Necrotizing Fasciitis. Elizabeth Ann Feely, M.D. Department of Internal Medicine Resident Grand Rounds December 1, 1998. Case Presentation. HPI : B.T. is a 48 YOWF with ESRD, DM, HTN, and CAD, who was recently hospitalized for uncomplicated
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Elizabeth Ann Feely, M.D.
Department of Internal Medicine
Resident Grand Rounds
December 1, 1998
HPI: B.T. is a 48 YOWF with ESRD, DM, HTN, and
CAD, who was recently hospitalized for uncomplicated
angioplasty of her LAD. She presented to WFU/BMC
ED with c/o a “painful boil on her bottom ” x 3 days.
Pain started in the region of her right groin catheterization
site and had progressively become unbearable. Mild
subjective fever and chills. Denied N/V, SOB, CP,
diarrhea, dysuria, or vaginal discharge.
Meds: ASA, Atenolol, Imdur, Insulin NPH, Prilosec,
Nu-Iron, Folate, and NTG SL
Pertinent Physical Exam Findings:
VS: T 96.6, P 56, BP 86/42, R 20
Gen: obese WF in NAD
CV/Lungs: within normal limits
Abd: soft, obese, slightly tender in right lower quadrant, nl. BS. Large hematoma in right groin w/ surrounding erythema. No purulence. On deep palpation, + soft tissue crepitus.
GU: grossly swollen labium, with crepitus on palpation.
S B L
94 2 2
ED Course: Pt. started on KVO NS and given 1 g IV Rocephin. Medicine consulted for ? infected Bartholin’s cyst. Plain film of pelvis was recommended. Plain film showed air within soft tissues from groin into labium. Given her crepitance, WBC, and DM, necrotizing fasciitis was high on differential. Surgery consult performed incision over groin hematoma, revealing foul-smelling, nonviable SQ tissue.
Necrotizing fasciitis (NF)
“… the erysipelas would quickly spread widely in all directions. Flesh, sinews and bones fell away in large quantities… Fever was sometimes present and sometimes absent… There were many deaths. The course of the disease was the same to whatever part of the body it spread.”
Type 1: mixed anaerobic, aerobic, and facultative bacteria; accounts for ~ 90% of cases.
Type 2: Group A Streptococcus only; occurs ~ 10% of cases.
Study by Lille et al. suggests a delay in the diagnosis by a matter of hours significantly increases mortality.
Lille et al.
Lille et al.
What is the best diagnostic modality available to establish the diagnosis of necrotizing fasciitis?
Stamenkovic and Lew studied frozen -section biopsy for diagnosis of NF in early stages.
Comparative Mortality and Time (Between Onset of Sympotms and Treatment) for Biopsy Group and Non-Biopsied Group
Stamenkovic and Lew
Majeski and Majeski performed a similar study.
Fisher et al. studied roentgenographic studies in diagnosing NF.
Fisher et al.
Wysoki et al. studied computed tomography (CT) characteristics of NF.
Wysoki et al.
Schmid et al. evaluated MRI in differentiating NF from cellulitis.
Schmid et al.
Cellulitis vs. Necrotizing Fasciitis on MRI
Loh et al. studied specificity of deep fascial hyperintense T2-weighted signal abnormalities for necrotizing soft-tissue infections.
Loh et al.
Pretty tables 1 and 2
Loh et al.
Rahmouni et al.