Analysis of the increasing prevalence of necrotising fasciitis referrals to a regional plastic surgery unit: A retrospective case series

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

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.

A Systematic Review and Meta-Analysis of the Effectiveness of LRINEC Score for Predicting Upper and Lower Extremity Necrotizing Fasciitis

This review and meta-analysis aims to assess the prognostic value of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing fasciitis in the extremities. The LRINEC score has been validated in multiple studies as a clinical tool for differentiating necrotizing fasciitis from non-necrotizing infections however many studies do not specify the location of infection. As the prevalence of diabetes and diabetic foot infections continues to rise, the utility of LRINEC scores in these populations becomes of increased importance. Four databases were reviewed for citations between January 2010 and December 2020. English, full text articles reporting the diagnostic effects of LRINEC were utilized in the systematic review portion of this paper. Further inclusion of 2 × 2 tables and discussion specific to the extremities were applied for citations implemented in the meta-analysis. Of the 111 results, 12 citations (n = 932) were included in this review. The diagnostic sensitivity of the LRINEC score ranged from 36% to 77% while specificity ranged from 72% to 93%. Cumulative odds ratio for LRINEC ≥6 among the 4 studies assessing extremity necrotizing fasciitis was 4.3 with p value of <.05. Sensitivity, specificity, positive predictive value, and negative predictive value was 49.39%, 83.17%, 34.91%, and 89.99%, respectively. Accuracy, the classification by whether a patient was correctly classified, was 77.95%. LRINEC score is effective at distinguishing necrotizing fasciitis from other soft tissue infections however the LRINEC's score greatest clinical application may be its ability to rule out necrotizing fasciitis while its ability to accurately identify the presence of infection remains suboptimal.

[Necrotizing Fasciitis]

Necrotizing fasciitis (NF) is a soft tissue infection spreading along the fasciae to the surrounding subcutaneous fat, overlying skin and finally musculature, that may rapidly lead to septic shock and death. In order to avoid a massive systemic spread of the infective process, an immediate and extensive radical debridement of necrotic tissues is mandatory complemented by a broad spectrum intravenous antibiotic therapy. Nevertheless, mortality is persistently high at 20-40 %. Because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Hence, early diagnosis is missed or delayed in 85 %-100 % of cases with the passage of valuable time.The aim of this review is to give an overview of the clinical and laboratory elements to be considered for diagnosis as well as the essential therapeutic patterns.

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.

Utility of Magnetic Resonance Imaging for Differentiating Necrotizing Fasciitis from Severe Cellulitis: A Magnetic Resonance Indicator for Necrotizing Fasciitis (MRINEC) Algorithm

We developed a new magnetic resonance indicator for necrotizing fasciitis (MRINEC) algorithm for differentiating necrotizing fasciitis (NF) from severe cellulitis (SC). All adults with suspected NF between 2010 and 2018 in a tertiary hospital in South Korea were enrolled. Sixty-one patients were diagnosed with NF and 28 with SC. Among them, 34 with NF and 15 with SC underwent magnetic resonance imaging (MRI). The MRINEC algorithm, a two-step decision tree including T2 hyperintensity of intermuscular deep fascia and diffuse T2 hyperintensity of deep peripheral fascia, diagnosed NF with 94% sensitivity (95% confidence interval (CI), 80–99%) and 60% specificity (95% CI, 32–84%). The algorithm accurately diagnosed all 15 NF patients with a high (≥8) laboratory risk indicator for necrotizing fasciitis (LRINEC) score. Among the five patients with an intermediate (6–7) LRINEC score, sensitivity and specificity were 100% (95% CI, 78–100%) and 0% (95% CI, 0–84%), respectively. Finally, among the 29 patients with a low (≤5) LRINEC score, the algorithm had a sensitivity and specificity of 88% (95% CI, 62–98%) and 69% (95% CI, 39–91%), respectively. The MRINEC algorithm may be a useful adjuvant method for diagnosing NF, especially when NF is suspected in patients with a low LRINEC score.

Necrotizing Fasciitis Within 72 hours After Presentation with Skin and Skin Structure Infection

Introduction

A small percentage of patients with skin infections later develop necrotizing fasciitis (NF). Diagnostic testing is needed to identify patients with skin infections at low risk of NF who could be discharged from the emergency department (ED) after antibiotic initiation. Elevated lactate has been associated with NF; existing estimates of the frequency of NF are based on retrospective reviews, and cases often lack testing for lactate. We present the incidence of patients with skin infections who developed NF and their baseline lactates.

Methods

In four phase-3 trials, 2883 adults with complicated or acute bacterial skin and skin structure infections were randomized to dalbavancin or comparator, with early and late follow-up visits through Day 28. We prospectively collected baseline plasma lactates in one trial to assess an association with NF.

Results

NF was diagnosed in 3/2883 patients (0.1%); all three survived. In the study with prospectively collected baseline lactates (n = 622), 15/622 (2.4%) had a lactate ≥4 millimoles per liter (mmol/L), including 3/622 (0.5%) with a lactate ≥7 mmol/L. NF was not seen in patients with a lactate <4 mmol/L; NF was seen in 1/15 (6.7%) with a lactate ≥4 mmol/L, including 1/3 (33.3%) with lactate ≥7 mmol/L.

Conclusions

NF incidence within 72 hours of antibiotic initiation in patients with complicated or acute bacterial skin and skin structure infections was extremely low (0.1%) and occurred in 6.7% with a lactate ≥4 mmol/L. Lactate <4 mmol/L can be used to identify patients at low risk of NF who could be safely discharged from the ED after antibiotic initiation.

Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities

OBJECTIVES

The Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities.

METHODS

We conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve.

RESULTS

A total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751).

CONCLUSION

The Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.

Management of necrotising fasciitis within a burns centre: do outcomes differ?

INTRODUCTION

Many similarities exist between the care of necrotising fasciitis (NF) and burn injury patients. Each group represents a small but complex cohort requiring multiple theatre trips, specialist reconstruction, meticulous wound care and multidisciplinary management. Over a six-year period, we sought to examine the clinical outcomes of NF patients managed within a burns centre against those managed by a plastic surgery service.

METHODS

A retrospective case-note review was performed for all identifiable patients referred to our institution's designated burns centre or plastic surgery service between 2008-2014. Patient characteristics, length of stay, wound-related and clinical outcomes were extracted and descriptively presented with statistical analysis performed for survival and length of stay.

RESULTS

Twenty-nine patients were included in the study (burns centre [B]: 17 patients; plastic surgery service [P]: 12 patients). Median total length of stay (B: 37 vs. P: 50 days, P=0.38), local length of stay (27 vs. 19 days, P=0.29) and survival till discharge (94.4% vs. 100%, P=0.73) demonstrated no statistically significant difference.

CONCLUSION

Caring for NF patients within a burns centre facilitated easier access to specialist reconstructive expertise and multidisciplinary care but did not lead to statistically significant differences in length of stay or survival. The management of NF within a burns centre facilitated provision of high-quality care to a highly challenging patient group.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Fournier Gangrene: A Review for Emergency Clinicians

BACKGROUND

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG.

DISCUSSION

Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications.

CONCLUSIONS

FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults

Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].

Necrotizing Fasciitis: An Overview and 2 Illustrative Cases

Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Healthcare Resource Utilization Associated with Burns and Necrotizing Fasciitis: A Single-Center Comparative Analysis

Necrotizing fasciitis (NF) patients are increasingly managed in burn units. Although treated similarly to burns, the healthcare resource utilization (HRU) in NF appears to be greater. Accurate knowledge of the HRU is important to better allocate resources and to compare outcomes between units. The goal of this study is to provide better understanding of the HRU for NF compared with burns. A retrospective chart review of patients ≥18 years admitted to two regional tertiary referral centers with either NF or burns requiring surgery. The authors examined age, sex, %TBSA, geographic region, anatomical location, length of stay (LOS) in hospital, LOS in intensive care unit, number of operative procedures, number of packed red blood cells transfused, amputation, death, and use of free tissue transfer or skin graft. There were 210 NF and 209 burn patients. The NF cohort had a smaller TBSA (3.3 vs 10.0%), longer LOS (20 vs 14 days), and consequently a longer LOS/%TBSA (6.0 vs 1.5 days). This difference persisted after adjusting for age. More of the NF cohort (44.8%) spent ≥1 day in the intensive care unit. The NF cohort also had more procedures (median 2 vs 1), required blood (46.2 vs 16.7%), died in hospital (13.3 vs 4.3%), had an amputation (12.4 vs 4.8%), or required free tissue transfer (7.6 vs 2.9%). This study shows that NF requires substantially more HRU compared with burns. This information is important in recognizing the impact of these patients on burn units and planning for allocation of appropriate resources.

Periocular Necrotizing Fasciitis with Toxic Shock Syndrome

Purpose

To report a case of periocular necrotizing fasciitis with toxic shock syndrome.

Methods

This is a case report of a previously healthy 69-year-old woman with left preseptal eyelid infection that spread rapidly and deteriorated into necrosis of the eyelid with toxic shock syndrome. She was admitted to intensive care unit for hemodynamic stabilization.

Results

Intravenous antibiotic and high-dose immunoglobulin were administered followed by surgical debridement. Rehabilitative eyelid reconstruction was performed after acute episode, resulting in patient satisfaction in relation to periocular function and appearance.

Conclusion

We reported a case of periocular necrotizing fasciitis with toxic shock syndrome that necessitated early aggressive medical treatment and adequate surgical intervention to decrease morbidity and mortality. A high level of suspicion of periocular necrotizing fasciitis is necessary to make a prompt diagnosis.

Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature

Introduction Early operative debridement of necrotising fasciitis is a major outcome determinant. Identification and diagnosis of such patients can be clinically difficult. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score first published in 2004 is based on routinely performed parameters and offers a method for identifying early cases. No literature review has yet been performed on the application of such a score. Methods A systematic review of English-language literature was performed from 2004 to 2014 to identify articles reporting use of LRINEC score and the incidence of necrotising fasciitis. We performed a critical review of PubMed, Medline and Embase in line with the PRISMA statement. A meta-analysis was performed with a random effects model and 95% confidence interval. Suitable correlation coefficient and receiver operating characteristic (ROC) curves were also calculated. Results After application of inclusion criteria, 16 studies with 846 patients were included. The mean LRINEC score in patients with necrotising fasciitis was 6.06. Two papers reported LRINEC score in patients without necrotising fasciitis with a mean 2.45. All six studies with a reported coefficient of variance were < 1; Pearson correlation coefficient was r = 0.637 (P = 0.011). An ROC curve showed an area under the curve of 0.927. Conclusions The LRINEC score is a useful clinical determinant in the diagnosis and surgical treatment of patients with necrotising fasciitis, with a statistically positive correlation between LRINEC score and a true diagnosis of necrotising fasciitis.

Necrotizing Fasciitis in Aesthetic Surgery: A Review of the Literature

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, potentially fatal, infective complication that can occur after surgery. Diagnosis is still difficult and mainly based on clinical data. Only a prompt pharmacological and surgical therapy can avoid dramatic consequences. There are few reports regarding NF as a complication after aesthetic surgical procedures, and a systematic review still lacks.

MATERIALS AND METHODS

We have performed a systematic review of English literature on PubMed, covering a period of 30 years. Keywords used were "necrotising fasciitis" matched with "aesthetic surgery complications", "breast surgery", "mammoplasty", "blepharoplasty", "liposuction", "facelift", "rhinoplasty fasciitis", "arm lift", "thigh lift", "otoplasty" and "abdominoplasty fasciitis". No additional search and temporal limitation were set.

RESULTS

Among 3782 papers concerning NF, only 18 were related to NF after an aesthetic surgical procedure. Liposuction was the most affected procedure, with buttocks and lower extremity the most involved anatomical regions. The majority of the infections were monomicrobial, promoted by Streptococcus pyogenes. In most cases, NF occurred within the third post-operative day with non-specific signs and symptoms. In 14 cases, a single or multiple surgical interventions were performed and survival was achieved in 11 patients.

CONCLUSIONS

In case of infection after aesthetic surgery, we should always bear in mind NF. Clinical hallmarks still guide NF management. Because early signs and symptoms are usually non-specific, a strict clinical control is highly suggested. Once clinical suspicion is raised, prompt antibacterial therapy should be administered, followed by surgical debridement in case of ineffective response.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An atypical presentation of necrotising fasciitis

Necrotising fasciitis is a rare infection with a high mortality rate. Clinical manifestation may be influenced by an underlying disease state. We report a case of a 70-year-old man with an anaplastic large-cell lymphoma who presented with inconclusive signs of necrotising fasciitis following a neutropenic phase after chemotherapy. Surgical exploration did not reveal the typical macroscopic features of necrotising fasciitis. Microbiological investigations revealed Escherichia coli. The lack of massive tissue inflammation, probably due to the neutropenia in our patient, has not been described by other authors. Diagnostic uncertainties owing to masked or uncharacteristic signs in immune compromised patients may lead to a delayed surgical debridement, of which clinicians should be aware.

Necrotizing Fasciitis: How Reliable are the Cutaneous Signs?

Necrotizing fasciitis (NF) is a surgical emergency. It is often aggressive and characterized by the rapidly progressive inflammatory infection of the fascia that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissue. As the disease progresses, thrombosis of the affected cutaneous perforators subsequently devascularizes the overlying skin. The course indeed can be a fulminant one. The diagnosis of NF, especially in the early stages, is extremely challenging, and it can be very close in presentation to other skin and subcutaneous tissue infections. The primary site of the pathology is the deep fascia. Necrosis of the tissues and fascia may manifest as erythema without sharp margins, swelling, warmth, shiny, and exquisitely tender areas. Pain out of proportion to physical examination findings may be observed. The subcutaneous tissue may be firm and indurated such that the underlying muscle groups cannot be distinctly palpated. Eventually, as the overlying skin is stripped of its blood supply, skin necrosis ensues and hemorrhagic bullae form. Bacteremia and sepsis invariably develop when the infection is well established. This paper discusses some of issues related to the cutaneous signs found in NF and also provides a review the current, available literature on the subject matter.

Triple diagnostics for early detection of ambivalent necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Over the last decade time to surgery decreased and outcome improved, most likely due to increased awareness and more timely referral. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. Signs and symptoms might be misleading or absent, while the most prominent skin marks might be in discrepancy with the position of the fascial necrosis. Gram staining and especially fresh frozen section histology might be a useful adjunct.

METHODS

Retrospective analysis of 3 year period. Non-transferred patients who presented with suspected necrotizing fasciitis are included. ASA classification was determined. Mortality was documented.

RESULTS

In total, 21 patients are included. Most patients suffered from severe comorbidities. In 11 patients, diagnoses was confirmed based on intra-operative macroscopic findings. Histology and/or microbiotic findings resulted in 6/10 remaining patients in a change in treatment strategy. In total, 17 patients proved to suffer necrotizing fasciitis. In the cohort series 2 patients died due to necrotizing fasciitis.

CONCLUSION

In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis.

Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department

Introduction

Necrotizing fasciitis (NF) is a life-threatening illness, particularly when surgical debridement is delayed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed to identify patients at higher risk for NF. Despite limited information in this regard, the LRINEC score is often used to “rule out” NF if negative. We describe the sensitivity of the LRINEC score in emergency department (ED) patients for the diagnosis of NF.

Methods

We conducted a chart review of ED patients in whom coding of hospital discharge diagnoses included NF. We employed standard methods to minimize bias. We used laboratory data to calculate the LRINEC score, and confirmed the diagnosis of NF via explicit chart review. We then calculated the sensitivity of a positive LRINEC score (standardly defined as six or greater) in our cohort. We examined the role of patient characteristics in the performance of the LRINEC score. Finally, we performed sensitivity analyses to estimate whether missing data for c-reactive protein (CRP) results were likely to impact our results.

Results

Of 266 ED patients coded as having a discharge diagnosis of NF, we were able to confirm the diagnosis, by chart review, in 167. We were able to calculate a LRINEC score in only 80 patients (due to absence of an initial CRP value); an LRINEC score of 6 or greater had a sensitivity of 77%. Sensitivity analyses of missing data supported our finding of inadequate sensitivity to rule out NF. In sub-analysis, NF patients with concurrent diabetes were more likely to be accurately categorized by the LRINEC score.

Conclusion

Used in isolation, the LRINEC score is not sufficiently sensitive to rule out NF in a general ED population.

Improvement of a Clinical Score for Necrotizing Fasciitis: 'Pain Out of Proportion' and High CRP Levels Aid the Diagnosis

Necrotizing fasciitis (NF) is a rare mono-/polymicrobial skin infection that spreads to underlying tissues. NF is quickly progressing and leads to life threatening situations. Immediate surgical debridement together with i.v. antibiotic administration is required to avoid fatal outcome. Early diagnosis is often delayed due to underestimation or confusion with cellulitis. We now compared the initial clinical and laboratory presentation of NF and cellulitis in detail to assess if a typical pattern can be identified that aids timely diagnosis of NF and avoidance of fatal outcome. 138 different clinical and laboratory features of 29 NF patients were compared to those of 59 age- and gender matched patients with severe erysipelas requiring a subsequent hospitalization time of ≥10 days. Differences in clinical presentation were not obvious; however, NF patients suffered significantly more often from strong pain. NF patients exhibited dramatically elevated CRP levels (5-fold, p>0.001). The overall laboratory risk indicator for necrotizing fasciitis (LRINEC) score was significantly higher in NF patients as compared to cellulitis. However, a modification of the score (alteration of laboratory parameters, addition of clinical parameters) led to a clear improvement of the score with a higher positive predictive value without losing specificity. In summary, clinical differentiation of NF from cellulitis appears to be hard. ‘Pain out of proportion’ may be an early sign for NF. An improvement of the LRINEC score emphasizing only relevant laboratory and clinical findings as suggested may aid the early diagnosis of NF in the future leading to improvement of disease outcome by enabling rapid adequate therapy.