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t unusual for nf to present without gas on imaging 17 in addition ct helps evaluate complications due to nf and find possible sources of infections 17 its use may be limited in pregnant patients and patients with kidney issues 17 magnetic resonance imaging mri edit axial t2 weighted mri a and contrast enhanced mri b of left wrist showing necrotizing fasciitis there is diffuse hyperintensity with irregular enhancement of the deep fascia asterisks the arrows indicate a lobulating abscess and the triangle a skin bulla magnetic resonance imaging mri is considered superior to computed tomography ct to visualize soft tissues and can detect about 93 of nf cases 17 it is especially useful in finding fluid in the deep fascia which can distinguish between nf and cellulitis 17 when fluid collects in the deep fascia or thickening or enhancement with contrast necrotizing fasciitis should be strongly suspected however mri is much slower than ct and not as widely available 17 there may also be limitations on its use in patients with kidney problems 17 point of care ultrasonography pocus edit necrotizing fasciitis as seen on ultrasound 19 necrotizing fasciitis with soft tissue gas seen on b plain radiography and c ultrasound point of care ultrasound pocus may be useful in the diagnosis of nf when mri and ct are unavailable 20 it can also help rule out diagnoses that mimic earlier stages of nf including deep vein thrombosis dvt superficial abscesses and venous stasis 20 linear probes are generally preferred for the assessment especially in the extremities 20 findings characteristic of nf include abnormal thickening air or fluid in the subcutaneous tissue 20 this can be summarized as the mnemonic staff subcutaneous irregularity or thickening air and fascial fluid 20 the official diagnosis of nf using ultrasound requires the presence of both diffuse subcutaneous thickening and fascial fluid more than 2 mm 20 gas in the subcutaneous tissue may show dirty acoustic shadowing 17 however similar to other imaging modalities the absence of subcutaneous free air does not definitively rule out a diagnosis of nf because this is a finding that often emerges later in the disease process 20 of note the quality and accuracy of pocus are highly user dependent it may also be difficult to visualize nf over larger areas or if there are many intervening layers of fat or muscle it is still unclear whether pocus improves the speed of diagnosis of nf or if it reduces the time to surgical intervention as a whole 20 plain radiography x ray edit it is difficult to distinguish nf from cellulitis in earlier stages of the disease using plain radiography 17 x rays can detect subcutaneous emphysema gas in the subcutaneous tissue which is strongly suggestive of necrotizing changes however air is often a late stage finding and not all necrotizing skin infections create subcutaneous emphysema hence radiography is not recommended for the initial diagnosis of nf 17 however it may be able to identify the source of infection such as foreign bodies or fractures and thus aid in subsequent treatment 17 scoring system edit correlated with clinical findings a white blood cell count greater than 15 000 cells mm 3 and serum sodium level less than 135 mmol l are predictive of necrotizing fasciitis in 90 of cases 3 if lab values do not meet those values there is a 99 chance that the patient does not have nf there are various scoring systems to determine the likelihood of getting necrotizing fasciitis the laboratory risk indicator for necrotizing fasciitis lrinec scoring system developed by wong and their colleagues in 2004 is the most common it evaluates people with severe cellulitis or abscesses to determine the likelihood of necrotizing fasciitis lrinec uses six laboratory values c reactive protein total white blood cell count hemoglobin sodium creatinine and blood glucose 2 a score of 6 or more indicates that there is a 50 75 probability of necrotizing fasciitis a score of 8 or more represents over 75 likelihood of nf 17 21 22 patients with a lrinec score 6 may have a higher rate of both death and amputation as well 23 the scoring criteria are 21 24 lrinec scoring system lab value criteria points crp 15 mg dl 150 mg l 4 wbc count 10 3 15 25 mm 3 1 25 mm 3 2 hemoglobin 11 13 5 g dl 1 11 g dl 2 sodium 135 meq l 2 creatinine 1 6 mg dl 141 μmol l 2 glucose 180 mg dl 10 mmol l 1 if the lab value does not meet the listed criteria it is assigned 0 points however this scoring system is yet to be validated 3 a lrinec score 6 is only able to detect 70 of nf cases and a lrinec score 8 has shown even poorer sensitivity 22 moreover these lab values may be falsely positive if any other inflammatory conditions are present therefore this scoring system should be interpreted with caution 2 treatment edit necrotizing fasciitis is treated with surgical debridement cutting away affected tissue 3 however antibiotics should be started as soon as this condition is suspected appropriate antibiotic coverage may change based on tissue cultures additional support should be initiated for those with unstable vital signs and low urine output 2 surgery edit aggressive wound debridement should be performed as soon as the diagnosis is made the affected area may need to be debrided several times usually once every 12 36 hours 3 large sections of tissue and muscle may need to be removed to prevent the infection from spreading amputation may be needed if the infection is too severe 3 en bloc debridement ebd is most commonly employed in treating nstis 25 this involves cutting away the skin overlying all diseased areas at the cost of increased scar formation and potential decreased quality of life post operatively 25 more recently skin sparing debridement ssd has gained traction as it resects the underlying tissue and sources of infection while preserving skin that is not overtly necrotic 25 however more studies are needed to examine whether ssd actually accelerates the healing process after surgery 25 fournier gangrene and subsequent vsd after the wound debridement adequate dressings should be applied to promote wound healing 2 wounds are generally packed with wet to dry dressings and left open to heal 3 in certain cases vacuum sealing drainage vsd may help the wound heal especially in fournier gangrene for necrotizing infection of the perineal area fournier s gangrene wound debridement and care in this area can be difficult because of the excretory products that often render the area dirty and negatively affect wound healing therefore regular dressing changes with a fecal management system can help to keep the wound in the perineal area clean sometimes colostomy may be necessary to divert the excretory products to keep the wound in the perineal area clean 2 wound after aggressive acute debridement of nf necrotic tissue from the left leg surgically removed postsurgical debridement and skin grafting after knee disarticulation amputation antibiotics edit empiric antibiotics are usually initiated as soon as the diagnosis of nsti has been made they are then changed to culture guided antibiotic therapy in the case of nstis empiric antibiotics are broad spectrum covering gram positive including mrsa gram negative and anaerobic bacteria 26 often a combination of clindamycin daptomycin iv vancomycin and gentamicin is used 2 gram negative coverage may entail the use of fluoroquinolones piperacillin tazobactam or carbapenems 3 despite multiple studies there is no consensus on how long antibiotics should be given 26 generally antibiotics are administered until surgeons decide that no further debridement is needed and the patient no longer shows any systemic signs of infection from a clinical and laboratory standpoint 3 evidence regarding the efficacy of treatment and adverse effects is also unclear add on therapy edit hyperbaric oxygen hbo in theory hbo decreases local inflammation in the wound and bolsters the body s immune response however the impact of hbo on patients with nstis remains unclear 26 intravenous immunoglobulin ivig ivig is intended to combat the exotoxins released by s pyogenes toxic shock syndrome tss 27 however studies have failed to find any effect on patient mortality 27 there may also be serious adverse effects with ivig use 26 ab103 reltecimod aka ab103 is a new drug that binds to the cd28 t cell receptor and thus mitigates the effects of bacterial toxins studies show that it may decrease the severity of organ failure in nf patients 27 however other studies found no difference in mortality with this therapy 26 supportive therapy intravenous hydration wound care anticoagulants to prevent thromboembolic events pain control vasopressors etc should always be provided to patients when appropriate 9 epidemiology edit prevalence edit necrotizing fasciitis occurs in about 4 people per million per year in the u s and about 1 per 100 000 in western europe 4 about 1 000 cases of necrotizing fasciitis occur per year in the united states but the rates have been increasing this could be due to increasing awareness of this condition and increased reporting or increasing antibiotic resistance 2 both sexes are affected equally 2 it is more common among older people and is rare in children 4 anatomical location edit necrotizing fasciitis can occur at any part of the body but it is more commonly seen at the extremities perineum and genitals a small fraction of cases arise in the head neck chest and abdomen 2 history edit in the fifth century bc hippocrates was the first to describe necrotizing soft tissue infections erysipelas all over the body while the cause was only a trivial accident bones flesh and sinew cord tendon or nerve would fall off from the body and there were many deaths necrotizing soft tissue infections were first described in english by british surgeon leonard gillespie and british physicians gilbert blaine and thomas trotter in the 18th century at that time there was no standardized name for nstis they were variably described as severe ulcers gangrene erysipelas or cellulitis 28 later hospital gangrene became more commonly used in 1871 confederate states army surgeon joseph jones reported 2 642 cases of hospital gangrene with a mortality rate of 46 in 1883 dr jean alfred fournier described necrotizing infections of the perineum and scrotum now named after him as fournier gangrene the term necrotizing fasciitis was coined by dr bob wilson in 1952 4 29 since then its definition has broadened to include infections of fascia and soft tissue 2 despite being disfavored by the medical community the term galloping gangrene was frequently used in sensationalistic news media to refer to outbreaks of necrotizing fasciitis 30 it is sometimes confused for eripheral symmetrical gangrene and acute rhabdomyolysis and all three are sometimes incorrectly referred to as flesh eating virus 7 31 society and culture edit notable cases edit 1994 lucien bouchard future premier of québec canada who was infected while leader of the federal official opposition bloc québécois party lost a leg to the illness 32 1994 a cluster of cases occurred in gloucestershire in the west of england of five confirmed and one probable infection two died the cases were believed to be connected the first two had acquired the streptococcus pyogenes bacteria during surgery the remaining four were community acquired 33 the cases generated much newspaper coverage with lurid headlines such as flesh eating bug ate my face 34 1997 jeff moorad former agent and partial owner of the san diego padres and arizona diamondbacks contracted the disease he had seven surgeries in a little more than a week and later fully recovered 35 2004 don rickles american stand up comedian actor and author known especially for his insult comedy contracted the disease in his left leg he had six operations and later recovered the condition confined him in his later years to performing comedy from a chair 36 2004 eric allin cornell winner of the 2001 nobel prize in physics lost his left arm and shoulder to the disease 37 2005 alexandru marin an experimental particle physicist professor at mit boston university and harvard university and researcher at cern and jinr died from the disease 38 2006 alan coren british writer and satirist announced in his christmas column for the times that his long absence as a columnist had been caused by his contracting the disease while on holiday in france 39 2009 r w johnson british journalist and historian contracted the disease in march after injuring his foot while swimming his leg was amputated above the knee 40 2011 jeff hanneman guitarist for the thrash metal band slayer contracted the disease he died of liver failure two years later on may 2 2013 and it was speculated that his infection was the cause of death however on may 9 2013 the official cause of death was announced as alcohol related cirrhosis hanneman and his family had apparently been unaware of the extent of the condition until shortly before his death 41 2011 peter watts canadian science fiction author contracted the disease on his blog watts reported i m told i was a few hours away from being dead if there was ever a disease fit for a science fiction writer flesh eating disease has got to be it this spread across my leg as fast as a star trek space disease in time lapse 42 2013 british actress georgie henley revealed in 2022 that she had contracted the disease several weeks after starting at cambridge university and that it had almost claimed her life 2014 daniel gildenlöw swedish singer and songwriter for the band pain of salvation spent several months in a hospital after being diagnosed with necrotizing fasciitis on his back in early 2014 after recovering he wrote the album in the passing light of day 43 a concept album about his experience during the hospitalization 44 2014 ricky bartlett sag aftra actor and s o v a s voiceover artist lost both legs to nf he contracted the disease during a trip to wyoming and south dakota 45 2015 edgar savisaar estonian politician had his right leg amputated he got the disease during a trip to thailand 46 2018 alex smith an american football quarterback for the washington football team of the national football league nfl contracted the disease after being injured during a game 47 he suffered an open compound fracture in his lower leg which became infected 48 smith narrowly avoided amputation and eventually returned to playing professional football in october 2020 49 smith s injury and recovery is the subject of the espn documentary e60 presents project 11 50 2019 og maco contracted nf after an untreated rash 2021 irish actor barry keoghan revealed in 2024 that he contracted nf shortly before filming the banshees of inisherin and nearly had his arm amputated 51 see also edit capnocytophaga canimorsus gangrene mucormycosis a rare fungal infection that can resemble necrotizing fasciitis see type iv nf listing above noma disease toxic shock sy...
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