Diagnosis Of Necrotizing Fasciitis Research Articles

Evaluation of laboratory risk indicator for necrotizing fasciitis score as an early diagnostic tool for necrotizing fasciitis: a prospective observational study

Introduction: From its historical identification to modern times with advancements in management modalities globally, the mortality of necrotizing fasciitis (NF) is high ranging from 19 to 30% for all affected sites. Although many diagnostic adjuncts have been developed to assist with the prompt and accurate diagnosis of NF, the primary diagnosis is still based on high clinical suspicion. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed as a tool for distinguishing NF from other soft tissue infections. The main objective of this study is to evaluate LRINEC as a tool for early diagnosis of NF and differentiating it from other soft tissue infections like cellulitis. Methods: This is a single-centered, prospective observational study. Patients presenting with soft tissue infections of the limbs to the emergency department from November 2020 to October 2021 were included in this study. The clinical findings and blood parameters for the LRINEC score were collected and the score was calculated. Based on clinical suspicion of NF, patients underwent debridement and had a tissue biopsy to confirm the diagnosis. The data obtained was analyzed using SPSS version 24 and MS Excel. The AUC curve was used to calculate a cutoff, sensitivity, specificity, positive predictive value, and negative predictive values for the LRINEC score based on our study. Results: Forty-five patients with 28 males and 17 females were included. The average age was 53.667 years within a range of 19–79 years. Among them 44.4% of the patients had NF and 66.6% had other minor forms of soft tissue infections. The ROC curve obtained a cutoff value of greater than or equal to 6, with an AUC of 0.751. At this cut of value study showed a sensitivity of 85% with a specificity of 52%. Similarly, positive predictive value was found to be 58.62%, negative predictive values of 81.25%, and overall accuracy of 66.67% in early diagnosis of NF. Conclusion: In conclusion, our study showed that the LRINEC score can be a reliable tool for the early diagnosis of NF in an ED setting. This scoring system is best to be used to rule out NF.

Investigation of the effects of clinical parameters on mortality in patients with necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressing, potentially fatal soft-tissue infection that spreads through the fascia. Due to the late onset of diagnostic signs during the disease's advanced stage and its rapid progression, it can be challenging to make a prompt diagnosis. However, with a rapid and accurate diagnosis, the progression of the disease can be halted through appropriate early surgical intervention. Even with correct and timely treatment, the mortality rate for necrotizing fasciitis is higher compared to other soft-tissue infections. This study aims to investigate the effects of clinical parameters in patients with necrotizing fasciitis on mortality. The study included 37 patients with a necrotizing fasciitis diagnosis between 2009 and 2018. Demographic characteristics of the patients (age, gender, comorbid conditions), duration from diabetes diagnosis if present, blood glucose level at the time of diagnosis, microorganisms isolated from wound cultures, presence of positive blood cultures, administered antibiotic therapy, laboratory risk indicator for necrotizing fasciitis (LRINEC) score at presentation, number and types of surgical procedures performed, length of hospital stay, and mortality rates were retrospectively recorded. Statistical analysis of dependent and independent variables was conducted using t-tests, Mann-Whitney U test, Chi-square test, and Fisher's exact test. Age was found to be an average of 70 in the mortality group, and it is significantly higher compared to the non-mortality group. A high LRINEC score, the presence of comorbidity, and a positive blood culture were also found to be significant in the mortal-ity group. The low number of surgical procedures performed is significantly lower in the mortality group. This study highlights the conditions associated with high mortality in patients with necrotizing fasciitis, which is a treatable disease through timely and accurate diagnosis followed by appropriate antibiotic therapy and surgical intervention. It emphasizes the importance of updating the approach for high-risk group patients and aims to provide information that will help lower the threshold for diagnosing necrotizing fasciitis.

Three Ds for diagnosing necrotizing fasciitis by front-line clinicians

Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages. To develop a diagnostic algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals. Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm. The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the "3Ds" of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation. The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.

The performance of clinical risk scores in the diagnosis of necrotising fasciitis

Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems. This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality. A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively). The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.

Clinical and Laboratory Parameters for Differential Diagnosis of Necrotizing Faciitis and Cellulitis.

Necrotizing fasciitis (NF) requires surgical intervention and has high morbidity and mortality. Furthermore, it can be confusing with some skin diseases such as cellulitis. We investigated the roles of clinical and laboratory parameters at the time of admission to the hospital in the differential diagnosis of NF and cellulitis patients. Patients with cellulitis and NF located between the nipple level and the knee between January 2018 and January 2021 were included in our retrospective study. The fever, history, complete blood count results, blood biochemistry, C-reactive protein and procalcitonin values of the patients at the time of admission to the emergency department, length of hospital stay, mortality rates, and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores were recorded and evaluated whether there was a difference in both patient groups. A total of 55 patients, including 26 patients in the NF group and 29 patients in the cellulite group, were included in the study. It was observed that patients with NF applied to the hospital statistically earlier, had higher leukocyte, platelet and neutrophil levels, had longer hospital stays and had higher mortality numbers. In high leukocyte, platelet, and neutrophil levels in the case of cellulitis patients, the clinician should follow the patient's clinic course closely and keep NF in mind.

Necrotizing Fasciitis Originating in the Hand: A Systematic Review and Meta-Analysis.

Necrotizing Fasciitis (NF) is a rapidly progressive and potentially lethal infection. This systematic review focused on the treatment and prognosis of the NF of the hand. The literature search was performed in PubMed database, and cohort studies and case reports were deemed eligible. Proportions were pooled to estimate overall mortality and amputation rates, and a logistic regression analysis was performed to evaluate predictors of amputation and mortality. The search algorithm resulted in 51 eligible articles including 48 case reports (54 patients) and 3 larger retrospective cohort studies (107 patients). Most patients had a monomicrobial infection, a surgical debridement on the day of admission, and hospital stay of more than 10 days. The estimated overall amputation rate was 28%, whereas overall mortality was equal to 8%. In the pooled set of case reports, mortality was significantly associated with age older than 54 years and marginally with diabetes mellitus. Necrosis expanding more proximally to the forearm correlated with both amputation and mortality. It is reiterated that early diagnosis of NF is of paramount importance and that early and decisive surgical intervention should have low threshold, especially when potential risk factors are identified.

Necrotizing Fasciitis Associated with Hailey-Hailey Disease: A Rare Case.

Necrotizing fasciitis (NF) is a rare and life-threatening infection of soft tissue characterised by rapid and extensive destruction of the skin, subcutaneous fat, and fascia. Early diagnosis of NF is challenging, and it can be very difficult to distinguish NF from other infectious diseases of skin and subcutaneous tissue. Imaging studies and laboratory investigations are crucial diagnostic means for NF. We diagnosed a case of NF with multiple organ dysfunction and septic shock, and this is the first case of NF associated with Hailey-Hailey disease (HHD) to our knowledge. Clinicians should be alert to signs and symptoms of NF in HHD and other skin diseases with damaged skin barrier function such as pemphigus, pemphigoid, and all kinds of ulcers, especially in diabetic and immunosuppressed patients. Key Words: Necrotizing fasciitis, Genodermatosis, Hailey-Hailey disease.

Retrospective case series: Necrotising fasciitis in 23 dogs.

Necrotising fasciitis (NF) is a rare, rapidly progressive subcutaneous bacterial infection. Few studies have characterised NF in dogs. To retrospectively describe clinical and laboratory findings, with treatments and outcomes, in dogs with NF. Twenty-three client-owned dogs treated at a veterinary teaching hospital between 1998 and 2021. Medical records and laboratory data from 23 dogs diagnosed with NF were reviewed. Male dogs were significantly over-represented (p= 0.003). The most common presenting complaint was sudden lameness. Infection occurred in one or two limbs in 19 of 23 dogs, with right hindlimbs most often affected (13 of 23). Pitting oedema was evident in 14 of 23 dogs. Antibiotic and nonsteroidal anti-inflammatory drugs were administered before presentation in nine and 13 of 23 dogs, respectively. Common clinicopathological abnormalities included hypoalbuminemia, hyponatremia, elevated liver enzymes, elevated creatine kinase, increased bands and lymphopenia. Streptococcus canis was isolated from 18 of 23 dogs. Histopathological features included acute necrosis and severe neutrophilic inflammation. Fifteen dogs were euthanised or died, while surgical intervention led to survival in eight of 23 dogs. Dogs presenting for acute swelling of a limb with oedema should have the diagnosis of NF considered and early surgical intervention might increase survival.

Seasonal variations and risk factors of Streptococcus pyogenes infection: a multicenter research network study.

Background:Streptococcus pyogenes, or Group A Streptococcus (GAS), causes acute pharyngitis and necrotizing fasciitis. Seasonal variations in GAS infections are not robustly characterized. We assessed seasonal variations and risk factors of GAS pharyngitis and ICD-10-diagnosed necrotizing fasciitis.Methods:From the period 2010–2019, we conducted a case–control study using laboratory-confirmed cases of GAS pharyngitis and a descriptive observational study of necrotizing fasciitis using ICD-10 codes. Data were collected from TriNetX, a federated research network. We extracted seasonal (quarterly) incidence rates. We used an autoregressive integrated moving average (ARIMA) model to assess seasonal variations. Demographic characteristics and 1-month outcomes were compared among adults with or without GAS pharyngitis.Results:We identified 224,471 adults with GAS pharyngitis (test-positive) and 546,142 adults without it (test-negative). GAS pharyngitis adults were younger (25.3 versus 30.2 years of age, p < 0.0001), more likely to be Hispanic individuals (10% versus 8%, p < 0.0001) and slightly more likely to be Black or African American individuals (14% versus 13%, p < 0.0001). Propensity score matching found that adults with test-positive cases of GAS pharyngitis had a higher risk of acute rheumatic fever while having no significant differences in risk of intensive care unit admission and mortality compared with test-negative cases. GAS pharyngitis average incidence peaked in the winter while dipping in the summer (0.32 versus 0.18 and 4.07 versus 1.78 per 1000 adults and pediatric patients, respectively). Necrotizing fasciitis diagnoses were highest during summer (0.032 per 1000 adults). There was a significant ARIMA seasonal variation in the time series analysis for adult and pediatric GAS pharyngitis (p < 0.0001 and p = 0.014, respectively). Necrotizing fasciitis diagnosis was not associated with seasonal variation (p = 0.861).Conclusion:Peaks in GAS pharyngitis occur in the winter months. ICD code–based necrotizing fasciitis did not show a quarterly seasonal variation.

LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) scoring system as a predictor for early diagnosis of necrotizing fasciitis in soft-tissue infections

Introduction: Necrotizing soft-tissue infections are often fatal, characterized by extensive necrosis of the fascia and subcutaneous tissues. To aid the early diagnosis of necrotizing fasciitis (NF), there is a Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system for the early diagnosis of NF. Our study was undertaken to evaluate LRINEC score, based on routine laboratory investigations that are readily available, that could help distinguish NF from other soft-tissue infections. Materials and Methods: The study was conducted on all inpatients, admitted with features of soft-tissue infections suspected to have NF and later underwent wound debridement or amputation in a tertiary care hospital. LRINEC score more than or equal to 6 was considered as case and the score <6 considered as control. Both were treated with intravenous (IV) antibiotics, IV fluids and surgical intervention based on their clinical findings and outcome. The confirmatory diagnosis for NF was done through culture of tissue and other body fluids. Results: The cutoff value of LRINEC for predicting NF was 6 with sensitivity of 85.7% and specificity of 70.7%. The negative predictive value of LRINEC-OC was 87.9% and positive predictive value (PPV) 66.7%. The accuracy was 76.8%. Conclusion: LRINEC scoring system has a better PPV in identifying the onset of NF and risk strategizing of the patients with severe soft-tissue infections. We recommend LRINEC score to be used as a predictor in the diagnosis of NF. Multi-disciplinary team may guide immediate operative and supportive management, thereby improving the clinical outcome of the patient.

Comparison of LRINEC Scoring System with Finger Test and Histopathological Examination for Necrotizing Fasciitis.

Background Necrotizing fasciitis (NF) is a life-threatening condition requiring urgent attention. It is clinically difficult to diagnose, linked to severe systemic toxicity, and has poor prognosis. In 2001, Andreasen and coworkers described the “Finger test” for the diagnosis of NF. Subsequent studies have suggested early recognition and management of NF. In this study, we compare the LRINEC—Laboratory Risk Indicator for Necrotizing Fasciitis—scoring system with the “Finger test” and histopathological examination for diagnosis of NF. Results In our study, LRINEC scoring system and Finger test are statistically significant in the diagnosis of NF. Males are more frequently affected, and the most common organism causing NF is Staphylococcus . Histopathology remained the gold standard for diagnosis of NF, while LRINEC score and Finger test were good diagnostic tools for early diagnosis, with sensitivities of 83.33 and 86.11%, respectively. Conclusion LRINEC laboratory-based scoring system is easy and reliable diagnostic tool though histopathology remains the gold standard. There is statistically significant correlation between histopathology and laboratory criteria. LRINEC test is independently better than bedside Finger test alone or combined LRINEC and bedside Finger test.

Are neutrophil count and neutrophil/lymphocyte ratio useful as markers of polycystic ovary syndrome in early reproductive age?

Necrotizing fasciitis (NF) is often fatal, characterized by extensive necrosis of the subcutaneous tissues and fascia. The present study was aimed to validate the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score as a tool to predict/diagnose NF and to differentiate it from other soft tissue infections depending on the score. A Prospective Observational study was conducted in ESICMC PGI MSR, Medical College Hospital, Rajajinagar, Bengaluru, from Jan 2019 to June 2020. Patients ≥18 years of age with severe soft tissue infections were included in the study. Based on the LRINEC score, the patients were categorised as low (≤5), moderate (6-7) and high risk (≥8) for the prediction of onset or diagnosis of NF. Data analysis was performed using SPSS version 21.0. A total of 55 patients were included in the study. A significant 3 association was observed with age (p=0.042), LRINEC score (p=0.0001), C Reactive Protein (CRP; p=0.0001), haemoglobin (p=0.008), serum Department of XXX, University of XXX, XXX Training and Research Hospital, City, Country sodium levels (p=0.004), serum creatinine (0.001), and amputation (p=0.004). Amputation was done in 5 cases. Only 1 mortality was observed 4Department of XXX, Faculty of XXX, City, Country in LRINEC high risk group with NSSTI. To conclude, LRINEC scoring system showed a better positive predictive value in identifying the onset of NF and risk strategizing of the patients with severe soft tissue infections. This study has aimed to contribute to the literature by investigating the value of inflammatory biomarkers of polycystic ovary syndrome (PCOS) that can be tested via a complete blood count. This retrospectively designed case-control study included 197 women in early reproductive age; who were in the age range of 18-24 years and who were admitted to the gynecology outpatient clinic. A total of 111 PCOS patients; in whom the diagnosis of PCOS was made based on Rotterdam criteria, were included in the study. A control group was formed by including 86 healthy women. All measurements of inflammatory biomarkers were obtained from the complete blood count test results. Of the inflammatory markers; the neutrophil count and the neutrophil/lymphocyte ratio were statistically significantly higher in the PCOS group compared to the control group (p=0.016 and p=0.002, respectively); however, the measured values of other parameters were similar between two groups. To evaluate whether or not the neutrophil count and neutrophil/lymphocyte ratio could be used as a screening tool to exclude PCOS, we constructed a receiver-operating characteristic curve (ROC). The ROC curve for the neutrophil count was 0.60 (p=0.016) and NLR was 0.627 (p=0.002). The neutrophil count and NLR were higher in the PCOS cases compared to the age-matched individuals in the control group. This finding confirms the presence of inflammation in PCOS cases of early reproductive age. However, it has been demonstrated that the diagnostic values of these markers are not strong in distinguishing PCOS patients from healthy individuals.

Laboratory risk indicator for necrotising fasciitis [LRINEC] score as a tool for differentiating necrotising fasciitis from other soft tissue infections

Necrotizing fasciitis (NF) is often fatal, characterized by extensive necrosis of the subcutaneous tissues and fascia. The present study was aimed to validate the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score as a tool to predict/diagnose NF and to differentiate it from other soft tissue infections depending on the score. A Prospective Observational study was conducted in ESICMC PGI MSR, Medical College Hospital, Rajajinagar, Bengaluru, from Jan 2019 to June 2020. Patients ≥18 years of age with severe soft tissue infections were included in the study. Based on the LRINEC score, the patients were categorised as low (≤5), moderate (6-7) and high risk (≥8) for the prediction of onset or diagnosis of NF. Data analysis was performed using SPSS version 21.0. A total of 55 patients were included in the study. A significant 3 association was observed Dweitpharatgmee(npt=o0f.0X4X2)X, ,LURnINivEerCsitsycorfeX(pX=X0,.0X0X01X),TCraRineiancgtiavnedPRroetseianrc(hCRHPo;spi=ta0l.,0C00it1y),,Choauenmtroyglobin (p=0.008), serum 4 sodium levels (p=0.004), serum creatinine (0.D00e1p)a,ratmndenatmopfuXtaXtiXon, F(pac=u0l.t0y0o4f).XAXmXp,uCtaityio,nCwouanstdryone in 5 cases. Only 1 mortality was observed in LRINEC high risk group with NSSTI. To conclude, LRINEC scoring system showed a better positive predictive value in identifying the onset of NF and risk strategizing of the patients with severe soft tissue infections.

OUR EXPERIENCE IN DIAGNOSIS AND TREATMENT OF NECROTIZING FASCIITIS

Background: Necrotizing fasciitis (NF) is a severe, relatively rare and potentially deadly infection, which is usually caused by one or two pathogenic microorganisms. The target areas that are affected are the skin and the subcutaneous tissues of the lower and the upper limbs, the scrotum, the perineal region (Fournier gangrene) and the abdominal wall. The early diagnosis and aggressive surgical treatment are of great importance for the outcome of this potentially lethal disease. &#x0D; Methods: Eleven patients with diagnosis of NF had been treated in the Clinic of Plastic and Reconstructive surgery of St. George Hospital, Plovdiv for a five-year period (2013-2018). Based on the demographic, clinical and laboratory data the presurgical, the following surgical treatment, and the postsurgical management were analyzed.&#x0D; Results: The mean age of the patients was 58.7 years (median: 56 years, range 37–87 years) and 75% were men. Old age (above 65 years) and female gender correlated significantly with lethality. Most often the regions affected were the perineum and the scrotum (46.8%), followed by lower limbs (35.5%), upper limbs and abdominal wall (8.1%). Diabetes mellitus, oncologic diseases, alcohol addiction and chronic hepatic and renal diseases were found to be predisposing factors for development of NF. We started treatment with broad spectrum antibiotics, early and vigorous drainage and meticulous debridement with wide excision of the damaged tissues. Vacuum therapy was applied as part of the treatment of the defects. It allowed continuous wound cleaning and accelerated formation of granulation tissue, followed by definite closure of the defect.&#x0D; Conclusion: The diagnosis of NF needs adequate proceedings and treatment of the cases among surgeons as its clinical presentation is unspecific. The prompt surgical debridement and excision is the mainstay in the treatment of all patients and repeated surgical excisions are required. Plastic surgery is an undeniable stage in the complex treatment of NF regarding the large size of the wound and necessity of definite closure of the soft tissue defects.

Necrotizing fasciitis: Usefulness of the LRINEC score in a third-level hospital

AimTo review patients seen in the emergency room, diagnosed with necrotizing fasciitis (NF) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). The purpose of this study is to assess the use of the LRINEC score for early diagnosis of NF and its prognostic use in a consecutive series of cases treated at our hospital. MethodsRetrospective observational study including patients with a diagnosis of NF in the emergency room of a tertiary hospital over 11 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric rank-ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher’s exact test. ResultsA total of 45 patients with a mean age of 51 years were identified. There was a 20% mortality rate (9 cases). The highest mortality rate was registered in the high-risk group (LRINEC greater than 8) with 4 deceased individuals (44.44%), while in the low and moderate-risk groups, 3 and 2 deceased individuals (33% and 22%) were registered, respectively, without considering this result statistically significant (p=0.811). There was an amputation rate of 15.6% (7 cases). The average LRINEC score was greater in the cases that required amputation 9 (95% CI 7; 13) in comparison to the other patients, 6 (95% CI 5; 8), p=0.044. The average hospital stay lasted 32.5 days (95% CI: 25; 40); 30 days in the low-risk group, 41 days in the moderate-risk group and 40 days in the high-risk group. Mortality was associated to a smaller number of interventions (p=0.005) and was preceded by septic shock in all cases. ConclusionsThe LRINEC score may be useful to aid diagnosis. However, clinical suspicion is the most important in diagnosis. A LRINEC low score does not exclude NF. In this retrospective series, 35.71% of cases presented a low LRINEC score, making the rate of false negatives high. In view of these results, The LRINEC score cannot be used as a prognostic value since an initial low score does not rule out serious evolution.

Clinical concern for necrotising fasciitis: a review of referrals to plastic surgery units at two tertiary centres.

To evaluate the impact of clinical suspicion on the diagnosis of necrotising fasciitis (NF) in two inpatient plastic surgery units. A multicentre retrospective audit of all referrals of adult patients to the inpatient plastic surgery units of two Melbourne metropolitan tertiary centres from 1 February 2018 to 31 December 2018. A total of 53 patients (37 male, 16 female) were referred to evaluate for NF. There were 20 patients (37.04%) who underwent operative debridement. Of those, 15 were pre-operatively suspected of having NF and there were seven confirmed cases of NF (13.21%). Laboratory risk indicator for NF (LRINEC) score ≥ 6 had a statistically significant association with a diagnosis of NF (P= 0.03) and with operative debridement (P= 0.04). The incidence of NF in the cohort where the referrer had clinical concern for NF was 13.21% (P< 0.001) and when the referrer and the plastic surgeon suspected NF was 46.67% (P< 0.001). The number of patients needed to be referred for one case of NF to be diagnosed was 7.58. Clinical suspicion of NF is essential for diagnosis and clinicians who suspect NF should not hesitate to refer to the appropriate surgical unit. Prompt review is required of patients in whom NF is clinically suspected as these patients have a 13.21% incidence of NF. The laboratory risk indicator for NF score is not sufficiently specific nor sensitive to exclude or to diagnose NF as a stand-alone diagnostic tool but may have a role as an adjunct.

Necrotizing fasciitis of the upper extremity: a retrospective analysis of 19 cases

Necrotizing fasciitis (NF) is both a limb—and life—threatening disease that affects skin, hypodermis as well as superficial fascia and deep fascia by rapidly progressive necrosis. Although this serious infection frequently occurs in the extremities, upper limb NF is a rare clinical presentation. The present study attempted to evaluate the clinical profiles, paraclinical findings, treatment modalities, outcomes and predictors of morbidity and mortality in patients with NF of the upper extremity. The validity of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scoring system was also assessed. Nineteen patients who were treated between January 2010 and December 2019 for NF of the upper extremity were eligible for this study. Data including demographics, clinical signs, paraclinical findings, treatment and outcomes were collected retrospectively from our medical records. Fisher's exact test was used to analyze predictive factors for mortality and morbidity. The mean age was 62 years, with a male predominance. The most common comorbidity was diabetes mellitus (42%). Main clinical manifestations were pain (79%), tense edema (79%) and a large infiltrated swollen erythematous plaque (58%). Severe sepsis and septic shock were identified in 32% and 21% of patients, respectively. Thirteen of our 19 patients (68%) were identified as having a high or intermediate likelihood of NF based of the LRINEC scoring system, while the other 6 (32%) were classified as having low likelihood. All patients received systemic broad spectrum antibiotic therapy in addition to surgical debridement. Two patients (10%) died and one (5%) required amputation. Mortality was associated with septic shock (p = 0.006), delay in surgery >24 h (p = 0.018), creatininemia >141 mmol/l (p = 0.018) and LRINEC score ≥ 8 (p = 0.035). Otherwise, anemia (p = 0.021), hypercreatininemia (p = 0.001) and delayed surgical debridement (p = 0.001) were risk factors for morbidity and mortality. The surviving patients underwent reconstructive surgery (skin grafting after wound preparation by using vacuum therapy) with positive outcome. Early diagnosis coupled with emergent surgical debridement and broad-spectrum empiric antibiotic therapy are the keystones of a successful outcome. The LRINEC score was not strongly correlated to the true diagnosis of NF and was a prognostic tool rather than a diagnostic one.

Usefulness of serum procalcitonin for necrotizing fasciitis as an early diagnostic tool

IntroductionWhile the early diagnosis of necrotizing fasciitis (NF) is crucial and could lead to a favorable outcome, it is difficult to differentiate NF from cellulitis, resulting in delay for the appropriate treatment. Patients and methodsFor the purpose of examining which diagnostic tools could correctly differentiate NF from cellulitis, we conducted this case-control study. We retrospectively reviewed all patients who were diagnosed with NF at our institute during 2014–2019. The patients who were diagnosed with cellulitis were randomly selected during the study period as the control group. The severity of NF is evaluated by serum-procalcitonin (PCT), LRINEC score, NTSI assessment and SIARI score. ResultsA total of 25 NF patients were enrolled in this study. The median age was 68 years (range 39–79) and 18 (72%) were male. Comparing NF and cellulitis groups, NF group showed a higher LRINEC score and serum PCT than cellulitis group did, even though there was no statistical significance in serum PCT.With respect to the diagnostic value for differentiating NF from cellulitis, the area under the ROC curve for of serum PCT and LRINEC scores were 0.928 [95% confidential interval (CI) 0.864–0.992, p < 0.001] and 0.846 (95% CI 0.757–0.936, p < 0.001). The appropriate serum-PCT cutoff value was 1.0 and had a sensitivity of 88%, a specificity of 89%, a positive predictive value of 81%, and a negative predictive value of 93%. ConclusionSerum-PCT could be a useful diagnostic marker for differentiating diagnosis of NF from cellulitis.

Fatal Necrotizing Fasciitis Following Uncomplicated Colonoscopic Polypectomy: A Case Report

Necrotizing fasciitis (NF) is a life-threatening infection that can be caused by various procedures or surgery and may develop in healthy elderly patients. Here, we report a case of a 66-year-old man with diabetes mellitus who underwent colonoscopic polypectomy, without complications. However, he visited the emergency department 24 hours after the procedure complaining of abdominal pain. Abdominopelvic computed tomography revealed multiple air bubbles in the right lateral abdominal muscles. After a diagnosis of NF was made, immediate surgical debridement was performed. However, despite three sessions of extensive surgical debridement and best supportive care at the intensive care unit, the patient died because of sepsis and NF-associated multiple-organ failure. In conclusion, physicians should pay special attention to the possibility of NF if a patient with risk factors for NF develops sepsis after colonoscopic polypectomy.

Necrotizing fasciitis with prior leprosy: a case report

&lt;p class="abstract"&gt;Necrotizing fasciitis (NF) is a life-threatening soft tissue infection with a high misdiagnosis rate. Here, we present the case of NF with hypoesthesia due to prior leprosy in a limited resource area. Laboratory risk indicator for NF (LRINEC) score was used to determine the diagnosis of NF. Resuscitation and broad-spectrum antibiotic were initiated, followed by surgical debridement due to lack of wound improvement and skin graft to cover the wound was done. This case report highlights the usage of LRINEC score to reduce misdiagnosis, ensure early diagnosis, and improve patient management in NF with masking effect.&lt;/p&gt;