Necrotising fasciitis

Wilson, 1952.

Erysipelas gangraenosum, necrotising fasciitis, necrotising fasciitis, streptococcal gangrene.

Severe, very rare, deep, necrotising infection of the tissue (of the skin, subcutaneous tissue, fascia, sometimes also of the muscles) with high lethality.

Causative agent

• Mostly group A streptococci (Streptococcus pyogenes) in 10% co-occurrence with Staphylococcus aureus or S. epidermidis
• Rarely mixed infection (e.g. Bacteroides, Peptostreptococcus spp., non-A streptococci and enterococci, E. coli, Enterobacter, Klebsiella, Proteus, Acinobacter baumannii).

• Necrotising myositis is rare. From 1900 to 1985, only 21 cases have been documented

• Predisposing factors: diabetes mellitus, steroid-containing externals, alcoholism, drug abuse, liver cirrhosis, neoplasia, children (even without underlying disease, but often after VZV infection), possibly NSAIDs

Injuries, surgical wounds, needle sticks, bruises, burns and sometimes insect bites can act as the cause.

• In the initial stage (first 3-7 days), severe pain (often not justifiable with the local findings) is characteristic. In some cases, no skin changes are visible. In the course of the disease, there is an extensive, oedematous, partly hard reddening with plaques and sometimes subcutaneous nodules
• Hemorrhagic infarction causes death of the skin, subcutis and fascia. Since nerves also die, there is clinical painlessness. However, systemic signs of infection are often already evident at this stage

• Clinical
• Diff.BB (leukocytosis), CRP, CK, renal parameters, electrolytes, blood cultures, blood gas analysis and multiple bact. smears with antibiogram
• Sonography of the muscles
• CT, MRI

• Neck or extremities (lower legs), abdomen and genital area (Gangraena acuta genitalium)

• Joint involvement
• Consumptive coagulopathy
• Toxic shock syndrome

In 50% of cases, a lethal outcome (sepsis) occurs despite optimal therapy.

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