This paper addresses various aspects of necrotizing fasciitis of medical interest. Necrotizing fasciitis is a rapidly spreading infection that affects the inner layers of the skin and also the adipose tissue, and spreads across the fascia (a plane that separates the skin from the muscle tissue). It leaves the tissues dead and damaged. It is a rare autoimmune disease sometimes found in individuals with conditions such as diabetes, those who are alcoholics, malignancies, chronic systemic diseases and immunosuppression. Treatment during early stages include the use of diseases like penicillin, but when the disease is advanced, surgery is often indicated, where debridement is done.
The existence of the disease dates many eons back. For many centuries now, however, there has been prolific research and literature coming up in the medical cycles describing the disease, epidemiology, directions for management etc. among the notable historical figures cited to have suffered from the disease include King Herod II of Judea and Lucien Bouchard a one time Premier of Quebec in the Canada. Many other popular figures have suffered from the disease too.
Types of Necrotizing Fasciitis
The types of necrotizing fasciitis are based on the strains of microorganism s involved. Type 1 is polymicrobial, where both aerobic and anaerobic bacteria are involved. Some of the microorganisms implicated include streptococcus aureus, enterococci, streptococci, E.coli, prevotella, bacterioides and clostridium. Type II is monomicrobial, and involves GAS (Kotrapa et al 1691).
Most of the instances of necrotizing fasciitis are type 1. Majority of soft tissue infections have anaerobic bacteria together with aerobic bacteria. The micro organisms populate in those areas with low oxygen supply due to trauma, surgery or compromise of medical integrity. The proliferation of facultative aerobes is due to the fact that there is the white blood cells called polymorphonucear leucocytes do not perform work properly when there is low oxygen concentration. Thus the combative activity of the body is also compromised. Further, this leads to minimization of the reduction/oxidation potential leading to more anaerobic respiration thus more bacterial cell proliferation( Kotrapa et al 1692)).
The end products of anaerobic respiration are normally carbon (IV) oxide and water. In addition, methane, nitrogen, hydrogen and hydrogen sulphide are formed when the aerobic and anaerobic bacteria combine in the infected soft tissue. Once formed, the gases are not dissolved in water (except carbon IV oxide) and continue to accumulate in the tissues.
The initiating microorganisms are usually the GABS (Group A beta Hemolytic streptococci) and staphylococci. Even so, other micro-organisms may often be present including Bacteroides, Klebsiella, Peptostreptococcus, Clostridium, coliforms, Enterobacteriaceae, Proteus and, Pseudomonas.Bactrioides commonly part of the mix of microorganisms in the soft tissue with necrotizing fasciitis is often in combination with other microorganisms such as E. coli. Although it does not cause the infections, it reduces the production of interferons and the capacity of the macrophages to be able to carry out phagocytic activity. A variant, synergistic necrotizing cellulitis is a form of the disease which is thought to be a non clostridial myonecrosis. Although it begins like N.F, its progression is faster and spreads wider and deeper. It sequels systemic toxicity( Medina et al 121).
It has been shown that some of the causes of necrotizing fasciitis may actually be caused by Vibrio vulnificans, commonly found in patients with chronic hepatic dysfunction. Eating of raw sea food is the major way of entry of the microorganism into the body.
There are about five hundred cases of the disease that have been reported in the United States since the late 19th century. Globally, those mostly affected are the populations in the Asian and African countries. The mortality and morbidity rates are put at between seventy to eighty percent. Among the survivors, the mean age is eighty five years. It is observed that necrotizing fasciitis of the upper extremity leads to higher rates of mortality. Basically a presentation of respiratory distress and altered consciousness were the major factors identified in patients who had poor prognosis.
The ratio of males to females suffering from the disease stand at 2-3:1, while the mean age of those who are affected is 38-44 years. Thus, the disease has an incredibly low incidence rates in children although the world average is surpassed by that from those countries with poor resources.
In assessment a history of surgery or trauma is significant. The patient will complain of pain at the site of trauma or surgery, although some of the patients would present with pain from a point distant to that of trauma or surgery. The pain progresses over several hours to days from local to anesthesia. As for the Fournier’s gangrene, there is initial onset of itching and pain at the scrotum. Additionally, history of other conditions like diabetes mellitus, malignancies, alcoholism should be pursued because they may offer direction for suspicion or diagnosis.
- Physical findings
The disease begins as an erythematous lesion that spreads fast, from hours to days. The red discoloration spreads while the margins widen outward. They do not however, become raised or exhibit very sharp demarcation. The erythema progresses to a purplish to dusky discoloration of skin at the site. Identical patches multiply and develop to make a wide patch of gangrenous skin. The initial picture is that of a massive undermining of the skin with subcutaneous layer. The subcutaneous tissue and normal skin are made loose. It is important to note that, far from the appearance of the condition, the problem is more advanced.
Causes and differential diagnoses
The causes include surgery especially for intraperitoneal infections, intramuscular or intravenous infusion sites, and minor bites by insects, alcoholism or even the use of some NSAIDs. Some of the differential diagnoses include cellulitis, gas gangrene epididymitis, herniations, testicular torsion or orchitis( Rapini et al 101).
Treatment should aggressively be directed to reduce morbidity and mortality. Endotracheal intubation should be done to those who have respiratory distress, an IV access should be prepared, the heart should be monitored continuously, and fluid balance should be ensured. As for antibiotics, penicillin FG should be used and clindamycin. Third generation cephalosporin or metronidazole should be used for the anaerobes. Incase enterococci are implicated, ampicillin should be used.
Necrotizing fasciitis is a very dangerous condition with high morbidity and mortality rates that should be given proper management. That it may not appear as serious as it actually is, proper diagnosis should be carried out so that aggressive management begins. If the infection is detected early enough, the disease may be treated with good prognosis.
Kotrappa, K., Bansal, R. and Amin, M., "Necrotizing fasciitis", Am Fam Physician, 1996 Apr;53(5):1691-7.
Medina P, Gonzalez-Rivas F, Blanco A, Tejido S, Leiva G."Fournier's Gangrene: Baurienne, 1764 and Herod the Great, 4 B.C.". European Urology Supplements 8 (5): 2009, 121–121
Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. Dermatology: 2-Volume Set. St. Louis: Mosby: 2007.