Introduction: Necrotizing fasciitis is an uncommon infectious entity that poses difficult diagnostic and therapeutic management decisions. Purpose: This paper addresses the presentation, evaluation and management of the patient with a necrotizing soft tissue infection. Case Report: A 54-year-old man presented to his physician with pain and swelling of the left anterior chest wall following a presumed insect bite several days prior. He was treated with oral antibiotics but returned to the office three days later with increased swelling, pain, and erythema in the axilla. Necrotizing fasciitis was diagnosed. He was hospitalized and taken to the operating room for debridement of the chest wall. Extensive necrosis of the skin, subcutaneous tissue and muscle was encountered. Muscle debridement extended from the pectoralis major and both obliques anteriorly to the latissimus dorsi and para-spinalis muscles posteriorly. Multiple operative debridements were performed over several days. The patient developed septic shock requiring blood pressure support, and multiple organ system failure requiring hemodialysis, prolonged ventilatory support and eventual tracheostomy. Split-thickness skin grafts were placed during the third operative debridement and concluded on the 15th day of hospitalization. The patient eventually recovered and on the 53rd hospital day was transferred to the rehabilitation service, where he spent the next four weeks recovering movement in the left arm. Conclusion: Necrotizing fasciitis is an infectious entity that requires rapid diagnosis, surgical debridement, and tissue coverage if the patient is to survive.

Necrotizing fasciitis: a plea for early diagnosis and treatment.

Necrotizing fasciitis (NF) is a soft-tissue infection, usually polymicrobial, that causes necrosis of fascia and subcutaneous tissue while sparing skin and muscle. We report a case of cervical NF complicating dental infection in a 50-year-old woman, who presented with infection involving mucosa of the right mandible and temporal muscle, and masticator spaces, requiring extensive surgery and antibiotic therapy. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections.

Cervical necrotizing fasciitis of odontogenic origin involving the temporal region--a case report.

Background: Given the association of diabetes with necrotizing soft tissue infections (NSTIs) and hyperglycemia with mortality in critically ill patients, this study investigates the impact of diab...

The impact of diabetes in patients with necrotizing soft tissue infections.

Necrotizing Fasciitis (NF) is a necrotizing soft tissue infection involving the fascia and subcutaneous tissue that can cause rapid local tissue necrosis and life-threatening severe sepsis. Aim: This article aims to review the aetiopathogenesis, investigations and management based on a literature review. Methods and Materials: The Medline literature search of relevant articles restricted to English language on necrotizing fasciitis was conducted and reviewed. Results: Necrotizing fasciitis is rare with an incidence ranging from 0.15 to 0.55 cases per 100,000 of the population. Accurate assessment and timely intervention are critical in the treatment of patients affected with NF. Understanding the history and unique characteristics of this disease is crucial to achieve early recognition, effective treatment and a favorable outcome. Classic symptoms include severe pain out of proportion to local findings, erythema, mottling, crepitus, skin anesthesia, warmth, tenderness, hemorrhagic bullous formation, edema in the affected area and fever. Predisposing conditions of NF are classified into 2 main categories (type I and II) based on causative microorganisms. Radical surgical debridement, broad spectrum antibiotics, negative pressure wound dressings, and hyperbaric oxygen therapy are considered to be the cornerstone of treatment. The mortality rate ranges widely from 10% to 75% and is related to delay in initial debridement, patient age of more than 60 years, associated hypotension, acidosis, bacteremia, renal failure, hyponatremia, peripheral vascular disease, myonecrosis and myositis. Conclusion: Necrotizing fasciitis is a devastating infection of the fascia and subcutaneous tissue. The presentation of the disease is nonspecific and variable. Delay in recognition and effective treatment increases the mortality. Prompt radical surgical debridement, appropriate antibiotics and adjuvant therapy contribute to an improved outcome.

Necrotizing fasciitis: The importance of early diagnosis, prompt surgical debridement and adjuvant therapy

Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier's gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases.

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Necrotizing Soft Tissue Infections: Surgeon's Prospective.

Twenty-two cases of severe necrotizing soft-tissue infections (SNSTIs), seen by the infectious disease service from 1983 to 1988 in a community teaching hospital, are described and compared with previously reported series. Clinical findings were distinguishable from cellulitis at the time of surgery in only 45% of the patients who had either necrosis, crepitus, vesicle or bullae, and/or an abnormal air pattern on x-ray studies. Patients with "cellulitis" were not less sick than patients with "necrosis" findings (ie, presence of shock, leukocytosis with left shift, fever, or anion gap). Despite the fact that all but one of the patients were seen by the infectious disease service preoperatively, and 55% underwent surgical intervention within 48 hours of admission, patient mortality (18%) was not better than some reported in earlier series. However, the epidemiology of SNSTI was different: in our series there were more diabetic patients (64%) and fewer postsurgical infections (14%). Among the diabetic patients, SNSTI developed more frequently at a site not related to peripheral vasculopathy or neuropathy. Abdominal wall involvement was 10 times more likely be diagnosed as cellulitis (5/8 vs 2/14 with involvement elsewhere, P < 0.02).

E Rubinstein

Papers

Severe necrotizing soft-tissue infections: report of 22 cases.