Necrotizing Fasciitis Research Articles

Facing a new reality: significant increase in necrotizing fasciitis in the post-covid era?

Necrotizing fasciitis (NF) is a rare, rapidly progressing soft tissue infection characterized by the widespread necrosis of fascial planes and surrounding tissues. We discuss four consecutive necrotizing fasciitis cases of the head and neck region, that accured in a time window of 6 months. Patient demographics, clinical features, laboratory analyses, imaging findings, surgical interventions, and outcome were collected, assessed and discussed. These findings were checked against recent epidemiological data of invasive Group A Streptococcus (iGAS) in Europe. Four patients (two males and two females) aged between 31 and 65 years were included. The most common presenting symptom was severe pain and facial swelling (100%), followed by fever (50%) and erythema (50%). All patients underwent emergency surgical debridement, and broad-spectrum antimicrobial therapy was initiated promptly. Streptococcus pyogenes was isolated in every patient. Three patients required multiple debridement procedures, and one case necessitated extensive neck resection due to the involvement of deeper structures. Overall, two patients recovered with no to minor residual deficits, one patient experienced persistent trismus and one patient passed away due to septic shock and multiorgan failure. Prevalence of iGAS infections have increased in European countries, therefore increased vigilance is recommended so that a quick diagnosis can be established and appropriate treatment can be administered to avoid serious morbidity and mortality.

Necrotizing fasciitis: treatment concepts & clinical outcomes – an institutional experience

BackgroundA severe infection of the skin and soft tissues, Necrotizing Fasciitis (NF), spreads quickly along the deep fascia. This study aimed to characterize the clinicopathological features, analyze the implicated bacteria’s antibiotic sensitivity, evaluate surgical management, and assess the diagnostic accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in Necrotizing Soft Tissue Infection (NST).MethodsThis single-center prospective observational study was conducted in the Department of General Surgery, Kasturba Medical College, Manipal, with 171 proven cases of NSTI between 2019 and 2021. Clinico-demographic data and laboratory investigation values were collected at two-time points (at admission and 72 h after admission). Imaging data, LRINEC score, culture results, and antibiotic sensitivity were recorded. Appropriate descriptive and analytical statistics were used for the statistical analysis.ResultsOf the 171 patients, 150 were male (87.7%). The mean age was 57.6 ± 13.1 years. The presenting features in all the cases were pain, swelling, and fever. Diabetes mellitus (DM) is the most common comorbidity. The lower extremities were the most commonly affected sites. Streptococcus pyogenes showed significant growth in 25.41% of the samples. Ceftriaxone sensitivity was seen in 41/141. A score of ≥ 8 was obtained in 118/171 (69%) patients, suggesting a higher severity and significant risk for NSTI. The Area Under the Curve of Receiver Operating characteristic Curve (ROC) for establishing diagnostic accuracy for LRINEC was 0.694. Mortality was significantly higher in the patients with higher LRINEC scores and elevated procalcitonin. The mortality rate was higher in patients who underwent surgery within 12 h.ConclusionNecrotizing fasciitis is a soft tissue infection with a high mortality rate. The clinical features and determinants of mortality in patients with NF are highlighted in this study. At the outset, a high index of suspicion was critical. Using prognostic evaluation techniques in daily clinical practice will assist medical professionals in providing adequate on-time care and significantly lowering mortality. The AUC for LRINEC score, although significant, is low. LRINEC score is not to be used to determine whether surgical intervention should be expedited or anticipated. Its role is to aid in prognosticating the outcome of the individual patient. Our study concludes that early extensive surgical debridement remains the single most crucial intervention in patients diagnosed with necrotizing fasciitis (NF), regardless of disease severity and the LRINEC score.

Opportunities and Challenges of Application of Cytosorb Therapy in Sepsis Management

Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. In 2017, an estimated 48·9 million incident cases of sepsis were recorded worldwide, and 11·0 million sepsis-related deaths were reported, representing 19·7% of all global deaths.1 Though overall data related to sepsis is poor but it is also a major health care challenge for resource limited countries. Severe sepsis is a significant & common health problem in ICU patients of Bangladesh2. A continuum of severity from sepsis to septic shock and multi-organ dysfunction syndrome (MODS) exists. MODS is a clinical syndrome characterized by the development of progressive and potentially reversible physiologic dysfunction in 2 or more organs or organ systems that is induced by a variety of acute insults, including sepsis. Sepsis leads to malignant intravascular inflammation, coagulopathy, circulatory derangement, tissue hypoxia, cytotoxicity and apoptosis. As a result, dysfunction of vital organ systems occur. Host response and other factors influenc outcome. Patients with sepsis must be treated with-timely, appropriate antibiotics, intravenousfluids, vasopressor and inotropic support & oxygen therapy.3 Other additional treatments including extracorporeal blood purification techniques (BPT). These techniques include hemofiltration, hemoperfusion, intermittent or continuous high-volume hemofiltration (HVHF), plasmapheresis or adsorption.4 The rationale behind such an approach is to achieve “immune homeostasis” which theoretically reduces the potential damage caused by dysregulation of the host response to infection. Given the pivotal role of cytokine production in sepsis, it follows that removal of these substances, through such BPT, may attenuate the response particularly in the early phase of sepsis.5 Indications include 1) Rhabdomyolysis resulting from Reperfusion syndrome, Trauma, Malignant Hyperthermia. 2) External injuries including Sepsis/Septic shock, Hemorrhagic shock, Trauma, Ruptured aortic aneurysm, Post-Cardiac Arrest Syndrome, Cardio-pulmonary resuscitation, Extensive surgery, Organ transplantation, Cardiosurgical intervention, Severe skin and soft tissue damage, Burns, Necrotizing fasciitis, Post-Cardiotomy Syndrome, Acute Respiratory Distress Syndrome. 3) Diseases: Pancreatitis, Liver insufficiency, Renal insufficiency, Stroke, Myocardial infarction, Cardiogenic shock/Heart failure, Tumor Lysis Syndrome, Hemophagocytosis Syndrome. Liver failure/Hyperbilirubinemia bridging to transplant or to recovery, Life-threatening bleeding under Direct Oral Anticoagulants (DOAC)6. Bangladesh Crit Care J September 2024; 12 (2): 79-80

Vulvar necrotizing wounds: Unveiling mortality-associated parameters and assessing the efficacy of VAC therapy

IntroductionVulvar Necrotizing Fasciitis (VNF) is a critical, severe soft tissue infection characterized by aggressive progression and significant morbidity and mortality. Rapid diagnosis and immediate, comprehensive treatment, including antibiotic therapy, meticulous surgical debridement, and multidisciplinary care, are crucial for improving outcomes. This study aimed to investigate mortality-related factors in VNF and evaluate treatment modalities, focusing on Vacuum-Assisted Closure (VAC) therapy versus traditional debridement. MethodsThis retrospective study analyzed data from 22 VNF patients. Criteria included adults diagnosed with vulvar necrotizing infections, excluding those transferred or not completing treatment at the center. The study examined mortality-related factors and the efficacy of VAC therapy compared to debridement, considering treatment costs and outcomes. ResultsAnalysis divided patients into survivors (13) and non-survivors (9). Higher heart rate, elevated WBC and CRP levels, and higher Clavien-Dindo scores were associated with increased mortality. VAC therapy, compared to traditional debridement, resulted in significantly lower CRP levels and reduced treatment costs. However, other parameters such as the length of hospital stay and debridement frequency showed no significant differences. ConclusionThe study highlights that older age, systemic inflammation, and severe postoperative complications are key factors associated with higher mortality in VNF. VAC therapy emerges as a promising modality, effectively reducing systemic inflammation and healthcare costs. Nonetheless, the retrospective nature and the small sample size of the study limit the generalizability of the findings. Future research, particularly larger, multicentric studies, is essential to further explore and validate the effectiveness of VAC therapy in VNF management.

Modified Laboratory Risk Indicator and Machine Learning in Classifying Necrotizing Fasciitis from Cellulitis Patients

Necrotizing fasciitis (NF) is a severe and life-threatening soft tissue infection that requires timely and accurate diagnosis to improve patient outcomes. The early diagnosis of NF remains challenging due to its similarity to other subcutaneous soft tissue infections like cellulitis. This study aims to employ machine learning techniques to differentiate NF from cellulitis and enhance the diagnostic accuracy of NF by developing a modified LRINEC (MLRINEC) score. These modifications aimed to improve the sensitivity and specificity of NF diagnosis. The study utilized three machine learning classifiers—Logistic Regression, decision tree, and Random Forest—to assess their effectiveness in distinguishing between NF and cellulitis cases. The MLRINEC score was developed by incorporating six key blood test parameters: creatinine, hemoglobin, platelet count, sodium, white blood cell count, and C-reactive protein using laboratory data from Maha Sarakham Hospital in Northeastern Thailand. Our findings indicate that the decision tree classifier demonstrated superior performance, achieving the highest recall, particularly in accurately identifying NF cases. A feature importance analysis revealed that hemoglobin levels and white blood cell counts were the most critical factors influencing the model’s predictions. The platelet count (PT), C-reactive protein (CRP), and creatinine (CT) also played important roles, while sodium levels (NA) were the least influential. The MLRINEC score demonstrates high accuracy in classifying NF and cellulitis patients, paving the way for improved diagnostic protocols in clinical settings.

Importance of a thorough history and physical examination: Case report of atypical necrotizing fasciitis.

This case report presents a 34-year-old Middle Eastern woman with atypical symptoms of Type II Necrotizing Soft Tissue Infection (NSTI). Due to the difficulty in diagnosing Type II NSTI, the patient experienced protracted illness. Once diagnosed, the patient underwent multiple surgical debridement procedures requiring antibiotic and pain management therapy before being successfully discharged home. Initial diagnosis of Type II NSTI is challenging to the provider due to vague symptoms and late occurrence of cutaneous changes. When cutaneous lesions are identified, rapid surgical evaluation is imperative to minimize morbidity and mortality. This paper emphasizes the complexity of diagnosing Type II NSTI and the need for a comprehensive history and frequent physical examinations.

Validation of necrotising infection clinical composite endpoint in a retrospective cohort of patients with necrotising soft tissue infections.

Rapidly progressive necrotising soft tissue infections (NSTIs) are associated with high mortality and morbidity. Low incidence and disease heterogeneity contribute to low event rates and inadequately powered studies. The Necrotising Infections Clinical Composite Endpoint (NICCE) provides a binary outcome with which to assess interventions for NSTIs. Partly with a view towards studies of hyperbaric oxygen treatment in NSTIs we aimed to validate NICCE in a retrospective cohort of NSTI patients. Eligible patients were admitted between 2012 and 2021 to an adult major referral hospital in Victoria, Australia with surgically confirmed NSTI. The NICCE and its constituents were assessed in the whole cohort (n = 235). The cohort was divided into two groups using the modified sequential organ failure assessment (mSOFA) score, with an admission mSOFA score ≥ 3 defined as high acuity. Baseline characteristics of the whole (n = 235), the high (n = 188) and the low acuity cohorts (n = 47) were similar. Survival rates were high (91.1%). Patients with an admission mSOFA ≥ 3 were less likely to meet NICCE criteria for 'success' compared to the lower acuity cohort (34.1% and 64.7% respectively). Meeting NICCE criteria was significantly associated with lower resource utilisation, measured by intensive care unit days, ventilator days, and hospital length of stay for all patients and for those with high acuity on presentation. The NICCE provides greater discriminative ability than mortality alone. It accurately selects patients at high risk of adverse outcomes, thereby enhancing feasibility of trials. Adaptation of NICCE to include patient-centred outcomes could strengthen its clinical relevance.

Streptokinase reduces Streptococcus dysgalactiae subsp. equisimilis biofilm formation

BackgroundStreptococcus dysgalactiae subspecies equisimilis (SDSE) is increasingly recognized as an emerging cause of invasive diseases including necrotizing soft tissue infections (NSTIs). In contrast to the closely related Streptococcus pyogenes, SDSE infections mainly affect older and comorbid patients. Biofilm formation has been demonstrated in soft tissue biopsies of S. pyogenes NSTI cases.ResultsHere, we show that bacterial aggregations indicative of biofilms are also present in SDSE NSTI. Although streptokinase (Ska) activity and biofilm formation did not correlate in a diverse set of clinical SDSE isolates, addition of exogenous Ska at an early time point prevented biofilm formation for selected strains. Deletion of ska in SDSE S118 strain resulted in increased biofilm forming capacity. Ska-deficient mutant strain was characterized by a higher metabolic activity and consequent metabolome profiling of biofilms identified higher deposition of a wide range of metabolites as compared to the wild-type.ConclusionsOur results argue that Ska suppresses biofilm formation in SDSE independent of its original plasminogen converting activity. However, the impact of biofilms and its consequences for patient outcomes in streptococcal NSTIs remain to be elucidated.

Impact of the COVID-19 Pandemic on Group A Streptococcal Necrotizing Soft Tissue Infections: A Retrospective Cohort Study.

Necrotizing soft tissue infections (NSTIs) are often caused by group A Streptococcus (GAS). As the number of invasive GAS infections decreased during the coronavirus disease 2019 (COVID-19) pandemic restrictions, this study aimed to compare the occurrence of GAS-NSTIs before, during, and after the COVID-19 pandemic restrictions. This retrospective cohort study included adult patients with NSTIs admitted to the intensive care unit (ICU) of the University Hospital Zurich, Switzerland, from July 2008 to December 2023. NSTI cases were categorized as pre-, during, and postrestrictions. The primary outcome was the proportion of GAS in NSTI, and the exploratory secondary outcome was in-hospital death. A data analysis was conducted using Firth logistic regression adjusted for age, sex, diabetes, and initially affected body region. Overall, 74 NSTI cases were identified, with 49 occurring before, 8 during, and 17 after the pandemic restrictions. GAS was isolated in 27 (36%) cases, with 17 (35%) pre- and 10 (59%) postrestrictions, but none during the restrictions. NSTIs caused by other bacteria persisted during the restrictions. The odds of GAS were significantly lower during the restrictions (adjusted odds ratio, 0.02; 95% CI, 0.001-0.81) compared with after, while no significant differences were found between the pre- and postrestriction periods. The significant decrease of GAS-NSTIs during the COVID-19 pandemic restrictions suggests that isolation measures may have prevented the transmission of GAS, resulting in a decline of GAS-NSTIs while NSTIs caused by bacteria transmitted by alternative routes persisted.

Case report: is necrotizing fasciitis in a rectal cancer patient after targeted systemic therapy related to the tumor site? - evidence from a hepatocellular carcinoma patient

Necrotizing fasciitis (NF) is a rare and life-threatening serious infectious disease, characterized by acute onset and rapid progress, leading to extensive necrosis of skin, soft tissue as well as fascia by a variety of aerobic and anaerobic bacteria, localized on external genitalia, scrotum, groin and perianal areas in males. There exist numerous common etiologies for NF, yet NF induced by malignant neoplasms is exceedingly rare. Several studies have reported that NF may be associated with tumor site (rectal/sigmoid colon cancer) and blood supply dysfunction caused by targeted therapy drugs (bevacizumab, aflibercept, ramucirumab). The perforation of colorectal cancer poses a unique risk factor for NF. However, in our two cases, the patient with rectal cancer received CapeOX (oxaliplatin + capecitabine) + bevacizumab + tislelizumab for 3 cycles without perforation but did develop NF. One month after debridement, the patient continued immunotherapy with tislelizumab alone for the fourth cycle and maintained for an additional 3 cycles without any recurrence of NF. Therefore, does the occurrence of NF correlate with the tumor site (rectum) and targeted immunotherapy? Another patient with hepatocellular carcinoma also developed NF after receiving 2 cycles of lenvatinib + sintilimab treatment. The third cycle of sintilimab immunotherapy was administered on the 13th day after operation, which was subsequently maintained for an additional 2 cycles without recurrence of NF. The absence of a direct correlation between hepatocellular carcinoma and rectal tumor location as well as immunotherapy, suggests that NF may be closely linked to targeted therapy.

WP7.16 - Usefulness of Cross-Sectional Imaging and Biochemical Markers in Diagnosing Necrotising Soft Tissue Infections

Abstract Introduction Diagnosis of Necrotising Soft Tissue Infections (NSTI) remains clinical, however pre-operative investigations and radiology may be useful for cases of diagnostic uncertainty or pre-operative planning. Aims To identify if cross-sectional imaging is useful in the diagnosis of NSTI's. To identify if Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score supports the diagnosis of NSTI’s. Methods Retrospective data collection of all relevant clinical data for all histologically confirmed NSTI’s in a single centre from 2012 to 2022 inclusive. Results 73 total cases of NSTI were confirmed. 27 patients underwent CT imaging as a direct result of their presenting complaint. CT was performed for the following reasons,Patient NoReason for CT10Clinically confirmed - CT to assess extent of involvement4Clinically suspicious – CT to confirm diagnosis5No clinical diagnosis – CT features of NSTI8Incidental findings – CT for alternative diagnosis Only 3 patients had a prospective documented LRINEC score. As such retrospective LRINEC scores were calculated for each case in this cohort. Average scores were 7.71 (Range 4-13), which is above the reported threshold value of 6. Conclusion CT scans are useful in clinically confirmed or suspected NSTIs for further assessment, however with regards to diagnosing NSTIs, clinical diagnosis remains the preferred modality. There remains limited data to suggest that a CT scan should be gold standard in identifying and confirming NSTI’s. LRINEC scoring however should be utilized for all suspected NSTI’s, it remains poorly utilized but would provide significant value and diagnostic guidance when above threshold values.

ThP6.10 - Overview of Necrotising Soft Tissue Infections' Risks and Outcomes

Abstract Introduction Necrotising Soft Tissue Infections (NSTI) are severe life-threatening conditions, which are increasing in incidence. Associated with high mortality and morbidity, NSTI’s are a significant burden to health care services globally. Identifying themes, risk factors and underlying causation is therefore of interest. Methods A retrospective data cohort study examining clinical data for all histologically confirmed NSTI cases in a single centre between 2012 to 2022 was conducted. Results 73 confirmed NSTI cases were identified. Patient co-morbidities included the following:CasesDiabetic34Smoker16Post-op12IVDU8Trauma7Immunosuppressed6Bowel Perf5Cancer5 68 patients underwent urgent surgical debridement, with an average of 3.59 (Range 1-11) further surgical interventions required. Patients spent an average of 8.24 days (Range 1-42 days) in ICU, with a hospital stay of 44.02 days. (Range 7-180 days) 6(8%) patients died (5 within first week of presentation). Defunctioning stomas were performed in 24 patients during the admission and 32 patients underwent reconstructive surgery after recovery from the acute phase. An array of causative organisms were identified with no clear delineating trends.NumberAnaerobes36Streptococcus35Staphylococcus20E Coli + Coliforms20Enterococcus15 Conclusion NSTIs continue to increase in incidence and prevalence. The old surgical adage ‘You will see one NSTI in your lifetime is no longer true. Associated morbidity and mortality is significant and a focus on early recognition and prevention is vital. Further larger data sets are required to delineate clear trends and associated risk factors that can effect meaningful health care policy change.

EP568 - A rare case of necrotizing fasciitis caused by Streptococcus Anginosus and Staphylococcus Lugdunensis

Abstract Necrotizing fasciitis (NF) is a rare soft tissue infection involving the fascial planes, causing rapid and extensive tissue destruction. We present a unique case of NF in a patient with poor glycemic control caused by atypical pathogens. A 66-year-old female with a recent biopsy for a wart-like lesion developed a wound infection, with greenish-black exudate. Initial observations were: temperature: 39.4 degrees, heart rate: 105, GCS: 15/15. Physical examination revealed a grossly filiform lesion below her abdominal apron measuring 7cm in diameter. The patient was empirically treated with IV Co-Amoxiclav. Abnormal biochemistry results are shown below. Microbiological analysis revealed Streptococcus Anginosus, anaerobes and Staphylococcus Lugdunensis. CT abdomen revealed extensive inflammatory changes with gas and fluid collection and enlarged pelvic and inguinal lymph nodes. Two urgent surgical explorations and debridements, with meticulous wound care using negative pressure wound dressings (Prevena) were done. Intravenous Gentamicin, Benzylpenicillin, Clindamycin, Metronidazole and Flucloxacillin were administered for six weeks. The patient's clinical status gradually improved. Streptococcus Anginosus, that is part of the Streptococcus Milleri group and Staphylococcus Lugdunensis, a coagulase-negative Staphylococci (CoNS) are commensal organisms of the oral and gastrointestinal tracts. These organisms possess virulence factors that facilitate tissue invasion and destruction, causing an aggressive course of NF. This case highlights the importance of considering atypical pathogens, especially in patients with predisposing factors such as diabetes and obesity. Early recognition, prompt surgical intervention and a multidisciplinary approach are essential for improving outcomes in these cases.TestResultWhite Blood Cells (WBC)22,200 [WBCs per microliter]Sodium123 [mmol/L]Chloride88 [mmol/L]C-reactive protein (CRP)318 [mg/L]Blood Glucose19.3 [mmol/L]

Investigating group A Streptococcus antibiotic tolerance in necrotizing fasciitis.

Group A Streptococcus (GAS) necrotizing fasciitis (NF) is a difficult-to-treat bacterial infection associated with high morbidity and mortality despite extensive surgery and targeted antibiotic treatment. Difficult-to-treat infections are often characterized by the presence of bacteria surviving prolonged antibiotic exposure without displaying genetic resistance, referred to as persisters. In the present study, we investigated the presence of GAS persisters in tissue freshly debrided from patients as well as in an in vivo mouse model of NF and examined the phenomenon of antibiotic tolerance. Time-lapse imaging of GAS plated directly upon isolation from NF debrided tissue and an antibiotic challenge-based persisters assay were used to assess the presence of persisters. We show for the first time that GAS recovered directly from freshly debrided NF tissue is characterized by heterogeneous and overall delayed colony appearance time, suggesting the presence of persisters. Acidic pH or nutrient stress exposure, mimicking the NF-like environment in vitro, led to a similar phenotypic heterogeneity and resulted in enhanced survival upon antibiotic challenge, confirming the presence of GAS persisters. GAS persisters might contribute to NF treatment failure, despite extensive surgery and adequate antibiotic treatment.IMPORTANCEDifficult-to-treat and recurrent infections are a global problem burdening society and the health care system alike. Unraveling the mechanisms by which bacteria can survive antibiotic treatment without developing genetic resistance is of utmost importance to lay the foundation for new, effective therapeutic approaches. For the first time, we describe the phenomenon of antibiotic tolerance in group A Streptococcus (GAS) isolated from necrotizing fasciitis (NF) patients. Dormant, non-replicating cells (persisters) are tolerant to antibiotics and their occurrence in vivo is reported in an increasing number of bacterial species. Tailored treatment options, including the use of persisters-targeting drugs, need to be developed to specifically target dormant bacteria causing difficult-to-treat and recurrent infections.

Suppurative Cervicomediastinitis From the Perspective of the Head and Neck Surgeon in a Tertiary Treatment Unit.

Introduction Cervical suppurations represent an emergency pathology, with a dramatic evolution in the absence of adequate treatment. It frequently affects young people, hence the medico-legal implications of these cases. The anatomical substrate for the development of these deep cervical suppurations is represented by the cervical fascia and spaces. A distinct and extremely serious sub-chapter within diffuse cervical suppurations is necrotic cervical fasciitis, a polymicrobial infection with the most common oropharyngeal or odontogenic starting point, with rapidly progressive, destructive evolution in the deep fascial planes of the neck. Materials and method We will present a retrospective clinical study carried out on 26 cases diagnosed and treated between September 2013 and September 2018 in the ENT Clinic Department of the Bucharest University Emergency Hospital. Results Our retrospective analysis of a cohort of 26 patients in a tertiary referral center showed that deep cervical suppurations are slightly more common in men than in women. The most affected age groups were 50-59 years, followed by 20-29 years, representing a percentage of 53.84% of all cases. Also, 53.84% of the studied patients with deep cervical suppurations had a precarious and modest status. The most common clinical signs at presentation were malaise, cervical swelling, neck pain, dysphagia, fever, dysphonia, dyspnea, and cervical erythema. More than 60% of suppurations were odontogenic and 23% were caused by a traumatic element. Diabetes mellitus represents a comorbidity in 30.8% of patients, while 42.3% of patients had no personal pathological history, and thus this pathology has a lethal potential also in a patient in full health. In the study group, 46 (15%) had cervicomediastinitis, and 61.53% developed necrotizing fasciitis. One-third (34.61%) of our patients had undergone previous drainage surgery. Bacteriological examinations of the wound were with group C, D, G betahemolytic streptococcus, while 61.53% of the cultures were negative. Most patients required at least two cervicotomies. The average duration of hospitalization was 28.26 days, and the mortality rate was 23.07%; therefore, practically, one out of four cases resulted in death. In the studied group, no direct relationship can be established between the length of hospitalization and the favorable and unfavorable evolution of the patient. We propose a 10-step management protocol for the management of a cervical suppuration. Conclusion The multidisciplinary approach to these suppurations by the head and neck surgeon, the thoracic surgeon, the oromaxillofacial surgeon, anesthetist, imagist, specialist in infectious diseases, pathologist, psychologist, and so on, is the key to success in a patient who presents not only a suppuration in the throat but also a disease with systemic resonance and significant lethal potential.

Necrotizing Fasciitis of Odontogenic Origin in a Patient with Unknown Diabetes Mellitus: A Case Report and Literature Overview

Necrotizing fasciitis (NF) is a life-threatening emergency that requires prompt and aggressive surgery with broad-spectrum antibiotherapy and resuscitation. This report aims to raise the index of suspicion for NF allowing early diagnosis mainly in patients with diabetes mellitus and who received non-steroid-anti-inflammatory. A 52-year-old man, without noticeable illness, was admitted for progressive submandibular swallowing, following wisdom tooth extraction, with extensive cervical redness centred by skin depression. The patient’s chief complaint was a sore throat, trismus and intensive pain leading to self-administration of non-steroid-anti-inflammatory drugs. Laboratory tests revealed an unknown diabetes mellitus. Enhanced Computed Tomography revealed the disappearance of fascial planes and tissular swelling containing multi-space emphysema with an airway compromise. The patient underwent surgical debridement of the involved fascial spaces and necrotic tissues until normal bleeding was obtained combined with intensive resuscitation and 37 inpatient days allowed patient rescue without soft tissue sequelae. Thus, Odontogenic NF should be suspected in patients with diabetes mellitus who have taken non-steroid-anti-inflammatory medication especially when there are discrepancies between signs of toxicity and deceptive clinical symptoms of an odontogenic infection. Computed tomography is crucial for prompt diagnosis, therapeutic management and postoperative assessment. Removal of the odontogenic focus simultaneously combined with thorough surgical debridement with broad-spectrum antibiotherapy and resuscitation improves survival rates and reduces visceral morbidity and soft tissue sequelae. Otherwise, Oral health education and care mainly in high-risk patients remain a key to prevent this serious health problem.

Necrotizing fasciitis or acute limb ischemia? Similarities and the diagnostic tactics

The symptoms of necrotizing fasciitis (NF) and acute limb ischemia (ALI) are almost identical. We present a case of a 48-year-old male, who reported to the emergency room complaining of sudden severe pain in the right limb. The complaint was accompanied by blackish, water-filled lumps, and numbness. On examination, his femoral pulse was palpable but the pulse was weak in the common femoral artery (CFA), superficial femoral artery (SFA) and popliteal artery (POP A). No pulse was palpable in the posterior tibial artery (PTA), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). SpO2 couldn’t be detected in first to fourth toes; it was 97% in the fifth toe. The laboratory investigations showed increased serum creatinine, so CT angiography could not be performed. Duplex Ultrasonography (DUS) was performed and showed triphasic morphology at the vascular level, while gas was seen in the subcutaneous tissues. Due to similar clinical appearances, it is difficult to differentiate the diagnosis of NF and ALI, while the treatments for both are very different. CT angiography, DUS examination and laboratory tests may be the first option to differentiate between the two conditions. Keyword: Necrotizing Fasciitis, Acute Limb Ischemia, Citation: Ardiana M, Putra TS, Sufiyah IM. Necrotizing fasciitis or acute limb ischemia: similarities and the diagnostic tactics. Anaesth. pain intensive care 2024;28(5):960−963; DOI: 10.35975/apic.v28i5.2237 Received: ; Reviewed: ; Accepted:

Necrotizing Fasciitis in Iv Drug Abuser by Oil Injection: A Case Report

Necrotizing fasciitis (NF) is a necrotizing soft tissue infection that can result in fast tissue loss, necrosis, and potentially fatal acute sepsis. Diabetes, cancer, alcohol abuse, and chronic liver and renal disease are all risk factors for NF. Our case was a 50 years old male with IV drug abuse that inject oil in his arms and admitted by diagnosis of Necrotizing Fasciitis and perform serial surgery and antibiotic therapy for him to save his life and his arm. NF is a rare bacterial inflammation (infection) that can destroy the skin and underlying tissues (connective tissue, subcutaneous fat, muscles, and muscle membranes). The disease can be very dramatic, with shock and damage to internal organs. In this case report, serial debridement with adequate antibiotherapy followed by reconstructive surgeries were made. An early diagnosis remains challenging and crucial for salvaging the affected area. Necrotizing fasciitis is a life-threatening soft tissue infection characterized by a rapid spreading infection of the subcutaneous tissue and in particular the fascia. The management of infected tissues requires a rapid diagnosis, immediate aggressive surgical management and an extended debridement. In some cases, early amputations of the affected tissues and maximum intensive care treatment, in case of sepsis, are required. Due to a rising number of cases we aimed to report this case.

Point-of-care ultrasound in skin and soft tissue infections.

Skin and soft tissue infections (SSTIs) are commonly encountered in clinical practice. Point-of-care ultrasound (POCUS) is becoming an increasingly valuable tool in hospital medicine, especially with advancements in ultrasound technology that make it easier to perform. POCUS can augment the history and physical exam in patients with suspected SSTIs. POCUS can detect deeper infections, such as abscesses, and expedite time to surgical debridement for life-threatening infections such as necrotizing fasciitis (NF). This review provides an introduction on how to perform and interpret a skin and soft tissue POCUS exam, the key sonographic findings for SSTIs, and how to incorporate these findings into clinical reasoning and management. SSTI POCUS literature was reviewed using PubMed. All relevant studies with a defined protocol and reported sensitivity and specificity pertaining to the use of POCUS to diagnose SSTIs in adults were included. The authors provide additional input based on their ultrasound expertise and clinical experience. A total of seven studies met the criteria to be included in this review. Soft tissue POCUS is a valuable tool for hospitalists to improve diagnostic accuracy and patient care when assessing suspected SSTIs. Access to equipment, POCUS training, and experience are barriers to widespread use. However, performing a soft tissue POCUS exam is straightforward. It requires less training compared to other POCUS exams, and it has notable potential for routine future practice in the evaluation and management of suspected SSTIs and other dermatologic conditions.

Periorbital necrotizing fasciitis: clinical perspectives on nine cases.

A multicenter review of Periorbital Necrotizing Fasciitis including nine cases, aged 41 to 82, mostly female, and mainly post-traumatic or idiopathic. Streptococcus pyogenes was the most frequent pathogen. Treatment involved debridement alongside antibiotic therapy in all cases. Two cases experienced toxic shock, with no fatalities. Visual outcomes varied from exenteration to preserved visual acuity with minimal aesthetic impact. Early detection and prompt intervention are paramount due to the significant risks associated with this condition, which may lead to severe complications ranging from vision loss to systemic decline or death.