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Necrotizing fasciitis
Classification and external resources

Caucasian male with necrotizing fasciitis. The left leg shows extensive redness and necrosis.
ICD-10 M72.6
ICD-9 728.86
MedlinePlus 001443
eMedicine emerg/332 derm/743
MeSH D019115

Necrotizing fasciitis (NF), commonly known as flesh-eating disease or flesh-eating bacteria, is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.

Type I describes a polymicrobial infection, whereas Type II describes a monomicrobial infection. Many types of bacteria can cause necrotizing fasciitis (e.g., Group A streptococcus (Streptococcus pyogenes), Staphylococcus aureus, Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis). Such infections are more likely to occur in people with compromised immune systems.[1]

Historically, Group A streptococcus made up most cases of Type II infections. However, since at least 2001, another serious form of monomicrobial necrotizing fasciitis has been observed with increasing frequency.[2] In these cases, the bacterium causing it is methicillin-resistant Staphylococcus aureus (MRSA), a strain of S. aureus that is resistant to methicillin, the antibiotic used in the laboratory that determines the bacterium's sensitivity to flucloxacillin or nafcillin that would be used for treatment clinically.

Contents

Symptoms

The infection begins locally, at a site of trauma, which may be severe (such as the result of surgery), minor, or even non-apparent. Patients usually complain of intense pain that may seem in excess given the external appearance of the skin. With progression of the disease, tissue becomes swollen, often within hours. Diarrhea and vomiting are also common symptoms.

In the early stages, signs of inflammation may not be apparent if the bacteria are deep within the tissue. If they are not deep, signs of inflammation, such as redness and swollen or hot skin, show very quickly. Skin color may progress to violet, and blisters may form, with subsequent necrosis (death) of the subcutaneous tissues.

Patients with necrotizing fasciitis typically have a fever and appear very ill. Mortality rates have been noted as high as 73 percent if left untreated.[3] Without surgery and medical assistance, such as antibiotics, the infection will rapidly progress and will eventually lead to death.[4]

Pathophysiology

"Flesh-eating bacteria" is a misnomer, as the bacteria do not actually eat the tissue. They cause the destruction of skin and muscle by releasing toxins (virulence factors), which include streptococcal pyogenic exotoxins. S. pyogenes produces an exotoxin known as a superantigen. This toxin is capable of activating T-cells non-specifically, which causes the overproduction of cytokines.

Treatment

Necrotic tissue from the left leg is being surgically debrided in a patient with necrotizing fasciitis (same patient as above).

Patients are typically taken to surgery based on a high index of suspicion, determined by the patient's signs and symptoms. In necrotizing fasciitis, aggressive surgical debridement (removal of infected tissue) is always necessary to keep it from spreading and is the only treatment available. Diagnosis is confirmed by visual examination of the tissues and by tissue samples sent for microscopic evaluation.

Early medical treatment is often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including penicillin, vancomycin, and clindamycin. Cultures are taken to determine appropriate antibiotic coverage, and antibiotics may be changed when culture results are obtained.

As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy but is not widely available.[5] Amputation of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound, which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an intensive care unit.

Historical victims

Notable recent victims

Examples in popular media

  • Dr. Atul Gawande, in his book Complications: A Surgeon's Notes on an Imperfect Science, correctly diagnoses NF in the leg of a patient named "Eleanor" and recounts his thought process behind making that diagnosis as a subject of discussion.
  • The 2002 horror film Cabin Fever surrounds teens plagued by a similar disease to NF.
  • In the Scrubs episode "My Lucky Day" (S2E09), Dr. John "JD" Dorian recalls a medical special he saw on television that stated necrotizing fasciitis is often mistaken for cellulitis. Following his instinct, he correctly diagnosed a patient that Dr. Perry Cox had misdiagnosed with cellulitis.
  • In the Scrubs episode "My First Step", Dr. Elliot Reid faces a difficult decision when confronted with a patient with NF.
  • In the 2005 comedy Fun with Dick and Jane, Dick Harper (Jim Carrey), while attempting to rob a bank as a fake vault inspector, gives "necrotizing fasciitis caused by an invasive streptococcus" as the reason why the usual vault inspector failed to turn up.
  • In the TV show House episode "Finding Judas" House and the team mistake a sick little girl as a patient with NF nearly leading to the amputation of her arm and leg.
  • In the Star Trek book The Rise and Fall of Khan Noonien Singh, Part II, the titular villain planned to unleash the bacteria upon the world in massive quantities (he and his augment kin were immune).
  • In the 2003 novel The Zombie Survival Guide, scientists experimenting ways to combat the living dead unsuccessfully attempt to culture and spread necrotizing fasciitis among zombie test subjects.
  • In an episode of 1000 Ways to Die, a Vegas showgirl was shaving with a rusty razor and cut herself, eventually contracting necrotizing fasciitis, which led to her death.
  • A case of Necrotizing fasciitis is diagnosed and operated on, throughout the fifteenth episode of the second season of the American television series Grey's Anatomy.

See also

References

  1. ^ K.S. Kotrappa, R.S. Bansal, N.M. Amin, "Necrotizing fasciitis", Am Fam Physician, 1996 Apr;53(5):1691-7.
  2. ^ Lee TC, Carrick MM, Scott BG, et al. (2007). "Incidence and clinical characteristics of methicillin-resistant fasciitis in a large urban hospital". Am J Surg 194 (6): 809–13. doi:10.1016/j.amjsurg.2007.08.047. PMID 18005776. 
  3. ^ http://www.medscape.com/viewarticle/444061
  4. ^ Necrotizing Fasciitis (Flesh-Eating Bacteria)
  5. ^ Escobar SJ, Slade JB, Hunt TK, Cianci P (2005). "Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotizing fasciitis reduces mortality and amputation rate". Undersea Hyperb Med 32 (6): 437–43. PMID 16509286. http://archive.rubicon-foundation.org/4061. Retrieved 2008-05-16. 
  6. ^ Medina P, Gonzalez-Rivas F, Blanco A, Tejido S, Leiva G (2009). "Fournier's Gangrene: Baurienne, 1764 and Herod the Great, 4 B.C.". European Urology Supplements 8 (5): 121–121. doi:10.1016/S1569-9056(09)60011-7. 
  7. ^ "Mystery of Herod's death 'solved'". 2002-01-25. http://archives.cnn.com/2002/HEALTH/conditions/01/25/king.herod/index.html. 
  8. ^ Flesh-eating bug killed top economist in 24 hours
  9. ^ The Once and Future Scourge
  10. ^ Cornell Discusses His Recovery from Necrotizing Fasciitis with Reporters
  11. ^ PM: foot infection could have been fatal
  12. ^ Before I was so rudely interrupted
  13. ^ "In Memoriam - Alexandru A. Marin (1945 - 2005)", ATLAS eNews, December 2005 (accessed 5 November 2007).
  14. ^ R. W. Johnson "Diary", London Review of Books, 6 August 2009, p41
  15. ^ "Moorad's life changed by rare disease

External links

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