Necrotizing fasciitis

From Self-sufficiency
Jump to: navigation, search
Necrotizing fasciitis
Classification and external resources
File:Necrotizing fasciitis left leg.JPEG
Caucasian male with necrotizing fasciitis. The left leg shows extensive redness and necrosis.
ICD-10 M72.6
ICD-9 728.86
MedlinePlus 001443
eMedicine emerg/332 derm/743
MeSH D019115

Necrotizing fasciitis (NF), commonly known as flesh-eating disease or Flesh-eating bacteria syndrome,[1] is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.

Type I describes a polymicrobial infection, whereas Type II describes a monomicrobial infection. Many types of bacteria can cause necrotizing fasciitis (e.g., Group A streptococcus (Streptococcus pyogenes), Staphylococcus aureus, Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis). Such infections are more likely to occur in people with compromised immune systems.[2]

Historically, Group A streptococcus made up most cases of Type II infections. However, since at least 2001, another serious form of monomicrobial necrotizing fasciitis has been observed with increasing frequency.[3] In these cases, the bacterium causing it is methicillin-resistant Staphylococcus aureus (MRSA), a strain of S. aureus that is resistant to methicillin, the antibiotic used in the laboratory that determines the bacterium's sensitivity to flucloxacillin or nafcillin that would be used for treatment clinically.

Signs and symptoms

The infection begins locally, at a site of trauma, which may be severe (such as the result of surgery), minor, or even non-apparent. Patients usually complain of intense pain that may seem in excess given the external appearance of the skin. With progression of the disease, tissue becomes swollen, often within hours. Diarrhea and vomiting are also common symptoms.

In the early stages, signs of inflammation may not be apparent if the bacteria are deep within the tissue. If they are not deep, signs of inflammation, such as redness and swollen or hot skin, show very quickly. Skin color may progress to violet, and blisters may form, with subsequent necrosis (death) of the subcutaneous tissues.

Patients with necrotizing fasciitis typically have a fever and appear very ill. Mortality rates have been noted as high as 73 percent if left untreated.[4] Without surgery and medical assistance, such as antibiotics, the infection will rapidly progress and will eventually lead to death.[5]

Pathophysiology

"Flesh-eating bacteria" is a misnomer, as the bacteria do not actually eat the tissue. They cause the destruction of skin and muscle by releasing toxins (virulence factors), which include streptococcal pyogenic exotoxins. S. pyogenes produces an exotoxin known as a superantigen. This toxin is capable of activating T-cells non-specifically, which causes the overproduction of cytokines and severe systemic illness (Toxic shock syndrome).

Treatment

File:Necrotizing fasciitis left leg debridement.JPEG
Necrotic tissue from the left leg is being surgically debrided in a patient with necrotizing fasciitis (same patient as above).

Patients are typically taken to surgery based on a high index of suspicion, determined by the patient's signs and symptoms. In necrotizing fasciitis, aggressive surgical debridement (removal of infected tissue) is always necessary to keep it from spreading and is the only treatment available. Diagnosis is confirmed by visual examination of the tissues and by tissue samples sent for microscopic evaluation.

Early medical treatment is often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including penicillin, vancomycin, and clindamycin. Cultures are taken to determine appropriate antibiotic coverage, and antibiotics may be changed when culture results are obtained.

As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy but is not widely available.[6] Amputation of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound, which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an intensive care unit.

Treatment for necrotizing fasciitis may involve an interdisciplinary care team. For example, in the case of a necrotizing fasciitis involving the head and neck, the team could include otolaryngologists, intensivists, microbiologists and plastic surgeons. [7]

Notable people afflicted

See also

References

Cite error: Invalid <references> tag; parameter "group" is allowed only.

Use <references />, or <references group="..." />

External links

de:Nekrotisierende Fasziitis

es:Fascitis necrotizante fr:Fasciite nécrosante it:Fascite necrotizzante arz:البكتيريا اللي بتاكل اللحم nl:Necrotiserende fasciitis ja:壊死性筋膜炎 no:Nekrotiserende fasciitt pt:Fasciite necrosante sr:Некротизирајући фасциитис sh:Nekrotizirajući fasciitis

zh:坏死性筋膜炎
  1. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
  2. K.S. Kotrappa, R.S. Bansal, N.M. Amin, "Necrotizing fasciitis", Am Fam Physician, 1996 Apr;53(5):1691-7.
  3. Lee TC, Carrick MM, Scott BG; et al. (2007). "Incidence and clinical characteristics of methicillin-resistant fasciitis in a large urban hospital". Am J Surg. 194 (6): 809–13. doi:10.1016/j.amjsurg.2007.08.047. PMID 18005776. 
  4. http://www.medscape.com/viewarticle/444061
  5. Necrotizing Fasciitis (Flesh-Eating Bacteria)
  6. Escobar SJ, Slade JB, Hunt TK, Cianci P (2005). "Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotizing fasciitis reduces mortality and amputation rate". Undersea Hyperb Med. 32 (6): 437–43. PMID 16509286. Retrieved 2008-05-16. 
  7. Malik V; Gadepalli, C; Agrawal, S; Inkster, C; Lobo, C (2010). "An Algorithm for Early Diagnosis of Cervicofacial Necrotizing Fasciitis". Eur Arch. Otorhinolaryngol. 267 (8): 1169–77. doi:10.1007/s00405-010-1248-5. PMID 20396897. 
  8. Medina P, Gonzalez-Rivas F, Blanco A, Tejido S, Leiva G (2009). "Fournier's Gangrene: Baurienne, 1764 and Herod the Great, 4 B.C.". European Urology Supplements. 8 (5): 121–121. doi:10.1016/S1569-9056(09)60011-7. 
  9. "Mystery of Herod's death 'solved'". CNN. 2002-01-25. 
  10. The Once and Future Scourge
  11. "Moorad's life changed by rare disease
  12. Cornell Discusses His Recovery from Necrotizing Fasciitis with Reporters
  13. PM: foot infection could have been fatal
  14. "In Memoriam - Alexandru A. Marin (1945 - 2005)", ATLAS eNews, December 2005 (accessed 5 November 2007).
  15. Flesh-eating bug killed top economist in 24 hours
  16. Before I was so rudely interrupted
  17. R. W. Johnson "Diary", London Review of Books, 6 August 2009, p41