Severe Soft Tissue Infections Research Articles

A case of streptococcal toxic shock syndrome due to Group G streptococci identified as Streptococcus dysgalactiae subsp. equisimilis

A 79-year-old man with a 3-month history of lymphedema of the lower limbs, and diabetes mellitus, was admitted to our hospital for suspected deep venous thrombosis. Several hours after admission, leg pain and purpura-like skin color appeared. On the 2nd hospital day, he was referred to our department for possible acute occlusive peripheral artery disease (PAD) and skin necrosis with blisters; however, computed tomography with contrast showed no occlusive lesions. He had already developed shock and necrotizing deep soft-tissue infections of the left lower leg. Laboratory findings revealed renal dysfunction and coagulation system collapse. Soon after PAD was ruled out, clinical findings suggested necrotizing deep soft-tissue infections, shock state, disseminated intravascular coagulation, and multiple organ failure. These symptoms led to a high suspicion of the well-recognized streptococcal toxic shock syndrome (STSS). With a high suspicion of STSS, we detected Group G β-hemolytic streptococci (GGS) from samples aspirated from the leg bullae, and the species was identified as Streptococcus dysgalactiae subsp. equisimilis (SDSE) by 16S-ribosomal RNA sequencing. However, unfortunately, surgical debridement was impossible due to the broad area of skin change. Despite adequate antimicrobial therapy and intensive care, the patient died on the 3rd hospital day. The M-protein gene (emm) typing of the isolated SDSE was revealed to be stG6792. This type of SDSE is the most frequent cause of STSS due to GGS in Japan. We consider it to be crucial to rapidly distinguish STSS from acute occlusive PAD to achieve life-saving interventions in patients with severe soft-tissue infections.

Anthrax Infection

Bacillus anthracis infection is rare in developed countries. However, recent outbreaks in the United States and Europe and the potential use of the bacteria for bioterrorism have focused interest on it. Furthermore, although anthrax was known to typically occur as one of three syndromes related to entry site of (i.e., cutaneous, gastrointestinal, or inhalational), a fourth syndrome including severe soft tissue infection in injectional drug users is emerging. Although shock has been described with cutaneous anthrax, it appears much more common with gastrointestinal, inhalational (5 of 11 patients in the 2001 outbreak in the United States), and injectional anthrax. Based in part on case series, the estimated mortalities of cutaneous, gastrointestinal, inhalational, and injectional anthrax are 1%, 25 to 60%, 46%, and 33%, respectively. Nonspecific early symptomatology makes initial identification of anthrax cases difficult. Clues to anthrax infection include history of exposure to herbivore animal products, heroin use, or clustering of patients with similar respiratory symptoms concerning for a bioterrorist event. Once anthrax is suspected, the diagnosis can usually be made with Gram stain and culture from blood or surgical specimens followed by confirmatory testing (e.g., PCR or immunohistochemistry). Although antibiotic therapy (largely quinolone-based) is the mainstay of anthrax treatment, the use of adjunctive therapies such as anthrax toxin antagonists is a consideration.

Necrotizing Fasciitis and Septic Shock Related to the Uncommon Gram-Negative Pathogen Sphingobacterium multivorum

We report the first case of necrotizing fasciitis due to the uncommon Gram-negative pathogen Sphingobacterium multivorum in an immunocompromised patient, who presented with septic shock. This case adds necrotizing fasciitis to the spectrum of S. multivorum-related infections and highlights the emergence of Gram-negative bacteria in severe soft tissue infections.

Diagnostic and Prognostic Value of Thrombocytosis in Admitted Medical Patients

IntroductionWhether secondary thrombocytosis is a distinguishing clinical biomarker of various diseases, and whether it is an independent predictor of short-term outcome of admitted medical patients is unknown and has never been examined. MethodsA cohort of all 138 patients with secondary thrombocytosis (platelets count ≥ 5 x 105/μL) admitted to the department of medicine during the last 2 years was analyzed. Epidemiological and clinical data, and the final diagnosis and outcome were recorded and compared with a cohort of 684 consecutive admitted patients without thrombocytosis. ResultsThrombocytosis was not a non-specific marker of inflammation, because uncomplicated infections and most admission causes were not associated with thrombocytosis, except for inflammatory rheumatic diseases (6% versus 1%), along with anemia (9.4% versus 2.5%) and tumor comorbidity (25% versus 14%). In contrast, thrombocytosis was a distinguishing biomarker for severe pyogenic infections, especially empyema (5% vs. 0%), any abscesses (14% versus 3%), and soft tissue infections (7% versus 3%). Moreover, the thrombocytosis group had significantly more admission days, infections (45% versus 33%), sepsis (21% versus 6%), in-hospital major complications (15% versus 3%) and mortality (19% versus 5%). Finally, thrombocytosis was found to be an independent predictor of mortality, in a multivariate regression analysis. ConclusionsThrombocytosis is not a simple marker of inflammation. Its presence warrants thorough investigation for the presence of severe underlying disease, mostly complicated pyogenic infections, inflammatory rheumatic diseases and malignancy. Moreover, thrombocytosis is a marker for major complications and is an independent predictor of mortality in admitted medical patients.

Necrotizing fasciitis of the perineum

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries a high mortality rate and requires prompt diagnosis and urgent treatment with radical debridement and antibiotics; but early diagnosis, which is essential to successful treatment, remains a challenge. Physical examination findings, preoperative and operative findings, histopathological results of the structure, and follow-up results of the patient are discussed with related reports. A 15-month old girl had a history of trivial perineal dermatitis after treatment of anemia and pneumonia. Perineal dermatitis progressed fastly as necrotizing fasciitis which was successfully managed with intensive medical treatment, surgical debridement and reconstructive surgery. Lack of cutaneous findings early in the disease makes the diagnosis challenging, so a high suspicion is essential. Recovery of the patient from this life-threatening condition needs a multi-disciplinary approach involving pediatrics, pediatric surgery, and plastic and reconstructive surgery.

Trauma Readiness Training for Military Deployment: A Comparison Between a U.S. Trauma Center and an Air Force Theater Hospital in Balad, Iraq

The U.S. Air Force created the Center for Sustainment of Trauma and Readiness Skills at the Shock Trauma Center (STC) where staffs rotate before deployment. We sought to investigate the value of this training. A retrospective review of prospectively collected data of patient volume, injury severity, mechanism of injury, operative cases, and massive transfusion data from September 2006 to August 2007 was obtained from the STC in Baltimore and the Air Force Theater Hospital (AFTH) in Balad. Severity of injury and massive transfusions were higher at the AFTH. Soft tissue wound care represented approximately 25% of AFTH cases; a soft tissue service performed 465 operative debridements for severe soft tissue infections at STC. The STC's high-volume of major soft tissue debridement cases may offer the closest approximation of high energy wound care. Training at selected U.S. trauma centers may prepare military staff to care for war injuries, particularly those who do not practice in high-volume Level 1 trauma centers.

The Changing Face ofStaphylococcus aureus:A Continuing Surgical Challenge

Staphylococcus aureus continues to be an important pathogen for surgeons. Surgical infections of interest caused by this pathogen include community-acquired infections, especially of skin and soft tissue; surgical site infections; and nosocomial infections during the post-operative period. A literature review was conducted to detail the history of S. aureus in surgical care; to identify the structural elements of the pathogen, the secreted exotoxins and enzymes, and the changing resistance patterns that make S. aureus an ever-formidable clinical foe; to consider whether screening for the pathogen and directed antimicrobial prophylaxis are useful; and to identify antimicrobial agents employed currently in treatment of established infections. Staphylococcus aureus has shown a pattern of increasing prevalence of infections among hospitalized patients and a pattern of increasing resistance. A broad array of virulence factors account for its continued pathogenicity, and new virulence characteristics continue to be acquired. Staphylococcus aureus has an uncanny ability to adapt and develop resistance to each new antibiotic as it is introduced into clinical care. Although screening and directed surgical prophylaxis against methicillin- (now sometimes referred to as meticillin-) resistant S. aureus (MRSA) is controversial, effective efforts to decrease the incidence of nosocomial infections may be decreasing the numbers of MRSA infections encountered, and current agents remain effective for therapy. Staphylococcus aureus continues to be a major pathogen for surgical patients. The scope of infections has expanded recently to include toxic shock syndrome, severe community-acquired soft tissue infections with unique virulence characteristics, and highly resistant pathogens. The adaptability of the organism requires that new prevention and treatment strategies be developed continuously to meet the challenge of future infections.

Anatomo-radiological study of the internal pudendal perforator vessels : clinical relevance in reconstructive surgery of the perineal region

Introduction . The mobilization of muscular and fasciocutaneous flaps represents a mandatory reconstructive surgery in a variety of soft tissue defects of the the pelvi-perineal area. Often oncological surgery, trauma or severe soft tissue infections such as Fournier’s gangrene, produce functional and morphological deformities of this region. An appropriate soft tissue reconstruction may limit the development of scar contractures and stenosys. The possibility to better localize the main vascular perforators may help the surgeon in a safe flap mobilization. Methods . To objectively document the topografical location of external and internal pudendal arteries and respectively perforators branches, an anatomo-radiological study on 24 CT angiographies of 12 lower limbs (multidetector CT 16 slides), and analysis of multiplannar images and 3D reconstructions (Terarecon™) were performed. The origin, number, course and location of perforators of the internal pudendal artery in vivo were recorded. Results . Superficial landmarks (anus, external urethral meatus and ischiatic tuberosity) may describe a safe cutaneous perineal region in which is possible to localize all internal pudendal perforator arteries. In this area the mean number of perforators was 2,6 (range: 0-4). In one case (4%) the perforators vessels originated from the inferior gluteal artery. The mean diameter of perforators was 2,3 mm (0,47SD; range 1,4-3,4). The most proximal perforator of the internal pudendal artery presented a mean caliber of 2,6 mm (range 2-3,4). Discussion . This study confirms the presence of a rich vascular network between the internal and external pudendal artery. Moreover a reliable caliber and constant location of the perforators of the internal pudendal artery are documented. These observations are also confirmed intraoperatively during the mobilization of perforators flaps for the reconstruction of perineal area. The knowledge of the rich vascular plexus allows to plan a variety of fascio-cutaneous perforator flaps that may guarantee better reconstruction results then the past.

Vacuum-Assisted Closure As a Surgical Assistant in Life-Threatening Necrotizing Fasciitis in Children

Necrotizing fasciitis is a severe soft tissue infection that can involve skin, subcutaneous fat, fascia and muscle. It can result in devastating sequelae including tissue necrosis, sepsis, toxic shock syndrome, cardiopulmonary collapse and death. To control rapidly spreading necrosis, early diagnosis and aggressive surgical treatment with extensive radical debridement of the affected areas is necessary, as well as systemic administration of broad-spectrum antimicrobials and, very often, intensive care support.The subatmospheric negative pressure dressing has been previously used in acute and complex wounds management. The concept of using vacuum-assisted closure dressing as another management component is presented in the current article.

Application of regulated oxygen-enriched negative pressure-assisted wound therapy in combating anaerobic infections

Regulated negative pressure-assisted wound therapy (RNPT) applies non-pharmaceutical technology for enhanced healing of hard to cure, acute and chronic wounds. Although used for over two decades, wound pO2 levels, an essential physical parameter inherent in RNPT that follows Henry’s Law of gases, have not been reported. Necrotizing fasciitis (NF), a severe soft tissue infection, necessitates prompt intensive therapeutic response using pharmaceutical, surgical, and hyperbaric oxygen treatment when anaerobes are involved. We report a linear decrease in pO2 values in direct correlation with sub-atmospheric pressure and concurrent changes in wound atmospheric pO2 by supplemented oxygen in an in vitro phantom leg simulated wound model treated with RNPT. We designed a system using regulated oxygen-enriched negative pressure therapy (RO-NPT) for controlling wound atmospheric pO2. A representative patient case report treated for NF with RO-NPT is presented. RNPT follows Henry’s law of gases and leads to a decrease in wound atmospheric pO2. The application of RNPT in anaerobic wound infections should be contraindicated. Wound pO2 is enhanced by simultaneous application of oxygen by RO-NPT. We have demonstrated the rationale for the possible use of RO-NPT for prevention of anaerobic wound infections and as a supplemental mode of treatment of NF.

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

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

Open landmine foot injury

We present the case of a young soldier admitted in emergency to a hospital with dangerous right foot injury. In primary surgical treatment, amputation of leg was discussed because of the presence of severe bone and soft tissue infection. However, excision of dead tissue and frequent rinsing of the wound in the operating room and antibiotic therapy may save the limb. The problem of stump covering was resolved by fasciocutaneous flap.

Serum antibodies toVibrio vulnificusbiotype 3 lipopolysaccharide and susceptibility to disease caused by the homologousV. vulnificusbiotype

In 1996 an outbreak of severe soft tissue infections caused by Vibrio vulnificus unexpectedly erupted in fish consumers in Israel with relatively little morbidity in fish farmers. To test the hypothesis that recurrent exposure of fishermen to the virulent strain may have provided protection against severe or symptomatic disease, we investigated the association between the immune response to V. vulnificus biotype 3 lipopolysaccharide (BT3 LPS) and disease susceptibility in fish farmers and fish consumers. Serum samples were tested for IgA and IgG of anti-BT3 LPS in fishermen and fish consumers who suffered from V. vulnificus BT3 infections and their matched controls. Pre-existing levels of IgG (IgG0) of anti-BT3 LPS were significantly lower in diseased fishermen who developed disease associated with the homologous biotype, compared to controls. In multivariate analysis, levels of IgG0 anti-BT3 LPS remained the only variable significantly associated with disease occurrence in fishermen. Higher levels of pre-existing IgG anti-BT 3 LPS antibodies may be associated with protection against severe or symptomatic disease with the homologous biotype in fishermen but not in subjects from the general public.

Management of febrile neutropenia: ESMO Clinical Practice Guidelines

Management of febrile neutropenia: ESMO Clinical Practice Guidelines J. de Naurois, I. Novitzky-Basso, M. J. Gill, F. Marti Marti, M. H. Cullen & F. Roila On behalf of the ESMO Guidelines Working Group* Department of Medical Oncology; Department of Haematology; Department of Clinical Microbiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK; Department of Medical Oncology, S. Maria Hospital, Terni, Italy

Necrotising soft tissue infection following mastectomy.

Necrotising fasciitis is a rare but rapidly progressive soft tissue disease which can lead to extensive necrosis, systemic sepsis and death. Including this case, only 7 other cases have been reported in the world literature with only 2 others affecting the patient post mastectomy.This 59 year old Caucasian lady presented with severe soft tissue infection soon after mastectomy, which was successfully treated with a combination of debridement, triangulation, VAC© dressing and skin grafting.Necrotising soft tissue infections following mastectomy are rapidly progressive and potentially extremely serious. It is essential that a high index of clinical suspicion is maintained together with prompt aggressive treatment in a multidisciplinary environment to prevent worsening physical and psychological sequelae.

Severe soft tissue infections

Severe soft tissue infections

Increased Range of Motion and Function in an Individual with Breast Cancer and Necrotizing Fasciitis—Manual Therapy and Pulsed Short-Wave Diathermy Treatment

Necrotizing fasciitis is a severe soft tissue infection of the subcutaneous tissue and fascia affecting those predisposed to immune system compromise. It is a life threatening condition; mortality can be reduced by rapid diagnosis, adequate early surgical debridement and antibiotic ointment. In this case report we present the use of manual therapy (MT) techniques, joint and soft tissue mobilization, following a regimen of pulsed short wave diathermy (PSWD) in the treatment of a woman 3 years post necrotizing fasciitis developed during chemotherapy treatment for breast cancer. During her course of chemotherapy, she developed necrotizing fasciitis which was treated with extensive surgical debridement (8 linear feet of incisions) followed by debridement to both hips and the pelvis area. When we started working with her, we put her on a course of PSWD/MT. After six weeks of following this regimen, she gained 25° of external rotation in both her left and right hips, 15° of left hip flexion and 17° of right hip flexion. The patient gained 10° of right hip extension, yet there was no improvement in left hip extension. The treatments led to a dramatic reduction in pain and scarring from previous surgeries. The patient also returned to running.

Valeur pronostique du score Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) dans les dermohypodermites infectieuses : étude prospective au CHU de Clermont-Ferrand

The LRINEC score was developed in a retrospective study in order to distinguish necrotizing fasciitis from severe soft tissue infections using laboratory data. To evaluate the prognostic value of the LRINEC score in infectious cellulitis. A prospective study was performed at the departments of infectious diseases and dermatology of the Clermont-Ferrand University Hospital. The three evaluation criteria were: time from initiation of antibiotics to regression of erythema, duration of fever and occurrence of complications (abscess, surgery, septic shock, necrotizing fasciitis, death, transfer to intensive care). Potential predictive variables were: LRINEC score>6 at admission, comorbidities, local appearance, clinical presentation and soft tissue ultrasound results. Fifty patients were included. The rate of complications was higher for patients with a LRINEC score>6 (54%) than for patients with a score<6 (12%, P=0.008). However, a LRINEC score>6 on admission was not significantly associated with increased duration of erythema or of fever. Prior lymphoedema was associated with a better prognosis. The LRINEC score may be a useful tool for the detection of complicated forms of soft tissue infections. Patients with a LRINEC score>6 on admission should be carefully evaluated (hospitalization, surgical assessment, close monitoring).

The Secreted Esterase of Group A Streptococcus Is Important for Invasive Skin Infection and Dissemination in Mice

Virulence factors regulated by the CovRS/CsrRS two-component gene regulatory system contribute to the invasive diseases caused by group A Streptococcus (GAS). To determine whether the streptococcal secreted esterase (Sse), an antigen that protects against subcutaneous GAS infection, is one of these virulence factors, we investigated the phenotype of a nonpolar sse deletion mutant strain (Deltasse). In addition, we examined the effects of covS mutation on sse expression. As assessed using a mouse model of subcutaneous infection, the virulence of the Deltasse strain is attenuated and the overall pathology is reduced. Furthermore, GAS was detected in the blood and spleens from mice subcutaneously infected with the parental strain, whereas mice subcutaneously infected with the Deltasse strain had no GAS present in their blood and spleens. The ability of the mutant to survive in the subcutis of mice appeared to be compromised. The growth of the Deltasse strain in rich and chemically defined media and nonimmune human blood and sera was slower than that of the wild-type strain. Complementation restored the phenotype of the Deltasse strain to that of the wild-type strain. The wild-type, Deltasse, and complement strains had no detectable SpeB activity. Expression of Sse is negatively controlled by CovRS. These findings suggest that Sse is a CovRS-regulated virulence factor that is important for the virulence of GAS in subcutaneous infection and plays an important role in severe soft tissue infections and systemic dissemination of GAS from the skin.

Children with lethal streptococcal fasciitis after a minor contusion injury

Necrotizing fasciitis is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. Mortality as a result of streptococcal necrotizing fasciitis has been associated with the presence of hypotension, streptococcal toxic shock syndrome, or bacteremia in the literature. These infections are rare in children, and the diagnosis should be considered in the presence of any soft tissue infection presenting with signs of toxicity and marked wound edema. In addition, traumatic compartment syndrome has also gained public attention. This condition is also potentially lethal if diagnosis and management are delayed, especially in patients with swollen limbs without fracture. A high index of suspicion is most important when there is a paucity of specific cutaneous findings early in the course of the disease. The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain. Even for treating patients with minor trauma, the emergency department physician should keep a high level of suspicion of the possibility of a fatal outcome from the subsequent invasive streptococcal infection.