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

Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018)

BACKGROUND

Necrotising fasciitis (NF) is a surgical emergency characterised by rapidly progressive infection of the subcutaneous tissues and fascial planes, leading to widespread fascial necrosis and systemic toxicity. Although NF can affect any part of the body, the upper limbs are a notable site, accounting for 27% of cases. Antibiotics and surgical debridement form the basis of treatment.

METHODOLOGY

We conducted a retrospective study on NF of the upper limb requiring surgical intervention from 1998-2018 using data from Hospital Episode Statistics. Age, sex, deprivation index, length of stay (LOS) and complications were analysed.

RESULTS

We identified 728 patients, comprising 468 males and 260 females, with a mean age of 54.97 years (95% CI: 53.76-56.17 years). The incidence of NF in the upper limb increased from 0.0035 per 100,000 in 1998 to 0.01 per 100,000 in 2018. Lower index of multiple deprivation scores correlated with higher NF prevalence, with 67.32% (n=474) presenting scores between 0 and 5. The average LOS was 27.55 days (95% CI: 25.08-30.02 days). Complications within 30 days of surgery included 8 (1.10%) cases of renal failure, 8 (1.10%) urinary tract infections (UTIs), and 103 (14%) deaths. Meanwhile, 90-day complications included 23 (3.15%) cases of renal failure, 6 (0.82%) pulmonary embolisms, 22 (3.02%) UTI, and 113 (16%) deaths.

CONCLUSION

This study highlights the impact of upper limb NF and provides crucial insights into its incidence, demographic correlations, and clinical outcomes, which can inform clinical management.

Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases

OBJECTIVES

Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects.

METHODS

A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data.

RESULTS

During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis.

CONCLUSIONS

The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

Regulation of inflammation during wound healing: the function of mesenchymal stem cells and strategies for therapeutic enhancement

A wound takes a long time to heal and involves several steps. Following tissue injury, inflammation is the primary cause of tissue regeneration and repair processes. As a result, the pathophysiological processes involving skin damage, healing, and remodeling depend critically on the control of inflammation. The fact that it is a feasible target for improving the prognosis of wound healing has lately become clear. Mesenchymal stem cells (MSCs) are an innovative and effective therapeutic option for wound healing due to their immunomodulatory and paracrine properties. By controlling the inflammatory milieu of wounds through immunomodulation, transplanted MSCs have been shown to speed up the healing process. In addition to other immunomodulatory mechanisms, including handling neutrophil activity and modifying macrophage polarization, there may be modifications to the activation of T cells, natural killer (NK) cells, and dendritic cells (DCs). Furthermore, several studies have shown that pretreating MSCs improves their ability to modulate immunity. In this review, we summarize the existing knowledge about how MSCs influence local inflammation in wounds by influencing immunity to facilitate the healing process. We also provide an overview of MSCs optimizing techniques when used to treat wounds.

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.

Necrotizing Soft Tissue Infection of the Upper Extremity as a Manifestation of Hansen’s Disease

Hansen’s disease is a well-described, largely historic infection that is caused by Mycobacterium leprae. Lucio's phenomenon is an aggressive, rare form of untreated lepromatous leprosy characterized by diffuse cutaneous lesions and systemic symptoms. To date, cases of necrotizing soft tissue infection in the setting of leprosy have rarely been reported in the literature. We present the case of a 51-year-old man with no known past medical history who presented for the evaluation of acute-on-chronic left upper extremity ulceration, soft tissue swelling, and pain. The patient was diagnosed with necrotizing soft tissue infection of the left upper extremity and underlying multibacillary lepromatous leprosy with Lucio's phenomenon. He underwent dermatofasciectomy of the affected extremity, followed by staged soft tissue coverage, including dermal allograft placement. Proper antibiotic management was also undertaken. In this article, we describe a case of previously undiagnosed leprosy with Lucio's phenomenon manifesting as necrotizing fasciitis of the upper extremity.

Necrotizing Soft Tissue Infections of the Hand and Wrist

Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.