Necrotizing fasciitis

COLLECTIVE REVIEW fasciitis, necrotizing

Necrotizing Fasciitis [Brenner BE, Vitullo M, Simon RR: Necrotizing fasciitis. Ann Emerg Med 11:384-386, July 1982.] INTRODUCTION In 1871, Joseph Jones, a Confederate A r m y surgeon, described the clinical findings of a c o m m o n wartime wound: " . . . a purple or blue spot first perceived . . . The cuticle is sometimes raised, and contains serum below . . . I have seen the skin In the affected spot melt away in 24 hours . . . Whilst a deep blue and purple, almost black, areola surrounding the dead mass, spreads rapidly in ever increasing c i r c l e s . . . This is witnessed most generally in the worst and fatal cases. ''1 The surgeon was describing necrotizing fasciitis, and the description remains essentially the same to this day. The clinical history and manifestations are significant. The disease encompasses all age groups - - from three days to 81 years - - with a predominance of males. 24 It is usually associated with injury, frequently trivial, and many patients are unaware that they have a wound. The etiology of fasciitis was minor trauma in 50% to 85% of the affected patients, and one-third of this group ha d only abrasions, z'59 Narcotic addicts may be prone to this entity at sites of parenteral injection. 1°'11 The initial lesion can be found anywhere in the body; however, it is usually on the legs or genitalia. 9,1217 Of 33 patients with necrotizing fasciitis, 14 had extremity involvement (12 legs, 11 aims), 5 had abdominal, 3 had inguinal, and all but one non-extremity lesion occurred in post-operative wounds. 9 The patient presents with acute pain, redness, and edema at the site of the involvement, followed by a spreading, diffuse inflammatory reaction. 2,7,t82° The skin is tense, smooth, and shiny. The lesions axe erythematous, flat, and fade into surrounding tissue. There is no discrete line of demarcation. After 48 to 72 hours the erythema fades and the area becomes purple or purplishblackY These areas of localized necrosis are due to thrombosis of nutrient vessels of the skin as they pass through the zone of fascia[ necrosis. 2,1s,2° Bullae form which contain serum or hemorrhagic fluid. When they rupture or are debrided, the underlying skin is a shiny dark red which, in a few hours, becomes dry and black. By the 4th or 5th day, frank cutaneous gangrene develops, and by the 8th or 10th day the necrotic tissue begins to separate by suppuration. 7'~1 In most studies there was mild to massive edema in 80% of the patients, but calf tendemess was noted in only 10%. Lymphangitis and lymphadenitis are rare but important differential findings. Venous thrombosis is common. The patient generally looks ill, and has rapid pulse and a temperature ranging from 38.3 C to 39.4 C. At the time of diagnosis, he may be prostrate and appear indifferent to his surroundings and circumstances of the disease, z,7,22 A hallmark of the disease is numbness of the involved areas, probably due to infarction of c u t a n e o u s nerves involved in necrosis of s u b c u t a n e o u s fascia. 2'7 8' 1'9 2'3 Rarely, local infection may metastasize to appear as painless, secondary, subcutaneous abscesses in areas of pressure points. 7A9 Electrolyte and fluid deficit m a y be severe, even though no external losses of fluid occur. The dehydration and resultant electrolyte imbalance m a y be the etiology of the lassitude and indifference that m a n y experience. ~,24,25

64•384

Annals of Emergency Medicine

Barry E. Brenner, M0, PhD Michael Vitullo, DO Robert R. Simon, MD Los Angeles, California From the Emergency Medicine Center and the Department of Internal Medicine, UCLA Center for the Health Sciences, Los Angeles, California. Address for reprints: Barry E. Brenner, MD, PhD, Emergency Medicine Center, UCLA Center for the Health Sciences, Los Angeles, California 90024.

11:7 July 1982

LABORATORY FINDINGS Anemia, possibly due to a bacterial: hemolysin, is a consistent finding. Hemoglobin levels below 10 g/dl were found in 68% to 90% of the patients. 7'9 Hypocalcemia with symptoms of muscle twitching, carpopedal spasm, and C h v o s t e k ' s sign were noted. 2,26 It is believed that fat was split by bacterial lipase and ionic calcium combined with fatty acids to f o r m soaps. 2,7 L e u k o c y t o s i s f r o m 12,000 to 30,000 WBC/mm 3 was the rule. A l b u m i n u r i a was mild, and abated when surgical drainage was instituted and necrotic tissue was removed. 7 Jaundice was noted in 20% to 70% of the patients, z Radiographic detection of gas in tissues seems to be far superior to clinical assessment, for 19 of 26 cases were apparent on radiography, but only 5 of 26 were diagnosed clinically. 2z Non-clostridial gas forming infection occurs predominantly" although not exclusively, in diabetics, z

BACTERIOLOGY Organisms are best cultured in the center of the lesions rather than in the periphery, although some studies have found that culturing either the center or the periphery was beneficial. 29 The organisms cultured varied greatly with the study. Staphylococcus was found in 10% to 88% of the cases. 2g'3° [3hemolytic streptococci were found in 25% to 100% of cases. 31 A pure culture of f3-hemolytic streptococci was noted in 5 of 19 cases, and ~3-hemolyric streptococci w i t h an enteric organism was noted in 4 of 19 cases. E co/i was present in 14% and Pseudomonas in 10%. 8 One case of necrotizing fasciitis in a premature infant due to Group B streptococcus 32 and one due to Hemophilus aphrophilus in a drug addict 1° have been described. Of 38 patients with necrotizing fasciitis, Rea 9 found 50% of cases to have predominantly f3-hemolytic streptococci and 50% of cases, pathogenic staphylococci. Thirty-three percent had staphylococci or streptococci along w i t h e n t e r i c o r g a n i s m s . In general~ staphylococci and streptococci, and occasionally gram-negative organisms, are the etiologic agents of necrotizing faciitis. 2 More recently anaerobic bacteria also have been cultured, but their role in p a t h o g e n e s i s is u n c e r t a i n . 2S'28 Blood cultures were positive in only one of six cases reported by Wilson, with lesion cultures positive in four of 11:7 July 1982

six cases. 2 in another study, 29 positive blood cultures were noted much more frequently. Hyaluronidase produced by the bacteria was shown to result in the spreading of the lesion once it was established. 31

DIFFERENTIAL DIAGNOSIS Erysipelas Generalized symptoms of erysipelas include rapid pulse and chills with a sudden rise in temperature to between 39.4 C and 40.5 C. The patient is apprehensive and irritable. 34 The lesions are small, and the area spreads slowly w i t h raised red margins. The tissue is soft with little edema. Organisms are cultured at and beyond the spreading margin, but not in the center. Pain is a c o m m o n symptom. 34 Lymphangitis and lymphadenitis are common, and are important differential findings distinguishing erysipelas from necrotizing fasciitis. 7,22

Gas Gangrene The patient with gas gangrene is irritable. Infection is deep and invasive, with involvement of the muscular layers. The gas present in muscle and subcutaneous tissue usually is associated with deep injury. 3s's6 The skin is relatively free of involvement. Generalized symptoms are alarming, but local signs are mild. There is crepitation and bronzed skin with limited redness and edema. 36 G r a m positive rods are noted from aspirates of lesions. Myonecrosis with myoglobinuria predominates. 7,22,3s

Fournier's Gangrene Foumier's gangrene is perineal gangrene with prominent scrotal involvement. 4° The infection was originally thought to be secondary to hemolytic streptococci, but evidence now points to E coli and mixed pathogens, including enterococcus, anaerobic streptococci, and hemolytic streptococci. 27 Perianal or ischiorectal abscesses, epididymo-orchitis, and perineal abscesses, usually in debilitated and/or compromised hosts, progress to cause this gangrene. 3941 In a series of 12 patients, 39 crepitation was present in 50%, temperature greater than 39.4 C in 75%, calcium less than 8 mg% in 50%, gangrene in 75%, and leukocytosis greater than 14,000 in 95%. Other, less common differential di-. agnoses with similar findings include pyoderma gangrenosa, amoebic skin infections, and fusospirochetal infections. The chronic nature of these synAnnals of Emergency Medicine

dromes is the salient distinguishing feature, and it allows the diagnosis to be made on a less urgent basis. 22

TREATMENT Surgical incision, drainage, and debridement is the only effective treatment. s Fascial necrosis in each case extended beyond the cutaneous manif e s t a t i o n s and a p p a r e n t l y n o r m a l skin. s'42 Multiple longitudinal incisions beyond the obvious skin manifestations is the technique of choice. 24'43 The pathognomonic finding in necrotizing fasciitis is easy dissection of subcutaneous tissue with blunt dissection indicating fascial necrosis. Extensive undermining of skin is a major differentiating point of cellulitis, erysipelas, and necrotizing fasciitis.2, 7 The incision is adequate when one can no longer separate the skin and subcutaneous fascia from the deep fascia. 31 Beathard al suggests 20 million units of penicillin intravenously daily, along with surgical drainage. We suggest high-dose oxacillin, clindamycin, and an aminoglycoside with modifications of this antibiotic therapy directed by the Gram stain and culture and sensitivity results. In 10 of 19 patients in one study, the disease developed or progressed during antibiotic therapy alone without surgical debridement, s One author suggests a continuous infusion into the wound of neomycin, bacitracin, and polymyxin in normal saline. 9 Fine mesh gauze was used in the wound and replaced every 8 hours. The surgical site was inspected every 8 hours by blunt finger dissection to assess the need for further incision. Cutter and Morris, TM using steroids, found some improvement, but other results h a v e been i n c o n s i s t e n t . 31 Hyperbaric oxygen treatment has good results in treating gas gangrene and Meleney's ulcer, but not necrotizing fasciitis. 18,~,4,29,30,43,44

MORTALITY AND PROGNOSIS Mortality ranged from greater than 50% in the pre-antibiotic era to 9% to 39% currently, s'9,4s Average time from onset of the disease to diagnosis and institution of therapy was four days in survivors and seven days in those who died. 9 Patients improve dramatically once incision and drainage are effected. In one study, 25% were moribund with generalized sepsis at the time of diagnosis and surgical drainage, and all died. 9 Diabetes mellitus and generalized arteriosclerosis were 385/65

NECROTIZING FACIITIS Brenner, Vitullo & Simon

the most serious complicating factors, with 37% of diabetics surviving. The mortality of all patients over the age of 50 was 50% to 67%. 9,45 Prognosis seems better if the disease is in an extremity rather than in the trunk, head, or Fleck. 2

14. Woodside JR: Necrotizing fasciitis after neonatal circumcision. Am J Dis Child 134:301-302, 1980. 15. Galibut DL, Gerber DL, Belgraier AH: Spontaneous necrotizing fasciitis. Occurrence secondary to occult diverticulitis. JAMA 238:2302, 1977.

SUMMARY

16. Bahary CM, Joel-Cohen SJ, Neri A: Necrotizing fasciitis. Obstet Gynecol 50: 633-637, 1977.

Necrotizing fasciitis is a serious illness which may arise from little or no trauma. It m a y spread dramatically, and early diagnosis w i t h aggressive surgical m a n a g e m e n t is necessary to prevent morbidity and mortality. REFERENCES 1. Jones J: Investigations on the nature, causes, and treatment of hospital gangrene as it prevailed in the confederate armies 1861-1865, in Surgical Memoirs of the War of Rebellion. Sanitary Commission, NY, 1871. 2. Wilson B: Necrotizing fasciitis. Am Surg 18:416-431, 1952. 3. Wilson HD, Haltalin KD: Acute necrotizing fasciitis in childhood: Report of 11 cases. Am J Dis Child 125:591-595, 1973. 4. Nutman J, Henig E, Wilunsky E, et at: Acute necrotising fasciitis due to streptococcal infection in a newborn infant. Arch Dis Child 54:637-639, 1979. 5. Meleny FL: Hemolytic streptococcus gangrene. Arch Surg 317-364, 1924. 6. Meleny FL: Hemolytic streptococcus gangrene. JAMA 92:2009-2021, 1929. 7. White W: Hemolytic streptococcal gangrene. Plast Reconstr Surg 11:1-14, 1953. 8. Crosthwait R: Necrotizing fasciitis. ] Trauma 4:149-157, 1964. 9. Rea WJ/ Wymick WJ: Necrotizing fasciitis. Arm Surg 172:957-964, 1970. 10. Crawford SA, Evans JA, Crawford GE: Necrotizing fasciitis associated with Haemophilus aphrophilus. Arch Intern Med 138:1714-1715, 1978. 11. Meluzzo PJ, Wiilscher M, Mason HDW, et al: Necrotizing fasciitis in narcotic addicts. Am Surg 42:251-253, 1976. 12. Fallahzadeh M, Allenbernd E, Mays ET: Necrotizing fasciitis. Am Surg 40:352, 1974. 13. Roser SM, Chow AW, Brady FA: Necrotizing fasciitis. J Oral Surg 35:730-732, 197Z

66/386

17. Pruyn SC: Acute necrotizing fasciitis of the endopelvic fascia. Obstet Gynecol 52:2s-4s, 1978. 18. Cutter PB, Morris JB: Acute streptococcal gangrene. J Bone Joint Surg 44B:891895, 1962. 19. Meade DW, Mueller B: Necrotizing infections of subcutaneous tissue and fascia. Ann Surg 168:274-280, 1968. 20. Kohen G: Necrotizing fasciitis. Arch Dermatol 114:581-583, 1978. 21. Webb HE, Hoover NW, Nichols DR, et al: Streptococcal gangrene. Arch Surg 85:969-973, 1962. 22. Meleney FL: A differential diagnosis between certain types of infectious gangrene of the skin. Surg Gynecol Obstet 56:847-867, 1933. 23. Andrews ECI Rockwood CA, Cruz AB: Unusual surgical infections: Gas gangrene, necrotizing fasciitis, phycomycosis, synergistic bacterial gangrene. Texas Med 65:4449, 1969. 24. Ledingham IM, Tehrani MA: Diagnosis, clinical course and treatment of acute dermal gangrene. Br [ Surg 62:364-372, 1975. 25. Tehrani MA, Ledingham IM: Necrotizing fasciitis. Postgrad Med J 53:237-241, 1977. 26. Kaiser RE, Cerra FB: Progressive necrotizing surgical infections - - a unified approach. J Trauma 21:349-355, 1981. 27. Fisher JR, Conway MJ, Takeshita RT: Necrotizing fasciitis; importance of roentgenographic studies for soft tissue gas. JAMA 241:803-805, 1979. 28. Guiliano A, Lewis F, Hadley K: Bacteriology of necrotizing fasciitis. Am J Surg 134:52-56, 1977. 29. Buchman CS: Necrotizing fasciitis due to group A strep. Arch Dermatol 101:664668, 1970. 30. McCloskey RV: Scarlet fever and necrotizing fasciitis caused by coagulase-

Annals of Emergency Medicine

positive hemolytic Staphylococcus aureus, phage type 85. Ann Intern Med 78:85-87, 1973. 31. Beathard GA: Necrotizing fasiitis due to group A beta hemolytic streptococci. Arch Intern Med 120:163-167, 1967. 32. Ramamurthy RS, Srinivasn G, Jacobs NM: Necrotizing fasciitis and necrotizing cellulitis due to group B streptococcus. Am J Dis Child 131:1169-1170, 1977. 33. Baxter CR: Surgical management of soft tissue infections. Surg Cldn North Am 52:1483-1499, 1972. 34. Hammar H, Wanger L: Erysipelas and necrotizing fasciitis. Br J Dermatol 96:409419, 1977. 35. Caplan ES, Kluge RM: Gas gangrene: Review of 34 cases. Arch Intern Med 136: 788-799, 1976. 36. Hedstrom SA: Differential diagnosis and treatment of gas-producing infections. Acta Chir Scand 141:582-590, 1975. 37. Lee C, Oh C: Necrotizing fasciitis of the genitalia. Urology 13:604-606, 1979. 38. Rosenberg PH, Shuck JM, Tempest BD, et al: Diagnosis and therapy of necrotizing soft tissue infections of the perineum. Ann Surg 187:430-438, 1975. 39. Blanehard RJ: F u l m i n a t i n g nonclostridial gas forming infection - - a case of necrotizing fasciitis. Can J Surg 18:339344, 1975. 40. Stone HH, Martin JD: Synergistic necrotizing cellulitis. Ann Surg 175:702-711, 1972. 41. Roberts DB, Hester LL: Progressive synergistic bacterial gangrene arising from abscesses of the vulva and Bartholin's gland duct. Am J Obstet Gynecol 114:285-288, 1972. 42. Tehram MA, Webster MHC, Robinson DW, et al: Necrotising fasciitis treated by radical excision of the overlying skin. Br J Plast Surg 29:74-77, 1976. 43. Trippel OH, Ruggie AN, Staley CJ, et al: Hyperbaric oxygenation in the management of gas gangrene. Surg Clin North Am 47:17-23, 1967. 44. Holland JA, Hill GB, Wolfe WG, et al: Experimental and clinical experience with hyperbaric oxygen in the treatment of dostridial myonecrosis. Surgery 77:75-81, 1975. 45. Defore WW, Mattox KL, Dang MH, et ah Necrotizing fasciitis: A persistent surgical problem. JACEP 6:62-65, 1977.

11:7 July 1982