Definition

Flesh-eating disease is more properly called Necrotizing fasciitis, a rare condition in which bacteria destroy tissues underlying the skin. This tissue death, called necrosis or gangrene, spreads rapidly. This disease can be fatal. The disease may also be called synergistic gangrene, among other terms.

Description
Although the term is technically incorrect, flesheating disease is an appropriate descriptor: the infection appears to devour body tissue. The arms and legs are most often affected, but the infection may appear anywhere. For example, Fournier's gangrene is a flesh-eating disease in which the infection encompasses the external genitalia.

Background
The disease was first discovered in 1783, in France. Doctors noted that it occurred sporadically throughout the 19th and 20th centuries. The disease was usually restricted to military hospitals, especially in war times. However, there have been some outbreaks in civilian populations. The disease appeared to markedly decrease in frequency after WWII, and reemerged worldwide in the 1980s.

Microbial Physiology
Flesh-eating disease is divided into two types. Type I is caused by anaerobic species in combination with facultative anaerobic organisms such as streptococci (non-group A), enterococci, and Gram-negative rods.

Type II, is called hemolytic streptococcal gangrene, and is caused by group A streptococci; other bacteria may or may not be present.

Microbial Physiology
Although Type I is far more common than Type II, It isnt nearly as dangerous. Most deaths and serious infections that are irreversible are caused by Type II infection.

Microbial Physiology
Necrotizing fasciitis infections can also be caused by fungus. These are rare and usually occur in patients with weakened immune systems. An example of a fungal infectant is Mucormycosis.

Group A Streptococci

( Streptococcus pyogenes) viewed directly by transmission electron microscopy (TEM). Chains of streptococci are clearly evident. To remove cell surface proteins, cells were treated with trypsin prior to preparation and mounting. Strain: D471; M-type 6. (6,500X)

Electron micrograph of Streptococcus pyogens (96,000X)

Group A Streptococci
Group A streptococcus is a bacterium often found in the throat and on the skin, people may carry Group A streptococci(GAS) in their throat or on their skin and have no symptoms of illness at all. Most GAS infections are relatively mild illnesses such as "strep throat," or impetigo. On rare occasions, these bacteria can cause other severe and even life-threatening diseases.

Group A Streptococci
A picture of Streptococcus pyogenes, part of the Group A Streptococci family.

A micrograph with computer aided coloring of Streptococcus pyogenes (25,000X)

Group A Streptococci
Severe, sometimes even life-threatening, GAS disease occurs when bacteria get into parts of the body where they usually are not found, such as the muscle, lungs or the blood. Invasive GAS infections occur when the defenses of the person fail to keep the bacteria out of the body.

Group A Streptococci cont

This may occur when a person has sores, cuts or other breaks in the skin that allow the bacteria to get into the tissue, or when the persons ability to fight off the infection is decreased because of chronic illness or an illness that affects the immune system. This is not the only factor, some virulent strains of GAS are more likely to cause severe disease than others.

The Biochemistry of the Disease

Usually the bacteria that cause Necrotizing fasciitis releases enzymes and toxins that spread rapidly through the body. Almost every type of bacteria produce different enzymes for example, Streptococci and staphylococci produce hyaluronidase, which destroys hyaluronic acid which is an essential part of connective tissue.

Mode of Infection
In nearly every case, a skin injury precedes the disease. As bacteria grow beneath the skin's surface, they produce toxins that degrade the tissue. Almost any puncture of the skin has the potential of becoming an infection.

Symptoms
The following symptoms are associated with the disease.

Symptoms
Swelling of the infected area Black patches that are filled with pus

Symptoms
Discoloration in the area of the infection It may appear reddened, bronzed, bruised, or purple (purpuric) It progresses to dusky, dark color

Symptoms
There is visible dead tissue The skin breaks and open wounds form Fever The combination of the symptoms results in organ failure

Symptoms
Comparing the uninfected skin to the early and advanced forms of the disease:

Normal skin

Early stage

Advanced stage

The appearance of the skin, paired with pain and fever raises the possibility of flesh-eating disease. An x ray, magnetic resonance imaging (MRI), or computed tomography scans (CT scans) are very helpful in diagnosing flesh eating bacteria. Necrosis is evident during exploratory surgery, during which samples are collected for bacterial identification.
CT scan (computed tomography scan): Cross-sectional xrays of the body are compiled to create a three-dimensional image of the body's internal structures.

Diagnosis

Diagnosis
A picture of a slide that was taken from an infected site of a patient, the streptococci cells are clearly seen. The bacteria have been stained with a Gram Stain.

Streptococcus pyogens viewed under a light microscope (1000X)

Diagnosis
The best diagnosis is visual (i.e. symptoms) X-ray Magnetic resonance imaging Computed tomography (CT scans) Exploratory surgery Swab streaking of the infected area and viewing microbes under microscope is helpful in bacterial identification.

Diagnosis
X-ray, magnetic resonance imaging (MRI) and computed tomography scans reveal what is underlying the skin and are used to show the feathery patterns in the tissue that are caused by the accumulation of gas in dying skin.

Diagnosis
Computed tomography demonstrates soft tissue gas collection from an invasive Group A Streptococci Bacteria.

Gas Gas vesicles vesicles

Treatment

Although a neutrophil can kill this bead-like string of Streptococcus pyogenes, this particular strain of bacteria expresses streptolysin-s on its surface which causes the white cell to self-destruct. The white cell's lytic granules, which are supposed to fire their antibacterial contents onto the bacteria, are emptied into the white cell's cytoplasm instead, leading eventually to cell membrane lysis.

Treatment
Rapid, aggressive medical treatment, specifically, antibiotic therapy and surgical debridement, is imperative. Antibiotics may be applied and include penicillin, an aminoglycoside or third-generation cephalosporin. Analgesics are employed for pain control during surgical debridement, in which dead tissue is stripped away. After surgery, patients are rigorously monitored for continued infection, shock, or other complications.

Prevention
The spread of all types of GAS infection can be reduced by good hand washing, especially after coughing and sneezing and before preparing foods or eating. Persons with sore throats should be seen by a doctor who can perform tests to find out whether the illness is strep throat.

Prevention
All wounds should be kept clean and watched for possible signs of infection such as redness, swelling, drainage, and pain at the wound site. A person with signs of an infected wound, especially if fever occurs, should seek medical care.

Living with the Disease

Most people who survived the horrible ordeal with the flesh eating bacteria have missing limbs and body parts. Often people choose to cut extra skin from such places as their thighs to cover the missing patches of skin cut off to limit the infection site. Some people had plastic surgery to repair their skin in instances where the infection occurred on their faces.

Warning: The next slide is graphic

Living with the Disease

A patient out of the surgery room after a flesh eating bacteria disease infected his leg. An arm infection.

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