Presence Of Bullae Research Articles

Pemphigoide of Pregnancy: Case Report and Review of the Literature

Pemphigoid of pregnancy (PG) is a rare autoimmune bullous dermatosis, affecting 1 in 20000 to 50000 pregnant women. PG is linked to anti-BP180 autoantibodies whose synthesis follows a breakdown in mother-fetal immunological tolerance. Bullae formation results from a complex mechanism involving TH2 lymphocytes, cytokines and polynuclear cells. PG manifests itself as a pruritic erythematopapular rash of varying extent, progressing to the inconstant but suggestive appearance of vesicles and bullae. The disease progresses to gradual recovery after delivery, sometimes after a post-partum flare-up. Recurrence during subsequent pregnancies is frequent. Relapses can also be triggered by estrogen-progestogen contraception. Diagnosis is confirmed by direct immunofluorescence, which shows C3 +/- IgG deposits along the basement membrane. The BP180-NC16A ELISA technique is highly sensitive for the detection of circulating antibodies. Fetal prognosis is good, but early onset in the 1st or 2nd trimester of pregnancy of pregnancy and the presence of bullae are risk factors for prematurity or hypotrophy. Very rarely, the newborn may present transient bullae. Several publications show that very strong dermocorticoids are effective and can be used as first-line treatment for moderate PG. We report the case of a patient admitted to a maternity hospital emergency department, with a pregnancy of 37 weeks' gestation and a non-reassuring fetal condition presenting as pemphigoid of pregnancy (PG).

Epidermolysis Bullosa Simplex – Dowling-Meara Type: A Case Report in a 10-year-old Boy

Epidermolysis bullosa simplex – Dowling-Meara type (EBS-DM) is characterized by the presence of bullae and vesicles with arcuate borders in a herpetiform manner at the trauma-prone areas of the body since birth. Here we report the clinical course of EBS-DM in a 10-year-old boy. We confirmed the diagnosis by antigen mapping which showed clumping of keratin 14 with decreased staining in few areas.

An observational study ascertaining the prevalence of bullae and blebs in young, healthy adults and its possible implications for scuba diving.

Introduction: Intrapulmonary air-filled cavities, e.g., bullae, blebs, and cysts, are believed to contribute topulmonary barotrauma (PBT) and arterial gas embolism (AGE) in divers. However, literature is unclear about the prevalence of bullae in healthy adults, ranging from 2.3-33.8%. While this could in part be explained due to increasing quality of radiologic imaging, such as computed tomography (CT) scans, other methodological factors may also affect these findings. This study aims to ascertain the prevalence of bullae in young and healthy adults. Methods: This single-center cross-sectional observational study re-assessed the CT scans of adults (aged 18-40) performed for a clinical suspicion for pulmonary embolism, from 1 January 2016 to 1 March 2020. Presence of bullae was recorded in an electronic database. Chi-square and Fisher exact tests were used for statistical analyses. Additionally, a multivariate logistic regression analysis was performed to study the independent predictive value of identified risk factors. Results: A total of 1,014 cases were identified, of which 836 could be included. Distribution amongst age groups (18-25, 26-30, 31-35, and 36-40) was almost equally, however, 75% of the population was female. Of the male proportion, 41% smoked, compared to 27% in females. In 7.2% (95% CI 5.6-9.1) bullae were identified. The prevalence increased with increasing age (p < 0.001), with odd ratios up to 5.347 (95% CI 2.164-13.213, p < 0.001) in the oldest age group. Males and smokers had higher odds ratios for bullae of 2.460 (95% CI 1.144-4.208; p = 0.001) and 3.406 (95% CI 1.878-6.157, p < 0.001), respectively. Similar results were seen in the multivariate logistic regression analysis, where age, male sex and smoking were all statistically significant independent risk factors for bullae. Discussion: Bullae were seen in 7.2% of a healthy population up to 40years old. Increasing age, smoking, and being male were identified as statistically significant risk factors, both in independent and in multivariate logistic regression analyses. Our observations may warrant a re-evaluation of the contribution of bullae to PBT and AGE, as the latter two occur very rarely and bullae appear to be more frequently present than earlier assumed.

The function of wing bullae in mayflies (Insecta: Ephemeroptera) reveals new insights into the early evolution of Pterygota

BackgroundMayflies are basal winged insects of crucial importance for the understanding of the early evolution of Pterygota. Unlike all other insects, they have two successive winged stages, the subimago and the imago. Their forewings feature so-called bullae, which are desclerotized spots in the anterior main veins. Up to now, they have been considered to play a major role in wing bending during flight.ResultsWe investigated bullae by multiple methods to reveal their structure and arrangement and to gain new information on the evolution of insect flight. Bullae are mostly present in the anterior negative wing veins, disrupting the otherwise rigid veins. High-speed videography reveals that mayfly wings do not bend during flight. Likewise, different arrangements of bullae in different species do not correlate with different modes of flying. Observations on the moulting of subimagines unravel that they are essential for wing bending during the extraction of the imaginal wing from the subimaginal cuticle. Bullae define predetermined bending lines, which, together with a highly flexible wing membrane enriched with resilin, permit wing bending during subimaginal moulting. Bullae are only absent in those species that remain in the subimaginal stage or that use modified modes of moulting. Bullae are also visible in fossil mayflies and can be traced back to stemgroup mayflies of the Early Permian, the 270 million years old Protereismatidae, which most probably had bullae in both fore- and hind wings.ConclusionsBullae in mayfly wings do not play a role in flight as previously thought, but are crucial for wing bending during subimaginal moulting. Thus, the presence of bullae is a reliable morphological marker for a subimaginal life stage, confirming the existence of the subimago already in Permian Protereismatidae. A thorough search for bullae in fossils of other pterygote lineages may reveal wheather they also had subimagines and at what point in evolution this life stage was lost. In mayflies, however, the subimago may have been retained due to selective advantages in connection with the transition from aquatic to terrestrial life or due to morphological requirements for a specialized mating flight.

FIRE IN THE HOLE: GIANT BULLOUS LUNG DISEASE IN A VETERAN WITH BURN PIT EXPOSURE AND SMOKING

FIRE IN THE HOLE: GIANT BULLOUS LUNG DISEASE IN A VETERAN WITH BURN PIT EXPOSURE AND SMOKING

Should Pneumothorax Developing During the Recovery Period After COVID-19 in Patients with Previously Healthy Lungs be Considered a Primary Spontaneous Pneumothorax or a Secondary Spontaneous Pneumothorax?

OBJECTIVE:It is still unknown how to call the pneumothorax that develops during the recovery period after coronavirus disease 2019. Patients who developed pneumothorax during the recovery period after coronavirus disease 2019 were compared with those who had a primary or secondary spontaneous pneumothorax without a coronavirus disease 2019 history.MATERIAL AND METHODS:Between 2020 and 2021, 160 patients with pneumothorax were retrospectively analyzed. Twenty-three patients had a history of coronavirus disease 2019 (coronavirus disease recovery) confirmed by real-time reverse transcriptase-polymerase chain reaction, whereas the remaining 137 patients did not have a history of coronavirus disease 2019 (18 of the patients with secondary spontaneous pneumothorax group and 119 patients with primary spontaneous pneumothorax group).Results:The median time between discharge and readmission to the hospital because of pneumothorax was 9 days in the coronavirus disease recovery group. There were statistically significant differences in regards to age (P < .001), gender (P = .02), the presence of bullae (P = .02), and dystrophic severity lung score (P = .04) between the coronavirus disease recovery and primary spontaneous pneumothorax groups, whereas no difference was found between the coronavirus disease recovery and the secondary spontaneous pneumothorax groups (P > .05). The prolonged air leak was observed in 17.6% (n = 25). Patients who had prolonged air leak were statistically higher in the coronavirus disease recovery group than the primary spontaneous pneumothorax group (56.5% vs. 10.1%), although it was almost similar between the coronavirus disease recovery and secondary spontaneous pneumothorax groups (P = .951). On logistic regression analysis, the coronavirus disease recovery group was the independent factor for prolonged air leak (odds ratio = 9.900, 95% CI = 1.557-62.500, P = .01).Conclusion:Pneumothorax may be developed during the recovery period after coronavirus disease 2019 in patients with previously healthy lungs, and it should be called as secondary spontaneous pneumothorax.

Clinical features of Rheumatoid Purpura in adults

Introduction: Rheumatoid purpura is a systemic vasculitis of small vessels that is more common in children than in adults. The aim of our study was to revise the characteristics of rheumatoid purpura in adults. Methods: We conducted a retrospective descriptive and analytical study [June 2016 - June 2021], including all the patients hospitalized in the dermatology department of Ibn Rochd University Hospital for rheumatoid purpura. We first described the characteristics of adult patients aged over 18 years old, and then we compared them to those of the children (&lt;18 years old) to determine the clinical features in adults. Results: A total of 18 adults (15 women/3 Men) and 9 children were collected. Adults had a mean age of 48 years [27-66 years]. Vascular purpura was constant, complicated by necrosis in 12 patients, bullae in 6 patients, and ulceration in 2 patients. Joint involvement was present in 16 patients. Ten patients presented digestive signs: epigastralgia (n= 4), abdominal pain (n= 8), and rectal bleeding (n= 2). Cutaneous biopsy showed leukocytoclastic vasculitis in all patients with IgA and C3 deposition in 13 patients. Renal involvement was present in 6 patients. After comparison with the children group, the particularities in adults were the absence of previous drug intake (p= 0.009), absence of pruritus (p= 0.009), presence of bullae (p= 0.05), presence of severe digestive involvement (p= 0.033), joint involvement (p= 0.003), and presence of anemia (p= 0.017). Conclusion: Rheumatoid purpura in adults is characterized by its severe clinical features.

Correlation of Primary Spontaneous Pneumothorax and Air Pollution in Adolescents.

BackgroundWe aimed to investigate the characteristics of primary spontaneous pneumothorax (PSP) in adolescents and to analyze the relationship between the occurrence of PSP and air pollutants.MethodsData pertaining to age, sex, body mass index, smoking status, initial pneumothorax volume, presence of bullae, treatment methods, and city of residence were retrospectively obtained from January 2010 to December 2014. We investigated the association between short-term exposure to air pollutants (SO2, NO2, O3, CO, and PM10) and the occurrence of PSP using a case-crossover design with conditional logistic regression.ResultsWe collected information from 598 patients who were admitted for PSP, with a mean follow-up duration of 62.9 months. The majority (91.1%) of the patients were male. In the case-crossover design, conditional logistic regression showed that no air pollutant was associated with the occurrence of pneumothorax. The results were consistent across all city subgroups (Anyang, Gunpo, Uiwang, and Gwacheon).ConclusionIn our study, the incidence rate of pneumothorax was 153.8 per 100,000 person-years in male adolescents and 16.7 per 100,000 person-years in female adolescents. The case-crossover design showed that PSP in adolescents is unlikely to be related to air pollution.

Radiologic Characteristics of Non-tuberculous Mycobacteria Infection in Patients with Bronchiectasis

Non-tuberculous mycobacteria pulmonary disease (NTM-pd) commonly complicates bronchiectasis. However, clinical and radiological features of NTM-pd and bronchiectasis are very similar. We aimed to develop a radiologic prediction tool for bronchiectasis to identify NTM-pd. We reviewed clinical, laboratory and radiological data in patients with bronchiectasis. Radiologic features on CT scans and the individual components of the Bhalla scoring system were compared between people with and without NTM-pd. Logistic regression and receiver-operating curve (ROC) analysis were performed to predict NTM-pd. People with NTM-pd had more pulmonary segments with bronchiectasis (13 ± 5 vs. 11 ± 5, p = 0.03), presence of mucus plugging (47% vs. 19%, p < 0.0001) and tree in bud infiltrates (53% vs. 28%, p = 0.004). The total modified- Bhalla score was worse among people with NTM-pd (median [IQR] 11[9,13] vs. 9[8,12], p = 0.03). Logistic regression identified the number of pulmonary segments involved, presence of bullae, consolidations, and a total score of 10 or more to be independently associated with presence of NTM-pd. ROC analysis with radiographic variables only identified an AUC of 0.706 (95% CI 0.644-0.762). When people with chronic Pseudomonas infection were excluded from the ROC analysis, prediction for NTM was improved: AUC = 0.87 (95% CI 0.796-0.945). Radiological features together with advanced age and female gender may predict NTM-pd among people with bronchiectasis. Infection with Pseudomonas aeruginosa may resemble NTM radiographically, and this prediction rule may better differentiate people with and without NTM-pd when Pseudomonas infection is not present.

First Report of Heterodera zeae on Maize (Zea mays) in Henan Province, China

First Report of <i>Heterodera zeae</i> on Maize (<i>Zea mays</i>) in Henan Province, China

Management of Spontaneous Pneumothorax in Children: A Systematic Review and Meta-Analysis.

Management of primary spontaneous pneumothorax (PSP) is mainly based on adults. Data are controversial with regards to its management in children. We aimed to assess: (1) the length of hospital stay (LOS) between conservative management (i.e., observation with O2 administration), aspiration/chest drain, and surgical management; (2) the risk of recurrence after nonsurgical treatment versus surgery; (3) the risk of recurrence in the presence of bullae. Using a defined search strategy, three independent investigators identified all the studies on the management of PSP in children. Case reports, opinion articles, and gray literature publications were excluded. The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A meta-analysis was performed using RevMan 5.3. Data are expressed as mean ± SD. Of 3,089 abstracts screened, 95 full-text were analyzed, 23 were included in the quantitative analysis, and 16 were included in the meta-analysis (1,633 patients). LOS was similar between conservative and surgical management (6.2 ± 0.8 days vs. 5.9 ± 1.4 days; p = ns). Recurrence of PSP was significantly higher among children with a nonsurgical management (32%) versus those surgically treated (18%; p = 0.002). The incidence of recurrence was slightly higher in patients managed by aspiration/chest drain (34%) compared with those with a conservative management (27%; p = 0.05). Risk of recurrence in patients with or without documented bullae was not significantly different (26 vs. 38%, respectively; p = ns). Given the lack of a standardized management of pediatric PSP, the present study seems to demonstrate a better outcome in children treated with surgery as first-line of management. This is a Level III study.

Is the recurrence of primary spontaneous pneumothorax predictable?

Background: Recurrence of Primary Spontaneous Pneumothorax (PSP) constitutes a serious challenge for both physicians and patients.Methods: A retrospective study was conducted in 115 patients who had chest tubes at their first onset of PSP. Considering the development of recurrence, two groups were composed and comparatively examined in terms of age, body mass index, smoking status, side and size of initial pneumothorax, presence of bulla and duration of chest tube drainage at the first episode.Results: Among 115 patients with PSP, 24 cases developed recurrence. Male gender was prominently relevant to develop recurrent PSP (p=0.034) whereas remaining inspected parameters revealed no significant relationship with a relapse. Interval between first onset and recurrence of PSP was calculated as 9.2 months. Interestingly, most of the patients developed recurrence in low-temperature months.Conclusions: Recurrence of PSP is substantially unpredictable. Therefore, close follow-up of cases in the following year of their first episode and also informing the patients about probability of a relapse and measures to consider under this circumstance is of great importance.

Clinical Correlation Between Recurrence Rate of Primary Spontaneous Pneumothorax and Presence of Bullae in Chest Computed Tomography in the First Episode of Pneumothorax

Objective: The initial treatment strategy for the first episode of primary spontaneous pneumothorax (PSP) in patients with bullae shown by chest computed tomography (CT) is currently controversial because the difference in recurrence rate with or without bullae in chest CT is not clearly established. Therefore, it is hard to evaluate the risks versus benefits of pleural drainage versus surgical treatment. The aim of this study is to identify the recurrence rate of PSP in patients who have bullae or blebs on chest CT.

Predictors of Severity in Diabetic Foot Infections

Diabetic foot infections (DFIs) constitute a large burden of the morbidity of diabetes, with more than 70,000 lower-extremity amputations (LEA) performed annually in the United States. A necrotizing infection signifies the most severe form of infection and is a key factor in the decision to proceed to LEA for source control. Key clinical and laboratory variables can assist in the identification of necrotizing infections; however, the effect of diabetes on these variables is unknown. Given the increased level and complexity of metabolic derangements in diabetic patients, we sought to examine characteristics predictive of necrotizing infection in patients with DFI who underwent LEA. We performed a single-institutional retrospective analysis of diabetic patients who underwent a LEA for DFIs over an 18-month period. Patients with necrotizing infection on final pathology were compared with patients without this pathologic finding. Multivariate analysis was performed to identify independent predictors of necrotizing infection. Of 183 patients, 57 (31%) had evidence of necrotizing infections. Factors associated with necrotizing infection on univariate analysis were the presence of bullae (11% vs. 2%; odds ratio [OR]=4.8, P=0.03), a higher mean admission white blood cell count (WBC; 15 vs. 12, P=0.002), a lower mean absolute sodium (132 vs. 134, P=0.01), a higher hemoglobin A1C (11.3 vs. 10.3, P=0.05), hyperglycemia (289 vs. 248, P=0.04), elevated C-reactive protein (20 vs. 11, P=0.02), and the presence of Pseudomonas aeruginosa on final tissue culture (12.3 vs. 1.6, P=0.004). These patients were taken to surgery more rapidly (22.5 vs. 31 hr, P=0.04), and they had a longer postoperative stay (7 vs. 4 days, P=0.02). On multivariate analysis, an elevated WBC was predictive of necrotizing infection (OR=1.1, P=0.01), whereas alcohol use was found to be protective (OR=0.3, P=0.04). Clinical and laboratory variables known to be associated with necrotizing infections among the general population appear to be predictive of disease severity among patients undergoing amputation for DFIs. Identification of these abnormalities preoperatively may allow for improved operative planning, shared decision making, and resource management. Prospective validation of these findings is potentially warranted.

Index of Suspicion in the Nursery

A 5-day-old girl is brought to the emergency department for evaluation of a new rash. The mother describes multiple small red lesions that started on the chest on the second day after birth and are progressing to become fluid-filled bumps involving the face, trunk, arms, and genitalia. The infant is eating and sleeping well, has adequate stool and urine output and has no fever or irritability. She was born at 38 weeks’ gestation via a spontaneous vaginal delivery to a mother with a previously treated chlamydia infection during early pregnancy. There are no other prenatal or perinatal complications. There is no documented rash in the newborn’s brief nursery records and no family history of any dermatologic conditions. Her initial physical examination reveals a well-appearing, afebrile infant with vital signs and weight within normal limits. A complete physical examination is within normal limits except for her skin examination. There are multiple discrete 1- to 3-mm pinpoint amber vesicles without underlying erythema present over the trunk, face, and genitalia and a 1-cm isolated bulla on her chest. The vesicles are nontender and do not rupture easily when touched. Many of the amber-colored vesicles on the face have eroded, leaving honey-colored crusts surrounding them (Fig 1). Additionally, there are several erythematous 1-cm round plaques on her trunk and upper extremities. Figure 1. Initial presentation of honey-colored small vesicles and superficial erosions with honey-colored crusts. Due to the presence of bullae and honey-colored crusting on many of the lesions, the patient is diagnosed with bullous impetigo and is discharged from the emergency department on a 10-day course of …

Spirometric Results of Combined Obstructive-Restrictive Lung Disease in Emphysema

Background: emphysema often cause obstructive pattern on spirometry, but for many reasons, it could cause obstructive and restrictive (mixed) especially in sever emphysema. Aim of the study: is to determine the prevalence of combined obstructive and restrictive lesion in emphysema. Methodology: 44 patients with emphysematous changes on CXR were enrolled in this study, in Al-Sader medical city in Al-Najaf, during the period in March to September 2012. All of them performed spirometry to determine the types of changes whether obstructive or mixed (obstructive and restrictive) pattern. Results: thirty one patients (70.5%) had obstructive and 13 patients (29.5%) had mixed obstructive and restrictive pattern. Patients with severe emphysema, and those with bullae showed mixed types which is significant in regarding to final diagnosis, while those on steroids show no significant differences. Conclusion: Combined obstructive-restrictive pattern in patients with emphysema is an uncommon entity, but it can occur in severe form of emphysema and in the presence of bullae. Recommendation: Study pulmonary function tests in all patients with emphysema particularly in the presence of bullae.

Early diagnosis of necrotizing fasciitis

Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis. A systematic literature search of PubMed was undertaken using the keywords 'necrotising fasciitis', 'necrotising skin infection', 'diagnosis' and 'outcome'. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included. Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44.5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80.8 per cent), pain (79.0 per cent) and erythema (70.7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24.8 per cent of patients). A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case.

Midinfrared Laser Pancorneal Coagulation as a Method of Treatment for Painful Bullous Keratopathy

To evaluate the efficacy of midinfrared laser pancorneal coagulation (PCC) for the management of secondary painful bullous keratopathy (PBK) with poor visual potential. A single-center, nonrandomized, retrospective observational study was performed on 137 eyes (137 patients) with PBK that underwent midinfrared laser PCC and were followed up in our clinic during 2000 to 2010. Preoperatively and at follow-up visits, all the eyes underwent a standard ophthalmologic examination; concurrently, 36 of these underwent corneal optical coherence tomography (OCT) and Scheimpflug camera examination (SCE). The main criteria for the efficacy of the treatment included a profile of the patients' corneal syndrome-related complaints (pain, dryness, etc), presence of bullae and deepithelization, and changes in the corneal thickness (CT) and transparency, based on OCT and SCE data, respectively, whereas additional ones included visual acuity changes. During the 24-month follow-up period, 69.3% of the patients had no complaints (complete epithelization), whereas 10.9% and 3.6% complained of having dryness and residual pain, respectively; the rest exhibited a recurrent corneal syndrome with isolated blister and/or corneal erosion areas, which was successfully managed with an additional focal-pattern laser coagulation session. In the OCT and SCE subgroup, on the day-3, day-7, and month-24 visits, the mean CT statistically significantly decreased from baseline (1027.1 ± 239.5) to 737.6 ± 157.4 μm, 592.3 ± 96.4 μm, and was 617 ± 95.9 μm, respectively, whereas the mean optical density decreased from the baseline (72.5 ± 9.5) to 62.3 ± 7.8, 58.5 ± 8.7, and was 56.33 ± 8.1 Scheimpflug densitometry units, respectively. PCC is a simple procedure that provides prompt relief from pain for eyes that have PBK with poor visual potential due to the reduction in CT and significant resolution of bullae and edema.

Radiological and Functional Findings in Presence of Bullae and Blebs

Radiological and Functional Findings in Presence of Bullae and Blebs

Using Clinical Pathways to Aid in the Diagnosis of Necrotizing Soft Tissue Infections Synthesis of Evidence

Necrotizing soft tissue infections (NSTIs) are rare, rapidly spreading infections that occur in the soft tissue compartments. The mortality rate is high and has been found to decrease if patients are treated early and aggressively with surgical debridement and broad-spectrum antibiotics. Unfortunately these infections present similarly to other types of skin and soft tissue infections (SSTIs) making diagnosis difficult. This paper reviews the evidence surrounding the early diagnosis of NSTIs. This was used to develop a clinical practice guideline (CPG) for implementation in the emergency department (ED) setting to assist the provider in distinguishing NSTIs from SSTIs to potentially decrease the time from presentation to diagnosis. A review of the literature was performed. Studies were identified and critiqued by two reviewers independently for clinical relevance, study design, and statistical analysis. Signs and symptoms, or "hard signs," associated with NSTIs include: pain out of proportion to the exam, rapidly spreading infection, presence of bullae, skin ecchymosis or sloughing, gas in the tissues, skin anesthesia, edema extending beyond the erythema, and symptoms of sepsis. Unfortunately only 43% of the patients with an NSTI will present with these signs. Studies have found an association between laboratory values and NSTIs with the most commonly associated findings being leukocytosis, azotemia, and hyponatremia. Using these complimentary clinical and laboratory values, the Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score is an emerging tool that providers can use to determine the risk of an NSTI. A clinical pathway was developed and implemented in the ED for all patients presenting with an SSTI to assist providers in confirming or negating the presence of an NSTI. Educating ED providers about the signs, symptoms, and laboratory findings associated with NSTIs will lead to earlier diagnosis and treatment and decreased morbidity and mortality.