Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis

Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection

IMPORTANCE

Necrotizing fasciitis is a relatively uncommon and potentially life-threatening soft tissue infection, with morbidity and mortality approaching 25% to 35%, even with optimal treatment. The challenge of diagnosis for necrotizing soft tissue infections (NSTIs) is their rarity, with the incidence of approximately 1000 cases annually in the United States. Given the rapid progression of disease and its similar presentation to more benign processes, early and definitive diagnosis is imperative.

FINDINGS

Signs and symptoms of NSTIs in the early stages are virtually indistinguishable from those seen with abscesses and cellulitis, making definitive diagnosis difficult. The clinical presentation will depend on the pathogen and its virulence factors which ultimately determine the area and depth of invasion into tissue. There are multiple laboratory value scoring systems that have been developed to support the diagnosis of an NSTI. The scoring system with the highest positive (92%) and negative (96%) predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC). The score is determined by 6 serologic markers: C-reactive protein (CRP), total white blood cell (WBC) count, hemoglobin, sodium, creatinine, and glucose. A score ≥ 6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive (59.2%) enough to rule out necrotizing fasciitis. In terms of imaging, computed tomography (CT) imaging, while more sensitive (80%) than plain radiography in detecting abnormalities, is just as nonspecific. Computed tomography imaging of NSTIs demonstrates fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Magnetic resonance imaging (MRI) has demonstrated sensitivity of 100% and specificity of 86%, though MRI may not show early cases of fascial involvement of necrotizing fasciitis.

CONCLUSIONS AND RELEVANCE

Necrotizing soft tissue infections are rapidly progressive and potentially fatal infections that require a high index of clinical suspicion to promptly diagnose and aggressive surgical debridement of affected tissue in order to ensure optimal outcomes.Prompt surgical and infectious disease consultation is necessary for the treatment and management of these patients. While imaging is useful for further characterization, it should not delay surgical consultation. Necrotizing soft tissue infection remains a clinical diagnosis, although plain radiography, CT imaging, and ultrasound can provide useful clues. In general, the management of these patients should include rapid diagnosis, using a combination of clinical suspicion, laboratory data (LRINEC score), and imaging (MRI being the recommended imaging modality), prompt infectious disease and surgical consultation, surgical debridement, and delayed reconstruction. Laboratory findings that can more strongly suggest a diagnosis of NSTI include elevated CRP, elevated WBC, low hemoglobin, decreased sodium, and increased creatinine. Imaging findings include fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Broad-spectrum antibiotics should be started in all cases of suspected NSTI. Surgical debridement, however, remains the lynchpin for treatment of cervical necrotizing fasciitis.

Necrotizing Fasciitis: Myalgia Is Diagnostic? A Case Series and Literature Review

Necrotizing fasciitis, commonly known as "flesh-eating disease," is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

Necrotizing Fasciitis of the Breast Requiring a Life-Saving Mastectomy: A Case Report and Literature Review

Necrotizing soft tissue infection of the breast is an extremely rare event in routine surgical practice. It is the most aggressive form of soft tissue infection and a real surgical emergency. It is associated with a high risk of mortality if not diagnosed promptly. A Literature search has revealed only a few such cases. The exact etiology is variable and very often multifactorial. Early recognition and prompt surgical treatment along with broad-spectrum antibiotic therapy are of paramount importance to prevent mortality. In this report, we present the first case of necrotizing fasciitis of the breast following an insect bite in the literature, in a 57-year-old diabetic patient with a delayed presentation that required a life-saving mastectomy.

Necrotising Fasciitis: Appearances Can Be Deceptive

BACKGROUND

Necrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment.

METHODS

In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre.

RESULTS

The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases.

CONCLUSION

Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.

Validation of finger test for necrotising soft tissue infection

Background:

Necrotising soft tissue infection (NSTI) is rare but fatal. Andreasen proposed finger test as an early diagnostic tool to differentiate NSTI from other soft tissue infections. We aim to evaluate the accuracy and reproducibility of the test for the diagnosis of NSTI.

Methods:

Patients who were admitted to our department from 2012 to 2016 with suspicion of NSTI and finger test done were retrospectively reviewed. Finger test was done and interpreted as described by Andreasen. Definitive diagnosis of NSTI was confirmed with surgical and pathological findings.

Results:

Among the 35 patients included in the study, NSTI was confirmed in 10 cases. Finger test had a sensitivity of 100%, a specificity of 80%, positive predictive value of 66.7%, negative predictive value of 100% and an overall accuracy of 85.7%. There was no difference in demographics or comorbidities between NSTI and non-NSTI groups. Surgeons involved had 76.7% agreement and moderate reproducibility (kappa = 0.48) on the diagnostic criteria of finger test.

Conclusion:

A negative finger test was reliable to exclude NSTI and a positive test suggested further surgical exploration. Yet, clinical judgement was still of paramount importance to treat NSTI promptly.

Post-traumatic necrotising fasciitis of the breast: a case study with literature review

Necrotising fasciitis is a rare infection of the skin and underlying soft tissue. It primarily involves the extremities and rarely the breast. Primary necrotising fasciitis of the breast in a non-lactating, healthy female is rarer still. The authors present the case report of a patient presenting with primary necrotising fasciitis of the breast after sustaining a penetrating injury. The patient was managed successfully with serial debridement and negative pressure wound therapy (NPWT). To our knowledge only 19 such cases have been reported in the indexed literature so far. This is also the eighth case globally of primary necrotising fasciitis of the breast in a non-lactating female without any associated immunosuppression, which is the basis of reporting this case.

Necrotising fasciitis complicating hand, foot and mouth disease

A literature search confirmed no previous cases of necrotising fasciitis (NF) complicating hand,foot and mouth disease (HFMD). This report explores the case of a previously well 55-week-old Caucasian boy who attended accident and emergency with an acutely swollen right hand and atypical viral rash affecting the hands and face. He was admitted under plastic surgery and treated with intravenous antibiotics and fluid resuscitation for sepsis secondary to cellulitis. Following dermatological review of the rash, a clinical diagnosis of atypical HFMD was made. He deteriorated over the first 12 hours with progression of cellulitis despite intervention. Emergency exploration and debridement were performed for suspected NF. NF was subsequently confirmed by laboratory testing. He required 5 days in paediatric intensive care but made a full recovery. Recent reports highlight an increase in atypical cases of HFMD. Clinicians should be aware of the potential for superadded necrotising infection in cases of atypical HFMD.

The Role of Computed Tomography in the Diagnosis of Necrotizing Soft Tissue Infections

BACKGROUND

The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established. We aimed to explore the role of CT in patients with clinical suspicion of NSTI and assess its sensitivity and specificity for NSTI.

METHODS

The medical records of patients admitted between 2009 and 2016, who received IV contrast-enhanced CT to rule out NSTI, were reviewed. CT was considered positive in case of: (a) gas in soft tissues, (b) multiple fluid collections, (c) absence or heterogeneity of tissue enhancement by the IV contrast, and (d) significant inflammatory changes under the fascia. NSTI was confirmed only by the presence of necrotic tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis, or if the patient was successfully treated non-operatively.

RESULTS

Of the 184 patients, 17 had a positive CT and hence underwent surgical exploration with NSTI being confirmed in 13 of them (76%). Of the 167 patients that had a negative CT, 38 (23%) underwent surgical exploration due to the high clinical suspicion for NSTI and were all found to have non-necrotizing infections; the remaining 129 (77%) were managed non-operatively with successful resolution of symptoms. The sensitivity of CT in identifying NSTI was 100%, the specificity 98%, the positive predictive value 76%, and the negative predictive value 100%.

CONCLUSIONS

A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI.

Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls

OBJECTIVE

The purpose of this article is to review the imaging findings of necrotizing fasciitis as seen on radiograph, ultrasound, CT, and MRI, and to recognize the early findings in this potentially fatal disease.

CONCLUSION

Although classically a clinical diagnosis, imaging is a powerful adjunct to facilitate early diagnosis in equivocal cases. Compared to plain radiography, ultrasound, CT and MR provide higher sensitivity and specificity for the diagnosis of necrotizing fasciitis. Cross-sectional imaging findings include asymmetric thickening of fascia, soft tissue air, blurring of fascial planes, inflammatory fat stranding, reactive lymphadenopathy, and nonenhancement of muscular fascia.

Magnetic resonance imaging of painful swollen legs in the emergency department: a pictorial essay

Patients presenting with a painful swollen leg are not infrequently encountered at the emergency department and can pose a diagnostic dilemma for attending physicians. The potential causes of leg pain and swelling include trauma, infection, inflammation, and neurogenic, vascular, and iatrogenic conditions; with magnetic resonance imaging (MRI) being an important tool in evaluation. We describe the MRI features of various conditions causing painful swollen legs. We also discuss the differential diagnosis and the useful clinical and laboratory findings that radiologists should be aware of, in order to arrive at an accurate diagnosis.

A rare case report of vulvar necrotizing fasciitis in a healthy patient

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NF should be considered regardless of atypical location and lack of associations.

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Clinical findings are important indicators when diagnosing NF.

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Immediate surgical intervention should be performed upon suspicion of NF.

Introduction

Necrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly.

Presentation of case

This case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors.

Discussion

Diagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication.

Conclusion

Acting quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations.

Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection

Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommendations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipelas and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets community-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline.

Role of Diffusion Weighted Imaging in Musculoskeletal Infections: Current Perspectives

Accurate diagnosis and prompt therapy of musculoskeletal infections are important prognostic factors. In most cases, clinical history, examination and laboratory findings help one make the diagnosis, and routine magnetic resonance imaging (MRI) is useful to identify the extent of the disease process. However, in many situations, a routine MRI may not be specific enough especially if the patient cannot receive contrast intravenously, thereby delaying the appropriate treatment. Diffusion-weighted imaging (DWI) can help in many such situations by providing additional information, accurate characterization and defining the extent of the disease, so that prompt treatment can be initiated. In this article, we illustrate the imaging findings of the spectrum of musculoskeletal infections, emphasizing the role of DWI in this domain.

KEY POINTS

• Abscess in background cellulitis is detected on DWI. • Infectious tenosynovitis shows diffusion restriction as compared to mechanical tenosynovitis. • Pyomyositis with abscess can be differentiated from diabetic myonecrosis on DWI. • Intraosseous abscess is bright on DWI versus devitalized tissue, sequestrum and air. • DWI can be used to differentiate spine infection from simple Modic changes.

Case Report of Necrotizing Fasciitis Associated with Streptococcus pneumoniae

Necrotizing fasciitis, caused by Streptococcus pneumoniae, is an extremely rare and life-threatening bacterial soft tissue infection. We report a case of early necrotizing fasciitis associated with Streptococcus pneumoniae infection in a 26-year-old man who was immunocompromised with mixed connective tissue disease. The patient presented with acute, painful, erythematous, and edematous skin lesions of his right lower back, which rapidly progressed to the right knee. The patient underwent surgical exploration, and a diagnosis of necrotizing fasciitis was confirmed by pathological evidence of necrosis of the fascia and neutrophil infiltration in tissue biopsies. Cultures of fascial tissue biopsies and blood samples were positive for Streptococcus pneumoniae. To our knowledge, this is the first report of necrotizing fasciitis resulting from Streptococcus pneumoniae diagnosed at early phase; the patient recovered well without surgical debridement.

Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult

A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.

The value of early intervention and a multidisciplinary approach in the management of necrotizing fasciitis of the neck and anterior mediastinum of odontogenic origin

Necrotizing fasciitis (NF) is a serious clinical condition, which, if diagnosed late, invariably leads to a fatal outcome. A high index of suspicion of the presenting clinical signs and symptoms, supported by knowledge of the clinicopathologic processes that underlie its aggressive nature, should prompt early surgical intervention. Ultimately, the success of treatment requires a robust clinical pathway in which all members of the health care team are aligned by their skill sets and competencies to manage NF. This report describes the management of a case of a young man with aggressive NF of odontogenic origin affecting the neck and anterior mediastinum. A multidisciplinary approach brought about early recognition of the disease and surgical intervention, the use of frozen section biopsies to determine the extent of fascial spread, and aggressive debridement of the affected tissue. Teamwork, critical thinking, and situational awareness ensured that the patient received optimum care in a timely manner. The psychological, clinical, radiologic, pathologic, and microbiological aspects of the patient's care are presented with a literature review.

Necrotizing soft tissue infections

Necrotizing soft tissue infections (NSTIs) are infrequent yet highly lethal infections, and a high index of suspicion is required for early diagnosis. Diagnosing NSTIs early can be challenging, and knowledge of the available tools is essential to provide appropriate treatment. The mainstay of treatment is early and complete surgical debridement combined with antimicrobial therapy, close monitoring with further debridement as needed, and physiologic support. Mortality continues to be high, and delayed surgical treatment is the most important risk factor. For the long-term recovery of patients with NSTI, providing early physiologic and nutritional support and physical rehabilitation is essential.

Magnetic resonance imaging of musculoskeletal infections: systematic diagnostic assessment and key points

Prompt diagnosis and treatment are essential in preventing the complications of musculoskeletal infection. In this context, imaging is often used to confirm clinically suspected diagnoses, define the extent of infection, and ensure appropriate management. Because of its superior soft-tissue contrast resolution, magnetic resonance imaging (MRI) is the modality of choice for evaluating musculoskeletal infections. This article describes the MRI features along the full spectrum of musculoskeletal infections and provides several illustrative case examples.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Necrotizing fasciitis

OBJECTIVE

To describe the defining characteristics and treatment of necrotizing fasciitis (NF), emphasizing early diagnostic indications.

QUALITY OF EVIDENCE

PubMed was searched using the terms necrotizing fasciitis and necrotizing soft tissue infections, paired with early diagnosis. Results were limited to human studies in English. Additional articles were obtained from references within articles. Evidence is levels II and III.

MAIN MESSAGE

Necrotizing fasciitis is classified according to its microbiology (polymicrobial or monomicrobial), anatomy, and depth of infection. Polymicrobial NF mostly occurs in immunocompromised individuals. Monomicrobial NF is less common and affects healthy individuals who often have a history of trauma (usually minor). Patients with NF can present with symptoms of sepsis, systemic toxicity, or evidence of skin inflammation, with pain that is disproportional to the degree of inflammation. However, these are also present in less serious conditions. Hyperacute cases present with sepsis and quickly progress to multiorgan failure, while subacute cases remain indolent, with festering soft-tissue infection. Because the condition is rare with minimal specific signs, it is often misdiagnosed. If NF is suspected, histology of tissue specimens is necessary. Laboratory and radiologic tests can be useful in deciding which patients require surgical consultation. Once NF is diagnosed, next steps include early wound debridement, excision of nonviable tissue, and wide spectrum cover with intravenous antibiotics.

CONCLUSION

Necrotizing fasciitis is an uncommon disease that results in gross morbidity and mortality if not treated in its early stages. At onset, however, it is difficult to differentiate from other superficial skin conditions such as cellulitis. Family physicians must have a high level of suspicion and low threshold for surgical referral when confronted with cases of pain, fever, and erythema.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Multidisciplinary management of periocular necrotising fasciitis: a series of 11 patients

BACKGROUND

Necrotising fasciitis is an uncommon but life-threatening soft tissue infection characterised by rapidly spreading inflammation and necrosis of skin, subcutaneous fat and fascia. Left untreated, the mortality can be more than 70%. Early surgical intervention can reduce morbidity and mortality.

PATIENTS AND METHODS

This is a series of 11 patients who presented to our oculoplastic and orbit unit with periocular necrotising fasciitis over a period of five years. We present the modes of presentation, predisposing factors, diagnosis, and the multidisciplinary team management of these patients.

RESULTS

Of the 11 patients, 1 patient died and 2 patients required intensive care management. Of the 10 surviving patients, 8 patients needed further surgical interventions for correction of complications, like eyelid malposition, ptosis and protective or corrective surgery in the form of ectropion correction, skin grafting and other rehabilitative procedures.

CONCLUSION

To the best of our knowledge, this is the largest series of periocular necrotising fasciitis in the literature. Necrotising fasciitis is a potentially fatal condition, resulting in a high rate of mortality and morbidity. Early surgical intervention reduces the mortality. A high index of suspicion is needed to make a prompt diagnosis. These patients need expeditious intervention and may require a long follow-up and subsequent surgery for complications related to scarring and other sequelae.

Flesh-eating disease: A note on necrotizing fasciitis

There has been much media attention in the past few years to the condition dubbed 'flesh-eating disease', which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all-invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed.

Necrotizing fasciitis: early sonographic diagnosis

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.

MR imaging of skeletal soft tissue infection: utility of diffusion-weighted imaging in detecting abscess formation

PURPOSE

Our objectives were to assess if diffusion-weighted imaging (DWI) can help identify abscess formation in the setting of soft tissue infection and to assess whether abscess formation can be diagnosed confidently with a combination of DWI and other unenhanced sequences.

METHODS

Eight cases of soft tissue infection imaged with MRI including DWI were retrospectively reviewed.

RESULTS

Two male and six female patients were studied (age range 23-50 years). Unenhanced MRI including DWI was performed in all patients. Post-contrast images were obtained in seven patients. All patients had clinically or surgically confirmed abscesses. Abscesses demonstrated restricted diffusion. DWI in conjunction with other unenhanced imaging showed similar confidence levels as post-contrast images in diagnosing abscess formation in four cases. In two cases, although the combined use of DWI and other unenhanced imaging yielded the same confidence levels as post-contrast imaging, DWI was more definitive for demonstrating abscess formation. In one case, post-contrast images had a better confidence for suggesting abscess. In one case, DWI helped detected the abscess, where gadolinium could not be administered because of a contraindication.

CONCLUSION

This preliminary study suggests that DWI is a useful adjunct in the diagnosis of skeletal soft tissue abscesses.

Spontaneous bacterial seeding of a biceps hematoma

A 19-year-old male construction worker presented with an injury to his left upper arm after lifting a heavy pipe. He reported an acute onset of sharp pain followed by swelling, warmth, and weakness with elbow flexion. The diagnosis of a distal biceps tendon rupture was made and elective repair was scheduled. Seventy-two hours later, the patient presented with a spontaneous draining wound on his anterior distal humerus. The wound was draining thick purulent material. The patient underwent surgery for irrigation and debridement of his abscess. Nearly 500 cc of hematoma and purulent fluid were evacuated. A large tear of both the biceps and brachialis muscle bellies were found. Cultures were obtained that revealed the infecting organism to be Streptococcus intermedius. Human immunodeficiency virus and hepatitis-C virus testing were negative, and no history, signs, or symptoms of any cause of underlying immunodeficiency were detected. No signs or history of drug use were present. He was discharged home on culture-specific oral antibiotics. At 4-month postoperative follow-up, the patient reported no pain or limitations. He has returned to full duty at his job. Elbow range of motion was measured from 7° to 150° of flexion. Strength of elbow flexion and extension was symmetric to the uninjured side. Pronation and supination of the forearm was symmetric on both sides. He has been released from scheduled follow-up and will be seen again on an as-needed basis.

An algorithm for early diagnosis of cervicofacial necrotising fasciitis

Cervicofacial necrotising fasciitis (CNF) is a potentially fatal infection which can occasionally present in the head and neck. An early diagnosis and aggressive treatment is imperative for minimising the associated mortality and morbidity. The early clinical features are usually non-specific which makes it difficult to differentiate it from other less serious infections. Necrosis of the skin is a late feature. Although it is more common in the immunocompromised, it can also affect normal individuals. We discuss our experience of five patients with CNF, review of literature and algorithm for early diagnosis of CNF. With experience, we were able to diagnose the subsequent cases early and minimise the mortality and morbidity. In conclusion, the incidence of CNF has increased in the last decade partly due to an increased clinical awareness. Early intervention is essential to minimise the mortality and morbidity. It should be managed by a team of at least otolaryngologists, intensivist, microbiologist and plastic surgeons; cardiothoracic surgeons may be required. Treatment involves early aggressive surgical debridement/fasciotomy, intravenous antibiotics and general metabolic support in the intensive care unit.

Integrated clinical care pathway for managing necrotising soft tissue infections

BACKGROUND

Necrotising soft tissue infections (NSTI) are relatively common infections with high morbidity and mortality rate, as they often present late in their course. Quick and aggressive surgical treatment improves survival and decreases hospital stay.

MATERIALS AND METHODS

All patients with NSTI managed at our centre from June 2007 to January 2009 were included in this prospective study. We evaluated various parameters like age, co-morbidities, biochemical parameters, time interval between admission and first operative intervention, against duration of hospital stay and out come of the case.

RESULTS

Fifty-four patients with NSTI were admitted and treated during the study period. Male to female ratio was 6:1. Mean time interval between admission and operative intervention was 6 hours. Mean period of hospitalisation was 53 days and we had limb salvage rate of 100% and one mortality (1.85%). Diabetes mellitus was the most common co-morbid condition and Staphylococcus aureus the most common isolate. Presence of leucocytosis, hyponatraemia, hypoalbuminaemia, anaemia and deranged renal functions were found to be poor prognostic factors.

CONCLUSION

Late and varied presentation is the rule rather than exception with NSTI. Early recognition of the condition, with emergency operative intervention and repeated debridement by a dedicated surgical team, is the key to patient survival and limb salvage.

Necrotizing fasciitis versus pyomyositis: discrimination with using MR imaging

Objective

We wanted to evaluate the MR findings for differentiating between necrotizing fasciitis (NF) and pyomyositis (PM).

Materials and Methods

The MR images of 19 patients with surgically confirmed NF (n = 11) and pathologically confirmed PM (n = 8) were retrospectively reviewed with regard to the presence or absence of any MRI finding criteria that could differentiate between them.

Results

The patients with NF had a significantly greater prevalence of the following MR findings (p < 0.05): a peripheral band-like hyperintense signal in muscles on fat-suppressed T2-weighted images (73% of the patients with NF vs. 0% of the patients with PM), peripheral band-like contrast enhancement (CE) of muscles (82% vs. 0%, respectively) and thin smooth enhancement of the deep fascia (82% vs. 13%, respectively). The patients with PM had a significantly greater prevalence of the following MRI findings (p < 0.05): a diffuse hyperintense signal in muscles on fat-suppressed T2-weighted images (27% of the patients with NF vs. 100% in the patients with PM), diffuse CE of muscles (18% vs. 100%, respectively), thick irregular enhancement of the deep fascia (0% vs. 75%, respectively) and intramuscular abscess (0% vs. 88%, respectively). For all patients with NF and PM, the superficial fascia and muscle showed hyperintense signals on T2-weighted images and CE was seen on fat-suppressed CE T1-weighted images. The subcutaneous tissue and deep fascia showed hyperintense signals on T2-weighted images and CE was seen in all the patients with NF and in seven (88%) of the eight patients with PM, respectively.

Conclusion

MR imaging is helpful for differentiating between NF and PM.

Sonographic findings of necrotizing fasciitis in the breast

Necrotizsing fasciitis is a rapidly developing, fatal bacterial infection of deep subcutaneous tissues. It may occur at any site in the body. We describe a case of necrotizing fasciitis in the breast that was diagnosed on the basis of sonographic findings. Sonographic examination revealed fluid collection in deep tissues with bright echoes likely to represent gas microbubbles. The diagnosis of necrotizing fasciitis was subsequently confirmed on surgical exploration.

Necrotizing fasciitis caused by Pseudomonas aeruginosa

An 85-year-old man patient was admitted to the hospital complaining of fever and bilateral leg pain with swelling and erythema. A laboratory investigation revealed leukocytopenia, thus suggesting sepsis. Gram negative rods were detected in the specimen from the affected skin and empiric antibacterial therapy was initiated. The following day, his symptoms worsened and Pseudomonas aeruginosa was isolated from the blood culture and the skin specimen. Magnetic resonance imaging (MRI) did not show the typical characteristics of necrotizing fasciitis. In spite of intensive medical treatment, the patient's condition became critical, and on day 10 after admission, he died of multiple organ failure. An autopsy revealed necrotizing fasciitis due to P. aeruginosa. This is a rare case and its clinical presentation was atypical. The clinical diagnosis of this infection may be difficult, and therefore such cases warrant the careful attention of physicians.

Staging of necrotizing fasciitis based on the evolving cutaneous features

BACKGROUND

Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant course and high mortality. Early recognition is difficult as the disease is often clinically indistinguishable from cellulitis and other soft-tissue infections early in its evolution. Our aim was to study the manifestations of the cutaneous signs of necrotizing fasciitis as the disease evolves.

METHODS

This was a retrospective study on patients with necrotizing fasciitis at a single institution. Their charts were reviewed to document the daily cutaneous changes from the time of presentation (day 0) through to day 4 from presentation.

RESULTS

Twenty-two patients were identified. At initial assessment (day 0), almost all patients presented with erythema, tenderness, warm skin, and swelling. Blistering occurred in 41% of patients at presentation whereas late signs such as skin crepitus, necrosis, and anesthesia were infrequently seen (0-5%). As time elapsed, more patients had blistering (77% had blisters at day 4) and eventually the late signs of necrotizing fasciitis characterized by skin crepitus, necrosis, and anesthesia (9-36%) were seen. A clinical staging system was developed based on our observations. Stage migration from early to late stage necrotizing fasciitis was evident with majority of patients in stage 1 at day 0 (59%), whereas by day 4, majority had developed into stage 3 (68%).

CONCLUSION

This study has demonstrated the continuum of cutaneous manifestations as necrotizing fasciitis evolves. This will help in the early recognition and intervention of this devastating condition.

Necrotizing fasciitis: a challenging diagnosis

The objective of the study was to evaluate our recent experience in diagnosis and management of necrotizing fasciitis. Records of patients who were diagnosed as having necrotizing fasciitis at Al-Ain Hospital in the period between March 2003 and August 2005 were studied retrospectively with regard to clinical features, risk factors, diagnosis, causative organisms, treatment, and outcome. Eleven patients, eight of whom were men of low socio-economic status, were studied. The median age (range) was 46 (8-65) years. The main risk factor was diabetes mellitus in seven patients (64%). The provisional clinical diagnosis was incorrect in seven patients (64%). Pure beta-hemolytic streptococcus group A or B was the causative organism in five patients (46%). Most of our patients underwent multiple surgical debridements with a median range of two (1-11) operations. Two patients died (overall mortality rate 18%). High clinical suspicion is essential for the diagnosis of necrotizing fasciitis. Accurate early diagnosis, aggressive resuscitation, using proper antibiotics, and extensive surgical debridement are essential for a favorable outcome.

Necrotizing soft-tissue infection: diagnosis and management

Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.

Necrotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality

BACKGROUND

Necrotizing fasciitis is a rare and often fatal soft-tissue infection. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections. The purpose of this study was to analyze the clinical presentation and evaluate factors that determine mortality associated with this uncommon surgical emergency.

METHODS

The study retrospectively investigated the medical records of 22 patients who were diagnosed and treated for necrotizing fasciitis of the lower extremity, 14 of whom had involvement of the foot (nine patients) or foot and ankle (five patients) at our hospital. The data collected for each of the 22 patients were age, sex, underlying systemic factors, location of infection, duration of symptoms, portal of entry of infection, initial diagnosis on admission, physical, radiographic and laboratory findings, microbiological cultures, the type of therapy used (debridement or amputation), treatment outcome, and number of days in the hospital.

RESULTS

A total of 23 extremities of 22 consecutive patients with necrotizing fasciitis who underwent surgical debridement or amputation were retrospectively reviewed. Radical surgical debridement was done in 16 extremities initially, and this treatment was repeated a mean of two times (range one to four debridements) to completely remove all the necrotic tissue. Nine patients (41%) required below-knee or above-knee amputation. There were three deaths, one related directly to sepsis and organ failure, one due to gastrointestinal hemorrhage, and one caused by pulmonary embolism. There were no significant differences between patients who had the amputations and those who did not with respect to mortality rate or age (p = 0.538 and p = 0.493, respectively). Those who died were significantly older than the survivors (p = 0.038).

CONCLUSIONS

The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain, especially if that person has diabetes mellitus or chronic liver disease. There was no difference in mortality rates between patients with or without amputation. The primary treatment is early and aggressive debridement of involved skin, subcutaneous fat, and fascia.

The diagnosis of necrotizing fasciitis

PURPOSE OF REVIEW

A delay in the diagnosis and appropriate treatment of necrotizing fasciitis has clearly been demonstrated to increase mortality. However, paucity of specific cutaneous signs makes early recognition extremely difficult. This review highlights recent developments in the approaches to the diagnosis of necrotizing fasciitis.

RECENT FINDINGS

A clinical staging of necrotizing fasciitis is proposed to better define the progression of the disease. Several clinical subtypes of necrotizing fasciitis have been described recently with hyperacute and sub-acute variants. Imaging techniques, such as magnetic resonance imaging and frozen section biopsies, have been reported to be of value in the early recognition of necrotizing fasciitis. However availability and cost limit the routine use of these tests. Several diagnostic adjuncts that have been developed recently to help in early recognition will be discussed. These include the fasciitis LRINEC (laboratory risk indicator for necrotizing fasciitis) score and transcutaneous tissue oxygen saturation monitoring. Some may have the potential for widespread application in the assessment of severe soft tissue infections.

SUMMARY

Delayed recognition, with consequent massive soft tissue loss and sepsis, remains a deadly pitfall in the management of necrotizing fasciitis. With a better understanding of the clinical manifestations and the potential use and limitations of various diagnostic adjuncts available for the assessment of equivocal cases of soft tissue infections, it is hoped that a clear and logical approach to the diagnosis of necrotizing fasciitis may be developed.