical decision maker opted for comfort care rather than aggressive surgical debridement. The patient progressed through the clinical stages of necrotizing fasciitis. Within 36 hours, the patient died as result of sepsis-induced organ failure.

Necrotizing fasciitis - a complication of autoimmune skin blistering diseases?

INTRODUCTION: Autoimmune bullous diseases (AIBD) are organ-specific skin blistering diseases clinically manifesting as bullae and vesicles of the skin and mucous membranes. The loss of skin barrier integrity renders patients susceptible to infection. Necrotizing fasciitis (NF), a rare yet severe infectious complication of AIBD has been insufficiently documented in the literature. CASE REPORT: We present a case of a 51-year-old male patient with NF initially misdiagnosed as herpes zoster. Given the local status, CT imaging, and laboratory parameters, NF diagnosis was made and the patient was taken for an urgent surgical debridement. In a further development, new bullae in remote areas erupted and a perilesional biopsy, direct immunofluorescence as well as local status, the patient's age, and atypical presentation, imposed an initial diagnosis of epidermolysis bullosa acquisita. Differential diagnoses were bullous pemphigoid (BP) and bullous systemic lupus. In the literature, 9 other described cases were found and are reviewed. CONCLUSIONS: Due to its unspecific clinical picture, necrotizing fasciitis itself presents a frequently misdiagnosed soft tissue infection. Altered laboratory parameters in immunosuppressed patients often lead to misdiagnosing of NF and loss of precious time, which plays a major role in survival. Given the manifestation of AIBD as loss of skin integrity and immunosuppressive therapy, these patients could be more predisposed to NF than the general population.

Is the LRINEC score useful for predicting necrotizing fasciitis as a complication of MRONJ?

INTRODUCTION: Necrotizing fasciitis as a complication of medication-related osteonecrosis of the jaw (MRONJ), which we named "ONJ-NF", has been sometimes reported. This study aimed to investigate the usefulness of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for predicting ONJ-NF. MATERIALS AND METHODS: We included patients with acute MRONJ who required hospitalization at a single institution from April 2013 to June 2022. They were divided into two groups: patients with ONJ-NF and those with severe cellulitis as a complication of MRONJ, which we named "ONJ-SC." LRINEC scores were compared between the groups and the cut-off value of the score was set by creating a receiver operating characteristic curve. RESULTS: Eight patients with ONJ-NF and 22 patients with ONJ-SC were included. The LRINEC score was significantly higher in patients with ONJ-NF (median: 8.0 points, range 6-10 points) than in those with ONJ-SC (median: 2.5 points, range 0-6 points). A LRINEC score of ≥ 6 points had a sensitivity of 100.0%, a specificity of 77.3%, and an area under the curve of 0.97. Among 6 parameters of LRINEC score, only C-reactive protein (CRP) and white blood cell count (WBC) had significant differences between two groups. Most of the patients with ONJ-NF were rescued by antibiotic therapy and surgical drainage including debridement of necrotic tissues, but unfortunately, one patient did not survive. CONCLUSION: Our results suggested that the LRINEC score may be a useful diagnostic tool to predict ONJ-NF but valuating only CRP and WBC may be sufficient particularly in patients with osteoporosis.

Life-threatening complication: the development of necrotising fasciitis in a preterm neonate with omphalitis.

Omphalitis is a mild medical condition that can turn severe in exceptional situations leading to necrotising fasciitis. The most common cause of omphalitis is umbilical vein catheterisation (UVC) where the cleanliness measures can be compromised. The treatment options for omphalitis include antibiotics, debridement and supportive care. Sadly, the fatality rate in such cases is high. This report is about a premature female baby who was admitted to a neonatal intensive care unit after her birth at 34 weeks of gestation. UVC was performed on her which led to abnormal changes in the skin around her umbilicus. Further tests revealed that she had omphalitis and was treated with antibiotics and supportive care. Unfortunately, her condition quickly worsened and she was diagnosed with necrotising fasciitis which ultimately resulted in her death. This report provides details about the patient's symptoms, course of illness and treatment for necrotising fasciitis.

Fulminant Overwhelming Necrotizing Vibrio vulnificus Sepsis Secondary to Oyster Consumption.

Vibrio vulnificus is an opportunistic gram-negative rod-shaped bacteria found in warm, low salinity waters. Transmission through open wounds or consumption of contaminated seafood can lead to wound infections, sepsis, and potentially death. A 44-year-old man with a history of poly-substance abuse, cirrhosis, and recent oyster consumption presented to the emergency department in June with acute onset bilateral leg pain associated with rash and fever. Within 6 hours of his arrival, the rash rapidly progressed to large bullae with extensive necrosis ascending to the level of the abdomen, and he developed septic shock. Despite prompt surgical intervention and appropriate antibiotic and resuscitative therapies, the patient had progressive multi-system organ failure and died 7 days after admission. Concurrent necrotizing fasciitis with sepsis secondary to V. vulnificus infection is rare and potentially fatal, as demonstrated in this case.

Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation.

INTRODUCTION: Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram. METHODS: A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival. RESULTS: There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge. CONCLUSION: There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.

Necrotizing Fasciitis-Severe Complication of Bullous Pemphigoid: A Systematic Review, Risk Factors, and Treatment Challenges.

Background and objectives: Bullous pemphigoid (BP), the most common subepidermal autoimmune skin blistering disease (AIBD) has an estimated annual incidence of 2.4 to 42.8 new cases per million in different populations, designating it an orphan disease. Characterized by disruption of the skin barrier combined with therapy-induced immunosuppression, BP could pose a risk for skin and soft tissue infections (SSTI). Necrotizing fasciitis (NF) is a rare necrotizing skin and soft tissue infection, with a prevalence of 0.40 cases per 100,000 to 15.5 cases per 100,000 population, often associated with immunosuppression. Low incidences of NF and BP classify them both as rare diseases, possibly contributing to the false inability of making a significant correlation between the two. Here, we present a systematic review of the existing literature related to the ways these two diseases correlate. Materials and methods: This systematic review was conducted according to the PRISMA guidelines. The literature review was conducted using PubMed (MEDLINE), Google Scholar, and SCOPUS databases. The primary outcome was prevalence of NF in BP patients, while the secondary outcome was prevalence and mortality of SSTI in BP patients. Due to the scarcity of data, case reports were also included. Results: A total of 13 studies were included, six case reports of BP complicated by NF with six retrospective studies and one randomized multicenter trial of SSTIs in BP patients. Conclusions: Loss of skin integrity, immunosuppressive therapy, and comorbidities commonly related to BP patients are risk factors for necrotizing fasciitis. Evidence of their significant correlation is emerging, and further studies are deemed necessary for the development of BP-specific diagnostic and treatment protocols.

Cervical necrotizing fasciitis caused by oral cavity infection: a case report considering therapeutic approach and its morphofunctional implications / Fascitis necrosante cervical causada por infección de la cavidad oral. Reporte de un caso considerando el abordaje terapéutico y sus implicaciones morfofuncionales

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.

Necrotizing fasciitis due to Streptococcus constellatus in a patient with uncontrolled diabetes and bilateral diabetic foot ulceration.

INTRODUCTION: Streptococcus constellatus is commensal flora of the oropharyngeal, gastrointestinal, and genitourinary tracts with a proclivity for abscess formation. Bacteremia due to S constellatus is rare; however, rising incidences have been reported, particularly in patients with diabetes. Prompt surgical debridement and antibiotic therapy with a cephalosporin are the mainstays of treatment. CASE REPORT: The case presented here involves a patient with poorly controlled diabetes who had necrotizing soft tissue infection secondary to S constellatus. The infection originated from bilateral diabetic foot ulcerations that led to bacteremia and sepsis. CONCLUSION: Immediate source control with wide and aggressive surgical debridement, initial empiric broad-spectrum antibiotic therapy followed by tailored treatment based on deep operative cultures, and staged closure led to effective limb-salvage and life-sparing intervention for this patient.

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.