Necrotizing Fasciitis (Flesh Eating Disease): Difference between revisions
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== Diagnostic Tests/Lab Tests/Lab Values == | == Diagnostic Tests/Lab Tests/Lab Values == | ||
Laboratory tests utilized for necrotizing fasciitis are the same as ones used for severe soft tissue infections which include:<br>• Complete blood count<br>• Electrolytes<br>• Erythrocyte sedimentation rate<br>• C-reactive protein<br><br> | Laboratory tests utilized for necrotizing fasciitis are the same as ones used for severe soft tissue infections which include:<br>• Complete blood count<br>• Electrolytes<br>• Erythrocyte sedimentation rate<br>• C-reactive protein<br> | ||
A numerical score sheet, called the laboratory risk indicator for necrotizing fasciitis (LRINEC), was devised from lab parameters as a possible indicating tool for detection of necrotizing fasciitis. Score of ≥6 has a positive predictive value of 92% and a negative predictive value of 96%. | |||
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== Etiology/Causes == | == Etiology/Causes == | ||
Revision as of 22:05, 2 April 2012
Original Editors - Sara Halliday & Ashley Walker from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Lead Editors - Your name will be added here if you are a lead editor on this page. Read more.
Definition/Description[edit | edit source]
Necrotizing Fasciitis is a bacterial infection characterized by rapidly progressing necrosis of fascia and subcutaneous fat with subsequent necrosis of the overlying skin; muscle involvement is minimal or non- existent.[1] The most rapidly progressing type of necrotizing fasciitis is Group A, streptococcal infection, also known as flesh-eating bacteria. Necrotizing Fasciitis can occur due to several reasons and in a variety of patient populations. Certain conditions may predispose patients to infection, such as immunosuppression, DM, malignancy, drug abuser, and chronic renal disease.[2]
The progression of the infection begins with the introduction of bacteria typically a result of trauma to the skin. Once the infection is seeded locally, the bacteria spreads through deep fascial planes causing widespread tissue damage and infection. The spread of bacteria results in thrombosis of blood vessels in dermal papilla, resulting in ischemia and gangrene of subcutaneous fat and dermis.[3]
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Prevalence[edit | edit source]
The incidence of necrotizing fasciitis in adults has been reported to be 0.40 cases per 100,000 population, while the incidence in children is 0.08 cases per 100,000 population.[4] Necrotizing Fasciitis is considered a rare condition, however, the mortality rate remains high. Recent studies have estimated the mortality rate at 20-40%.[5]
Characteristics/Clinical Presentation[edit | edit source]
The patient may initially present with increasing pain, erythema, crepitus and usually a history of some type of trauma. Complaints of flu-like symptoms (nausea, vomiting, fever, etc.) are also common. Patients with NF can present with constitutional symptoms of sepsis (eg, fever, tachycardia, altered mental state, diabetic ketoacidosis) alone or with evidence of skin inflammation.[3]
Clinical presentation of necrotizing fasciitis varies and can typically be mistaken for other pathologies, such as cellulitis and superficial skin infections. Awareness of the presentation of necrotizing fasciitis clinically is critical due to the rapid progression of the disease. Studies have shown that only 15% to 34% of patients with NF have an accurate admitting diagnosis.[3] Misdiagnosis occurs often due to the vague symptoms that may be present or the lack thereof. The following table consists of the typical presentation of necrotizing fasciitis.
Associated Co-morbidities[edit | edit source]
Studies have shown that there are certain factors that can predispose patient to infection. In a Singapore study, 70.3% of patients with NF had diabetes mellitus. [6]
Risk factors for necrotizing fasciitis:[3]
• Diabetes
• Chronic disease
• Immunosuppresive drugs (e.g. Prednisone)
• Malnutrition
• Age > 60
• Intravenous drug misuse
• Peripheral vascular disease
• Renal failure
• Underlying malignancy
• Obesity
Typically necrotizing fasciitis occurs following some type of trauma to the skin, however, non-traumatic causes have also been reported. However, the injury can be quite trivial; eg, insect bites or scratches.[3] There have also been reported cases of necrotizing fasciitis occurring following acupuncture treatment. The following table consists of common causes of necrotizing fasciitis.
Medications[edit | edit source]
Necrotizing fasciitis is treated with antibiotics usually administered intravenously, however, tissue hypoxia limits the efficacy of intravenous antibiotics until surgical debridement has occurred.[3] Also, inflammation at the fascial level is associated with intense discomfort that is often unrelieved by analgesic agents such as NSAIDs or even narcotics.[7]These two clinical findings present in necrotizing fasciitis assist to differentiate it from cellutis.
Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
Laboratory tests utilized for necrotizing fasciitis are the same as ones used for severe soft tissue infections which include:
• Complete blood count
• Electrolytes
• Erythrocyte sedimentation rate
• C-reactive protein
A numerical score sheet, called the laboratory risk indicator for necrotizing fasciitis (LRINEC), was devised from lab parameters as a possible indicating tool for detection of necrotizing fasciitis. Score of ≥6 has a positive predictive value of 92% and a negative predictive value of 96%.
Etiology/Causes[edit | edit source]
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Systemic Involvement[edit | edit source]
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Medical Management (current best evidence)[edit | edit source]
Treatment for Necrotizing Fasciitis is required to be aggressive due to the rapid progression of the infection once contracted. Management includes fluid resuscitation, if indicated, intravenous broad-spectrum antibiotics, and early surgical debridement.[3] Early recognition is vital for successful treatment. If detected during the early stages, surgical debridement can be minor and more localized to the infected epidermis, subcutaneous and adipose tissue. Blood tests and imaging, especially magnetic resonance imaging and computed tomography scans, can be helpful but are not diagnostic.[3]
In the later stages of necrotizing fasciitis, systemic shock can occur resulting in failure of many organ systems. Respiratory failure, heart failure, low blood pressure and renal failure may occur in this stage. Limb amputation is necessary once the infection begins to spread to other organ systems.
Hyperbaric oxygen therapy has been proposed as an adjunct therapy for the treatment of necrotizing fasciitis. However, evidence has found conflicting results on the efficacy of this treatment. A systemic review found the main advantages of the addition of HBO to standard regimes appear to be tissue preservation and decreased mortality.[5] However, Golger et al showed that morbidity associated with NF was higher in patients who underwent hyperbaric oxygen therapy.[8] A need exists for higher levels of research to be conducted for more conclusive results.
Physical Therapy Management (current best evidence)[edit | edit source]
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Alternative/Holistic Management (current best evidence)[edit | edit source]
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Differential Diagnosis[edit | edit source]
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Case Reports/ Case Studies[edit | edit source]
Groth D, Henderson SO. Necrotizing Fasciitis Due to Appendicitis. Am J Emerg Med 1999; 17: 594- 596.
Hefny AF, Abu-Zidan FM. Necrotizing fasciitis as an early manifestation of tuberculosis: report of two cases. Turkish Journal of Trauma & Emergency Surgery 2010;16 (2):174-176.
(case studies should be added on new pages using the case study template)
Resources
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The National Necrotizing Fasciitis Foundation. Available online at http://www.nnff.org/
PubMed Health. Available online at www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002415/
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
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References[edit | edit source]
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- ↑ Shupak A, Shoshani O, Goldenberg I, Barzilai A, Moskuna R, Bursztein S. Necrotizing fasciitis: An indication for hyperbaric oxygenation therapy? Surg. 1995 November; 118 (5): 873-78.
- ↑ Hsiao C-T, Weng H-H, Yuan Y-D, Chen C-T, Chen I-C. Predictors of mortality in patients with necrotizing fasciitis. American Journal of Emergency Medicine. 2008 April 19; 26: 170–75
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7 Cite error: Invalid
<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content Cite error: Invalid<ref>tag; name "Puvanendran" defined multiple times with different content - ↑ File Jr TM, Tan JS, DiPersio JR. Group A streptococcal necrotizing fasciitis. Diagnosing and treating the “flesh-eating bacteria syndrome”. Cleve Clin J Med 1998; 65(5):241-9.
- ↑ 5.0 5.1 Jallali N. et al. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. The American Journal of Surgery 2005; 198:462–466 Cite error: Invalid
<ref>tag; name "Jallali" defined multiple times with different content - ↑ Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surgery Am 2003;85-A(8):1454-60.
- ↑ Bisno AL, Cockerill FR, Bermudez CT. The Initial Outpatient-Physician Encounter in Group A Streptococcal Necrotizing Fasciitis. Clinical Infectious Diseases. 2000 Aug; 31:607–8.
- ↑ Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg 2007; 119(6): 1803-7.
