Case Of Necrotizing Fasciitis Research Articles

Necrotizing Fasciitis Caused by Staphylococcus aureus

Staphylococcus aureus is an uncommon causative agent of monomicrobial necrotizing fasciitis, but we have noted several cases over the years. The patients treated for necrotizing fasciitis between January 1998 and December 2008 in our institution were identified, and their medical records were reviewed. Of 105 necrotizing fasciitis cases during the study period, 18 were caused by monomicrobial S. aureus infection (17%). The median age was 62 years (range, 12-81 years). Among this cohort, 10 patients had coexisting medical conditions or risk factors, including diabetes and hypertension. Lower limbs and upper limbs are the most commonly involved sites. Among the bacterial isolates from these cases, 8 were methicillin-sensitive S. aureus (MSSA) and 10 were methicillin-resistant S. aureus (MRSA). One patient died in the MSSA group, and 5 patients died in the MRSA group. The mortality rate and other clinical characteristics were not significantly different between the 2 groups. However, all MRSA necrotizing fasciitis developed after the year 2000, and it was significantly different from MSSA necrotizing fasciitis that predominantly took place before the year 2000. In conclusion, S. aureus is an important pathogen of monomicrobial necrotizing fasciitis, and MRSA has emerged as the predominant causative agent in recent years. Therefore, MRSA-directed antibiotic therapy should be considered when treating patients suspected with necrotizing fasciitis in endemic areas.

Retrospective study of necrotizing fasciitis and characterization of its associated Methicillin-resistant Staphylococcus aureusin Taiwan

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) has emerged as a prevalent pathogen of necrotizing fasciitis (NF) in Taiwan. A four-year NF cases and clinical and genetic differences between hospital acquired (HA)- and community-acquired (CA)-MRSA infection and isolates were investigated.MethodsA retrospective study of 247 NF cases in 2004-2008 and antimicrobial susceptibilities, staphylococcal chromosomal cassette mec (SCCmec) types, pulsed field gel electrophoresis (PFGE) patterns, virulence factors, and multilocus sequence typing (MLST) of 16 NF-associated MRSA in 2008 were also evaluated.ResultsIn 247 cases, 42 microbial species were identified. S. aureus was the major prevalent pathogen and MRSA accounted for 19.8% of NF cases. Most patients had many coexisting medical conditions, including diabetes mellitus, followed by hypertension, chronic azotemia and chronic hepatic disease in order of decreasing prevalence. Patients with MRSA infection tended to have more severe clinical outcomes in terms of amputation rate (p < 0.05) and reconstruction rate (p = 0.001) than those with methicillin-sensitive S. aureus or non-S. aureus infection. NF patients infected by HA-MRSA had a significantly higher amputation rate, comorbidity, C-reactive protein level, and involvement of lower extremity than those infected by CA-MRSA. In addition to over 90% of MRSA resistant to erythromycin and clindamycin, HA-MRSA was more resistant than CA-MRSA to trimethoprim-sulfamethoxazole (45.8% vs. 4%). ST59/pulsotype C/SCCmec IV and ST239/pulsotype A/SCCmec III isolates were the most prevalent CA- and HA-MRSA, respectively in 16 isolates obtained in 2008. In contrast to the gene for γ-hemolysin found in all MRSA, the gene for Panton-Valentine leukocidin was only identified in ST59 MRSA isolates. Other three virulence factors TSST-1, ETA, and ETB were occasionally identified in MRSA isolates tested.ConclusionNF patients with MRSA infection, especially HA-MRSA infection, had more severe clinical outcomes than those infected by other microbial. The prevalent NF-associated MRSA clones in Taiwan differed distinctly from the most predominant NF-associated USA300 CA-MRSA clone in the USA. Initial empiric antimicrobials with a broad coverage for MRSA should be considered in the treatment of NF patients in an endemic area.

Increasing incidence of necrotizing fasciitis in New Zealand: A nationwide study over the period 1990 to 2006

Because of concerns following necrotizing fasciitis (NF) reports in the media, we aimed to describe the incidence, mortality, case fatality and distribution of NF in New Zealand (NZ). By using International Classification of Disease codes to identify NF cases we analyzed the national hospital discharge and mortality data and reviewed 299 charts from 8 hospitals. The sensitivity and positive predictive value (PPV) of the hospital discharge data were calculated by comparing with the mortality dataset and chart review finding respectively. Between 1990 and 2006 there was a highly significant rise in annual incidence and mortality rates of NF from 0.18 to 1.69 and from 0 to 0.3 per 100,000 person-years respectively. The causes of this increase are unknown, and were not related to 2004 coding changes for NF. Hospital discharge data had a PPV of 82.6% and sensitivity of 76.8%. The case fatality was 20.8%. Disease risk was highest in the elderly, males, and Pacific and Maori populations. These findings suggest that incidence and mortality of NF are increasing in NZ. Further work is needed to investigate the causes of this increase and the marked ethnic inequalities in disease rates, particularly factors that may be preventable.

Recurrent Fatal Necrotizing Fasciitis due to &lt;i&gt;Streptococcus pyogenes&lt;/i&gt; in a Child with Hereditary Sensory and Automic Neuropathy Type IV

Although necrotizing fasciitis (NF) is a rapidly progressive infection, recurrent NF is very rare. Herein we report a rare case of recurrent NF due to Streptococcus pyogenes. A 12-year-old female with hereditary sensory and autonomic neuropathy (HSAN) type IV presented with fever and swelling on her left knee. NF was diagnosed and she was treated successfully. Two years later she was readmitted with NF of the right knee and limb. Despite treatment, progressive tissue necrosis developed and proximal femur amputation was performed. Eight months following the second attack she was readmitted with NF of her left knee and her entire leg. Despite a wide surgical debridement and antibiotic treatment, the clinical status of the patient failed to improve and she subsequently died. Although many conditions have been reported to be predisposing factors for NF, this is the first report of an association between HSAN type IV and recurrent NF due to S. pyogenes. We recommend antibiotic prophylaxis for patients with NF due to S. pyogenes, especially for those with predisposing factors.

Virulence of serotype M3 Group A Streptococcus strains in wax worms (Galleria mellonella larvae)

Group A Streptococcus (GAS) causes human infections that range in severity from pharyngitis ("strep-throat") to necrotizing fasciitis ("flesh-eating disease"). To facilitate investigation of the molecular basis of host-pathogen interactions, infection models capable of rapidly screening for differences in GAS strain virulence are needed. To this end, we developed a Galleria mellonella larvae (wax worm) model of invasive GAS infection and used it to compare the virulence of serotype M3 GAS strains. We found that GAS causes severe tissue damage and kills wax worms in a dose-dependent manner. The virulence of genetically distinct GAS strains was compared by Kaplan-Meier survival analysis and determining 50% lethal doses (LD50). Host-pathogen interactions were further characterized using quantitative culture, histopathology and TaqMan assays. GAS strains known to be highly pathogenic in mice and monkeys caused significantly lower survival and had significantly lower LD50s in wax worms than GAS strains associated with attenuated virulence or asymptomatic carriage. Furthermore, isogenic inactivation of proven virulence factors resulted in a significantly increased LD50 and decreased lesion size compared to the wild-type strain, a finding that also strongly correlates with animal studies. Importantly, survival analysis and LD50 determination in wax worms supported our hypothesis that a newly emerged GAS subclone that is epidemiologically associated with more human necrotizing fasciitis cases than its progenitor lineage has significantly increased virulence. We conclude that GAS virulence in wax worms strongly correlates with the data obtained in vertebrate models, and thus, the Galleria mellonella larva is a useful host organism to study GAS pathogenesis.

Two Cases of Necrotizing Fasciitis in Patients with SLE

Necrotizing fasciitis (NF) is an uncommon, life-threatening infection of the subcutaneous tissue and superficial fascia. The clinical course of NF is rapid and progressive, and it is often fatal despite the appropriate therapy. The prognosis of NF depends on a timely diagnosis and then proper treatment. At onset it may not be possible to clearly distinguish NF from minor soft-tissue infections. Although infection are common due to the use of steroids and immunosuppressive agents in patients with systemic lupus erythematous (SLE), it is interesting that NF has rarely been reported with SLE. Here, we present two cases of NF with SLE.

Clinical evaluation of forty-four patients with necrotizing fasciitis

Necrotizing fasciitis is a rare but life-threatening soft-tissue infection primarily involving the superficial fascia and subcutaneous tissue. We conducted a retrospective study of 44 patients with necrotizing fasciitis between 2004 and 2008 in Akdeniz University Hospital, Department of Infectious Diseases and Clinical Microbiology and other departments. The aim of this study was to determine the causative agents of the necrotizing fasciitis, and the localization, predisposing factors, and comorbid conditions. We found that diabetes mellitus, trauma and surgery were the most important predisposing factors. Moreover, the lower extremity and perianal region were the most frequently involved sites. Polymicrobial agents were the most frequent and the mortality was found as 25%. In conclusion, necrotizing fasciitis cases followed in our hospital were evaluated in this study.

Two Survived Cases of Necrotizing Fasciitis Caused by Sacral Decubitus

壊死性筋膜炎は急速に進行する致死性の高い疾患で，基礎疾患として糖尿病が多い。今回，仙骨部褥瘡に起因した壊死性筋膜炎で，広範囲の切開排膿，洗浄ドレナージとデブリードマンを行ない救命できた症例を2例経験したので報告する。症例1は74歳男性で，既往歴に糖尿病とうつ病を認めた。症例2は82歳男性で，既往歴に糖尿病，脊椎損傷による対麻痺，仙骨部褥瘡を認めた。いずれも壊死性筋膜炎発症早期に臀部と背部の広範囲の切開排膿，洗浄ドレナージとデブリードマンを行ない，広域スペクトルの抗菌薬投与で救命できた。また術前の全身状態，糖尿病などの基礎疾患や術後の創部からの蛋白漏出により，術後に栄養状態が著明に悪化したため，糖尿病のコントロールとそれに伴う栄養管理で栄養状態は改善した。活動性低下に対しては，体圧分散寝具の使用，体位交換やリハビリテーションが創の早期改善のために必要であった。

Bilateral necrotizing fasciitis of the breast following quadrantectomy

Necrotizing fasciitis (NF) is a rare and highly lethal soft-tissue infection that involves the skin, subcutaneous tissue, and fascia. Although it can affect any part of the body, the breast is seldom involved. We describe a case of bilateral NF of the breast following elective quadrantectomy, successfully treated with antibiotics, bilateral mastectomy, and a vacuum-assisted wound closure system.

Necrotising fasciitis secondary to intra-abdominal sepsis

Dear Editor: Necrotising fasciitis (NF) is a soft tissue infection where a microorganism or microorganisms spread along superficial and deep fascial planes. NF as a disease entity was first described by Hippocrates circa 500 BC, but it was not until 1952 that the term necrotising fasciitis was coined. The spread is facilitated by bacterial exotoxins such as streptococcal pyrogenic exotoxins (SPEs) A, B, C which are directly toxic. SPEs cause thrombosis of perforator vessels, resulting in tissue necrosis. SPEs also lead to the production of cytokines causing clinical signs, such as sepsis. Surface protein expression increases streptococcal adherence to tissues and also protects bacteria against phagocytosis by neutrophils. Herein, we report a case of NF caused by a perforated rectal carcinoma, and we review the literature to reveal other intra-abdominal causes of necrotising fasciitis. A 53-year-old gentleman was admitted in septic shock with a 7-day history of abdominal pain and limping. The patient had a background history of recent onset diarrhoea and weight loss. On examination, his abdomen was distended, with localised peritonitis in the left iliac fossa. There was a large area of erythema and palpable crepitus on the posterior aspect of his left thigh extending from the gluteal fold to the mid thigh. Proctoscopy revealed frank pus in the rectum with no signs of a perineal source of sepsis. Blood tests showed a white blood cell count of 12.2, and C-reactive protein was 269. He was initially fluid-resuscitated and treated with cefuroxime and metronidazole. Computed tomography (CT) scan of the abdomen and pelvis revealed extensive free air in the left upper thigh. Air fluid levels were also visualised. Within the pelvis, there was circumferential thickening of the sigmoid and rectal wall and extensive pre-rectal inflammatory change and enlarged retrocrural and para-aortic lymph nodes. A provisional diagnosis of necrotising fasciitis secondary to perforated diverticulitis or a perforated neoplasm was made, and the patient proceeded on an emergent basis to a laparoscopy, lavage, and defunctioning transverse colostomy. Ensuing exploration of the left thigh and pelvic floor revealed the offensive purulent material and findings were consistent with necrotising fasciitis. Extensive debridement of all involved tissues, including skin, fascia, and muscles including semi-membranosus, semi-tendinosus, and gracilis was carried out. A washout of wounds and redressing was carried out every 48 h. A split-thickness skin graft was used to close the wounds once the patient had improved clinically 3 weeks later. Microbiology confirmed the presence of Escherichia coli and mixed anaerobes from wound swabs. Histology later confirmed that the debrided tissue was consistent with necrotising fasciitis. Flexible sigmoidoscopy was performed, and a tumour was visualised at 5 cm. Biopsies taken showed evidence of rectal adenocarcinoma. The tumour was staged radiologically as T4N2Mx. Neoadjuvant chemoradiotherapy was used following complete wound healing. The chemotherapy regime included five cycles of 5-fluorouracil (5-FU). Twenty-five fractions of radiotherapy were used. The patient subsequently underwent an abdominoperineal resection. Histology confirmed D. P. O’Leary (*) : E. Myers :M. McCourt Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland e-mail: Olearypeter83@hotmail.com

Necrotizing fasciitis caused by Staphylococcus epidermidis in a neonate with extremely low birthweight

Necrotizing fasciitis (NF) is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. The initial skin presentation ranges from minimal rash to cellulites. The lesions subsequently spread rapidly. Even with appropriate medical and surgical therapy, the mortality rate in NF is more than 50%. In cases of neonates, mortality rate is higher than that ratio. High index of suspicion, prompt aggressive surgery, appropriate antibiotics and supportive care are the mainstays of management in the newborn infant with NF. Herein, we report a case of invasive and mortal NF caused by Staphylococcus epidermidis in an infant with extremely low birthweight.

Cervical necrotizing fasciitis of odontogenic origin involving the temporal region – A case report

Necrotizing fasciitis (NF) is a soft-tissue infection, usually polymicrobial, that causes necrosis of fascia and subcutaneous tissue while sparing skin and muscle. We report a case of cervical NF complicating dental infection in a 50-year-old woman, who presented with infection involving mucosa of the right mandible and temporal muscle, and masticator spaces, requiring extensive surgery and antibiotic therapy. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections.

Infections cutanées chez les patients atteints de pemphigoïde bulleuse traités par dermocorticoïdes

Potent topical corticosteroids (TCS), such as clobetasol propionate are more efficacious than systemic corticosteroids in the treatment of bullous pemphigoid (BP) and in reducing the rate of systemic infectious complications. However, TCS can have cutaneous side effects, such as atrophy and purpura. The risk of cutaneous infections due to TCS in BP is known but has never been studied, despite prolonged use of high doses. Since we noted three cases of fatal necrotizing fasciitis (NF) in patients treated with TCS for BP over a one-year period in our institution, we decided to analyse the frequency of cutaneous infections in all BP patients hospitalized in our department.In this retrospective single-centre study, all files of patients presenting BP treated with TCS and hospitalized between April 2008 and April 2009 were reviewed. When the clinical file indicated a cutaneous infectious problem, bacteriological data were requested from the bacteriology laboratory. For each patient, clinical data, history, ongoing treatment, type of cutaneous infectious complication, general symptoms and details of outcome were collected.In the 30 files studied, we found ten cutaneous infections in nine patients: minor complication (three cases of impetiginisation), moderate complications (two erysipelas, one lymphangitis with sepsis, one flexor tendon phlegmon with cutaneous fistula), and severe complications with a fatal course (three NF, one of which had involved erysipelas of favourable outcome a few months earlier). These cutaneous complications occurred after various treatment times (ten days to two years) and various dosages of TCS (two-three tubes/day to two tubes every two days). Three of the nine patients with cutaneous infections had diabetes, in particular two of the three patients with FN. In contrast, four of the 21 patients without cutaneous complications had diabetes. Patients with cutaneous infections did not have more extensive BP or receive more TCS than the others. In two of three patients with NF, an immunosuppressant drug (methotrexate or mycophenolate mofetil) had been recently initiated (inferior to one month). The offending organism was Staphylococcus aureus in seven cases (methicillin-resistant in three cases) and Streptococcus A in five cases (three NF, one lymphangitis and one impetiginisation). The outcome was fatal in the three cases of NF but was favourable with local and/or systemic antibiotic therapy in the remaining cases.In this study, we noted cutaneous superinfection in nine of 30 (30%) patients receiving topical corticosteroids for bullous pemphigoid, among which were three cases of fatal NF due to streptococcus A (10%). The infectious risks associated with TCS must not be neglected, particularly since treated patients are old and fragile, and frequently have multiple well-known risk factors for NF (e.g. extensive lesions, diabetes, etc.). In the event of signs of cutaneous superinfection, especially in cases of diabetes and prolonged TCS treatment, bacteriological analysis should be conducted. Adequate treatment should be initiated without delay, especially in cases of beta-haemolytic streptococcal infection.

Neonatal necrotizing fasciitis and fungal infections in preterm infants

Necrotizing fasciitis (NF) in premature infants is a rare, yet life-threatening, soft tissue infection. We report four cases of NF that were encountered over a seven-year period. The onset of the disease was between four and twelve days of age. Predisposing factors were omphalitis in two infants and intestinal perforation in the other two infants, one of whom had necrotizing enterocolitis. Surgical biopsies from the affected sites showed mucormycosis in one infant and bipolaris fungi in another. One of these infants was treated with antifungal therapy in addition to broad spectrum antibiotics. This infant survived, even without surgical intervention while the other three died. We conclude that intestinal perforation and omphalitis are important predisposing factors of NF in premature infants. Fungal infection should be considered as one of the possible causes of NF in preterm infants. Early initiation of antifungal therapy, in addition to broad spectrum antibiotics, is justifiable in this disease entity.

Coagulase-Positive Staphylococcal Necrotizing Fasciitis Subsequent to Shoulder Sprain in a Healthy Woman

Necrotizing fasciitis (NF) is a deep infection of the subcutaneous tissue that progressively destroys fascia and fat; it is associated with systemic toxicity, a fulminant course, and high mortality. NF most frequently develops from trauma that compromises skin integrity, and is more common in patients with predisposing medical conditions such as diabetes mellitus, atherosclerosis, alcoholism, renal disease, liver disease, immunosuppression, malignancy, or corticosteroid use. Most often, NF is caused by polymicrobial pathogens including aerobic and anaerobic bacteria. NF caused by Staphylococcus aureus as a single pathogen, however, is rare. Here we report a case of NF that developed in a healthy woman after an isolated shoulder sprain that occurred without breaking a skin barrier, and was caused by Staphylococcus aureus as a single pathogen.

Necrotizing fasciitis in a patient with overlap syndrome of systemic sclerosis and systemic lupus erythematosus

Necrotizing fasciitis (NF) is an uncommon destructive disease and fatal infection of the subcutaneous tissue. The literature includes a limited number of NF cases in rheumatic disease such as rheumatoid arthritis and systemic lupus erythematosus (SLE). We report a 40-year-old patient who had complicated with NF during treatment with corticosteroid and azathioprine for overlap syndrome of systemic sclerosis and SLE. She underwent urgent surgical debridement and internal drainage with antibiotics and had complete recovery from NF. To our knowledge, this is the first case of NF developed in a patient of overlap syndrome with diffuse type of systemic sclerosis and SLE and suggests that NF can be a very rare cutaneous manifestation of this disease.

Necrotizing fasciitis caused by Streptococcus pneumoniae

A 69-year-old woman presented with shivering and pain in the lower extremities on 5 April 2006; she was referred to the dermatology division of our hospital on the following day with difficulty in walking. She had been suffering from non-viral, non-alcoholic liver cirrhosis, and was being treated by the Division of Internal Medicine. Physical examination showed edema in the lower extremities and light purpuras on the groin and legs. Low blood pressure had been observed since admission. Necrotizing fasciitis (NF) was suspected on the basis of the skin symptoms, systemic conditions, and magnetic resonance imaging. During surgical debridement under general anesthesia, cardiopulmonary arrest occurred, and the patient died 12 h after admission. NF, in its early stages, exhibits few skin changes. In order to differentiate it from other skin infections, it is necessary to take into account blood pressure, abnormal systemic conditions, and severe pain out of proportion to its minor skin changes. In the present case, Streptococcus pneumoniae was detected by blood culture. Soft tissue infectious diseases caused by S. pneumoniae, especially NF, are very rare. We have reviewed reported cases of NF caused by S. pneumoniae.

First Report of a Necrotising Fasciitis of the Breast Following a Core Needle Biopsy

Necrotising fasciitis (NF) is the most aggressive form of soft tissue infection. We report the first case of NF of the breast following a core needle biopsy. Aggressive management including surgical debridement and vacuum therapy allowed wound healing and breast conservation.

Cervical necrotizing fasciitis.

Necrotizing fasciitis (NF) is a rapidly progressing soft tissue infection that carries a significant mortality rate despite intensive treatment. Terms such as hospital gangrene, streptococcal gangrene, Meleney gangrene, gangrenous erysipelas, necrotizing erysipelas ,a ndsynergistic necrotizing cellulitis have been used as synonyms. More commonly seen in the abdomen, perineum, and lower extremities, the neck, owing to its rich vascular network, is a rare site for this fulminant condition. It is characterized by widespread destruction of the subcutaneous tissues and fasciae and gas formation in anatomic spaces. Overlying skin and muscles are spared initially but may undergo necrosis with disease progression. Cervical NF is most commonly caused by dental infection, especially from the mandibular molars, followed by trauma. 1,2 Less common causes of cervical NF are peritonsillar abscess, insect bites, osteoradionecrosis, and hypodermic needle infection. 3 NF can be caused by a single organism but usually occurs as a polymicrobial infection. Among causative bacteriae are group A b-hemolytic and other types of streptococci, Staphylococcus aureus, Eschericihia coli, Klebsiella spp, and some obligate anaerobes, such as Bacteriodes spp and Peptostreptococcus spp 1,4 In this article, three cases of cervical NF are described and the clinical features and management of this fulminant disease are discussed.

Abdominoplasty as a reconstructive surgical treatment of necrotising fasciitis of the abdominal wall

Necrotising fasciitis (NF) is a potentially fatal, uncommon infection of the soft tissue with rapid progression. This article presents one case of NF of the abdomen wall, describing the presentation, diagnosis and long-term successful treatment. The defect of the abdominal wall was treated with medical support (antibiotics broad-spectrum coverage), V.A.C. therapy and plastic surgery procedures. The coverage of the abdominal wall defect has been achieved by abdominoplasty-type advancement flaps in one step with the preservation of the umbilicus. One month after the surgical procedure, the patient returned to a normal lifestyle with a good quality of life. The success of this case should be attributed to an early diagnosis, aggressive debridement and a good intensive medical management; these elements are essential to a better prognosis for NF.