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Necrotizing Fasciitis

A Derm Emergency
by

Jason Williams

on 12 July 2013

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Transcript of Necrotizing Fasciitis

New Patient Evaluation
-HPI: Pt is a 80 yo female who arrives to the ED this morning with a chief complaint of leg pain. Pt is a poor historian, but her son states that she fell 3 days prior and scraped her thigh on the stove the night before.He states that she walks with the use of a cane and he is concerned she may have fractured her hip. that she has trouble walking and that this is new.
PMH: HTN, DM2
Medications: lisinopril, insulin
Allergies: none
Family history: noncontributory
Social history: retired, lives with son, -S/-D/-I
ROS: febrile, fatigue, rash is painful
Vitals: T 101.1, HR 110, BP 90/50, RR 18, O2 sat 98%
References and Questions?
1.Aebi, C., A. Ahmed, and O. Ramilo, Bacterial complications of primary varicella in children. Clin Infect Dis, 1996. 23(4): p. 698-705.
2.Anaya, D.A. and E.P. Dellinger, Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis, 2007. 44(5): p. 705-10.
3.Eneli, I. and H.D. Davies, Epidemiology and outcome of necrotizing fasciitis in children: an active surveillance study of the Canadian Paediatric Surveillance Program. J Pediatr, 2007. 151(1): p. 79-84, 84 e1.
4.Fugitt, J.B., et al., Necrotizing fasciitis. Radiographics, 2004. 24(5): p. 1472-6.
5.Hasham, S., et al., Necrotising fasciitis. BMJ, 2005. 330(7495): p. 830-3.
6.Markeson, D., et al., An elderly patient presenting with hip pain following a fall: an unusual presentation of necrotising fasciitis. BMJ Case Rep, 2012. 2012.
7.Stevens, D.L., Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis, 1995. 1(3): p. 69-78.
8.Stevens, D.L., A.E. Bryant, and S.P. Hackett, Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis, 1995. 20 Suppl 2: p. S154-7.
9.Stevens, D.L., A.E. Bryant, and S. Yan, Invasive group A streptococcal infection: New concepts in antibiotic treatment. Int J Antimicrob Agents, 1994. 4(4): p. 297-301.
10.Sudarsky, L.A., et al., Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg, 1987. 206(5): p. 661-5.
11.Wong, C.H., et al., The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med, 2004. 32(7): p. 1535-41.
12.Zimbelman, J., A. Palmer, and J. Todd, Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J, 1999. 18(12): p. 1096-100.
13.Fustes-Morales A, G.-C.P.D.-M.C.O.-C.L.T.-S.L.R.-M.R., Necrotizing fasciitis: Report of 39 pediatric cases. Archives of Dermatology, 2002. 138(7): p. 893-899.
14.Gibbon, K.L. and A.P. Bewley, Acquired streptococcal necrotizing fasciitis following excision of malignant melanoma. Br J Dermatol, 1999. 141(4): p. 717-9.
15.Buchanan C, H.J.R., Necrotizing fasciitis due to: Group a ß-hemolytic streptococci. Archives of Dermatology, 1970. 101(6): p. 664-668.
Jason Williams, MSIV
10-17-2012

Necrotizing Fasciitis
Work-up
DDX: Cellulitis, DVT, Septic Arthritis, warfarin induced skin necrosis, brown recluse spider bite, gangrene with secondary infection, Necrotizing Fasciitis
Patient was given IV fluids and started on broad spectrum antibiotics
Pt was transferred to General Surgery for exploration to confirm diagnosis
Quick Review about Necrotizing Fasciitis
Pt's present with
Caused by GAS, Staph, clostridia, Vibrio*
quickly progressing, need to start IV antibiotics and consult surgery early
may occur as a complication of a variety of surgical procedures or medical conditions, including cardiac catheterization, vein sclerotherapy, and diagnostic laparoscopy
3 types: I (poly), II (mono), III (gas gangrene)
Predisposing factors:
hx of skin injury
laceration, burn, blunt trauma, recent surgery, childbirth ,IV drug use, VZV
If no clear portal of entry, the pathogenesis of infection likely consists of hematogenous translocation of GAS from the throat to a site of blunt trauma or muscle strain
Most cases have a single site of soft tissue infection
Treatment: Surgery + antibiotics (aggresive and broad)
carbapenem or beta-lactam/beta-lactamase inhibitor + clindamycin (dosed at 600 to 900 mg intravenously every eight hours + vancomycin, daptomycin, or linezolid)
Necrotizing fasciitis:
life-threatening, invasive soft-tissue infection that is characterized by widespread, rapidly developing necrosis of the subcutaneous tissue and fascia
causal agents include Streptococcus pyogenes, Staphylococcus aureus, Clostridium perfringens, Bacteroides fragilis, Aeromonas hydrophila
Results in progressive destruction of the muscle fascia & overlying subcutaneous fat
Typically muscle tissue sparing
Infection spreads over muscle fascia
Initially the overlying tissue can appear unaffected.
It is this feature that makes necrotizing fasciitis difficult to diagnose without surgical intervention
Diagosis: Necrotizing Fasciitis
Physical Exam
minor puncture wound is no longer visible. Do see mottled, edematous area that is warm to touch. Crepitis is noted in the left knee
1.
X-Ray ordered for suspicion of broken hip showed no fractures or dislocations, but did show air in the subcutaneous tissues.
2.
CT ordered, General Surgery is consulted
*
3.
CT images revealed skin thickening and increased attenuation of the subcutaneous fat with both subcutaneous and intermuscular stranding. Crescentic subfascial fluid collections were seen (Fig 2). No air or discrete abscess was identified. Some muscle groups were thickened with increased attenuation, suggesting edema
X-Ray and CT
Necrotizing Fasciitis
Type I:
polymicrobial necrotizing fasciitis, usually occurs after trauma or surgery. This form may initially be mistaken for a simple wound cellulitis
assoc w/ urogenital or anogenital infections

Type II:
group A streptococcal necrotizing fasciitis, is the so-called flesh-eating bacterial infection.
Usually monobacterial but can be assoc with assoc with other bacteria (usually Staph A.)

Type III:
clostridial myonecrosis, is gas gangrene. This skeletal muscle infection may be associated with recent surgery or trauma. rare! only 21 cases btwn 1900-1985
It progresses
rapidly
Affected area may be erythematous (without sharp margins), swollen, warm, shiny, and exquisitely
tender
Absent lympadenopathy
Most cases of necrotizing fasciitis involve a
single site
of soft tissue infection;
Characteristic features include thin, dark, sometimes
foul-smelling
wound drainage
+/- purpura +/- bullae
Immunocompromised
persons are at higher risk
pain, swelling, and systemic toxicity are
NOT
prominent features
Relative mildness helps distinguish the process from true gas gangrene.
Crepitus
is observed in the skin, but there is sparing of the fascia and deep muscles.
Surgical exploration
and debridement are required: anaerobic cellulitis/fasciitis vs myonecrosis
LABS:
Typically non-specific
Elevated CK
Leukocytosis w/ left shift
cultures + in 60% of cases
Surgery (exploration)
is the DEFINITIVE way to establish diagnosis
Fever + toxicity +pain + inc CK +/- WBC +/- Radiographic evidence
Necrotizing Fasciitis
Not really "Flesh-eating bacteria"
FEB is misnomer,
Virulence factors cause destruction of skin which causes the overproduction of cytokines (TH1 mediated)
H&E of necrotizing fasciitis:
showing necrosis dense connective tissue (fascia) interposed between fat lobules
Microscopic Necrotizing Fasciitis
Consists of 6 serologic measures:
WBC count (x 10^6 per mm3)
<15 - 0 points
15-25 - 1 point
>25 – 2 points
Hemoglobin (g/dL)
>13.5 – 0 points
11–13.5 – 1 point
<11 - 2 points
Sodium (mmol/L)
<135 - 2 points
Creatinine (umol/L)
>141 – 2 points
Glucose (mmol/L)
>10 – 1 point
"robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.
Diagnosis : LRINEC
Typically misdiagnosed in children
Retrospective study in 2002 by Morales et al
39 cases
11 were diagnosed at admission (28%)
Single lesions were seen in 30 (77%) of patients, with 21 (54%) in extremities.
malnutrition in 14 (36%).
Most frequent initiating factor was varicella in 13 patients (33%).
Pseudomonas aeruginosa was the most frequently isolated bacteria though 71% were type I NF (poly).
Complications were present in 33 patients (85%)
Mortality in 7 (18%)
Most common risk factor was immunosupression
NF in Children
Full transcript