Necrotizing Fasciitis

David Hough MSIII Penn State College of Medicine

Outline

Overview of Necrotizing Fasciitis Clinical/ Pathological signs Risk Factors Type 1 vs. Type 2 Necrotizing Fasciitis (NF) Fourneirs Gangrene Diagnosis Treatment Outcomes

NF- Definition

A subcutaneous infection of fascia and fat which may or may not spare the skin.

Description of NF

Clinical features

Fulminant destruction of tissue Systemic signs of toxicity High rate of mortality

Pathological features

Extensive tissue destruction Thrombosis of blood vessels Abundant bacteria spreading along fascial planes Unimpressive infiltration of acute inflammatory cells

Secondary to collagenases, hyaluronidases, and other destructive enzymes

Clinical Signs of NF

Fever Tachycardia Hypotension Tense edema around involved skin Disproportionate pain Blisters/ bullae Crepitus (present 10% of time) Subcutaneous gas

These are all fairly specific, but have a sensitivity of only 10-40%

Clinical Signs of NF

Skin findings

May be normal, erythematous, edematous, cyanotic, bronzed, indurated, blistered, or frankly gangrenous. Generally the appearance of the skin underestimates the degree of underlying disease.

Risk Factors for NF

No true risk factors have been identified Conditions associated with necrotizing vs. non-necrotizing infections

Drug use Diabetes mellitus (present in up to 60% of cases) Obesity Immunosuppresion Malnutrition HIV infection Alcoholism

Considerations in NF

Progresses rapidly from seemingly benign disease to extensive destruction of tissue, systemic toxicity, need for amputation, or death

Necrotizing Fasciitis (NF)

Type 1

A mixed infection caused by aerobic and anaerobic bacteria. These occur most commonly after surgery or in individuals with diabetes and peripheral vascular disease. A monomicrobial infection caused primarily by group A streptococcus (GAS), although it is occasionally caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA)

Type 2

Type 1 NF

Primarily includes 3 categories (locations) of infection

Diabetes Mellitus- infections of the feet Cervical necrotizing fasciitis- infection of the neck Fourniers Gangrene- infection of the perineum

Type 1 NF

2/3 of cases have mixed aerobic and anaerobic infections The bugs: The average case had 4.6 isolates

Staphylococcus aureus Streptococci Enterococci Escherichia coli Peptostreptococcus Preveoella and Porphyromonas Bacteroides fragilis Clostridium

Diabetes Mellitis

Cervical Necrotizing Fasciitis

Fourniers Gangrene (FG)

First described by French verenologist Jean Alfred Fournier who witnessed a rapidly progressing gangrene of the penis and scrotum of 5 previously healthy young men. A polymicrobial necrotizing fasciitis (NF) of the perinium, perianal area, or genitals. It may involve either men or women.

Fourniers Gangrene

Found in the perineal area- it is an infection caused by penetration of the gastrointestinal or urethral mucosa by bacteria. Characterized by an abrupt onset with severe pain which may spread rapidly to the anterior abdominal wall, gluteal muscles, or the scrotum and penis in males.

Epidemiology of FG

Not very common. On average 97 cases were reported each year from 1989 to 1998. Mostly age 30-60, although all ages have been reported Effects men 10:1 over females. This may be due to better perineal drainage in females through vaginal secretions.

FG following vasectomy

Extensive reconstruction post Fourniers Gangrene

Diagnosis of NF

DDx: include gas gangrene, pyomyositis, and myositis.

Type 1 Type 2 Gas Gangrene Pyomyositis Myositis viral/ parasitic

Clinical Findings
Fever Diffuse Pain Local Pain Systemic Toxicity Gas in tissue Obvious portal of entry Diabetes Mellitus

++ + ++ ++

++++ + ++++ ++++

+++ + ++++ ++++

++ + ++ +

++ ++++ ++ +

++ ++++
++++

+
+

++++ ++++
-

Diagnosis of NF- Labs

Labs- use risk score

Serum C-reactive protein > 150 mg/L (4 points) WBC count 15,000 to 25,000 (1 point) or > 25,000 (2 points) Hemoglobin 11.0 to 13.5 g/dL (1 point) or < 11 g/dL (2 points) Serum sodium less than 135 meq/L (2 points) Serum glucose greater than 180 mg/dL (1 point)

Diagnosis of NF- Labs

Interpretation of Risk Score

> 6 should raise suspicion of NF > 8 is highly predictive of NF (75-80% in one study with NF had scores over 8)

Diagnosis of NF- Imaging

Soft tissue X-ray, CT, and MRI can be helpful to identify gas in tissue. However, gas is specific, but not very sensitive. Tissue swelling that is seen could simply be from trauma, surgery, or postpartum

Diagnosis of NF- Cultures

Blood cultures are positive in 60% of patients with Type II NF, and 20% of patients with Type I NF (usually polymicrobial)

However in Type I, blood cultures may not grow all organisms involved in the tissue infection

Aspiration of bullae or skin also may not give an accurate representation of the infection

Diagnosis of NF- Surgery

Surgical exploration with sampling of deep tissue is the most accurate means of diagnosis. This also allows debridement of the infection

Treatment of NF- Surgery

Surgery

Early and aggressive surgical exploration and debridement This should be done in the first 24 hours of symptoms Repeat debridement should be repeated daily until all necrotic tissue has been removed (typically 2-4 times) Fourneirs Gangrene may require cystostomy, colostomy, or orchiectomy (although this is rare).

Treatment of NF- Antibiotics

Antibiotics

Virtually 100% of patients will die on antibiotics without surgical debridement Type 1- ampicillin or ampicillin-sulbactam and clindamycin or metronidazole. For patients with prior hospitalization substitute ticarcillinclavulanate or piperacillin-tazobactam for ampicillin-sulbactam Type 2- clindamycin. Add vancomycin to cover for MRSA

Treatment of NF- Toxic Shock

Type 2

In the case of streptococcal toxic shock massive amounts of fluid (10-20 L/day) may be necessary to maintain perfusion. Pressors such as dopamine may also be added IVIG has also been used to neutralize the streptococcal superantigens, however no studies have been done to support this use

Mortality of NF

Type I- 21% Type II- 14-34%

Cervical NF- 22% Fourniers Gangrene- 22-40%

Summary

NF can progress rapidly leading to amputation or death A degree of suspicion is necessary to get a patient to surgery for diagnosis and treatment Treatment primarily involves surgery and antibiotics Even with rapid treatment mortality remains high

References

www.uptodateonline.com Thomsen, Todd. Fourneirs Gangrene. http://www.emedicine.com/emerg/topic929.ht m