Necrotising fasciitis

Last Updated: 2023-07-07

Author(s): Anzengruber F., Navarini A.

ICD11: 1B71.Z

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.

  1. Barry W, Hudgins L, Donta ST, Pesanti EL. Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA 1992;267:3315-6.
  2. Kaul R, McGeer A, Norrby-Teglund A, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis 1999;28:800-7.
  3. Norrby-Teglund A, Basma H, Andersson J, McGeer A, Low DE, Kotb M. Varying titers of neutralizing antibodies to streptococcal superantigens in different preparations of normal polyspecific immunoglobulin G: implications for therapeutic efficacy. Clin Infect Dis 1998;26:631-8.
  4. Norrby-Teglund A, Kaul R, Low DE, et al. Plasma from patients with severe invasive group A streptococcal infections treated with normal polyspecific IgG inhibits streptococcal superantigen-induced T cell proliferation and cytokine production. J Immunol 1996;156:3057-64.
  5. Norrby-Teglund A, Muller MP, McGeer A, et al. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis 2005;37:166-72.
  6. Darenberg J, Ihendyane N, Sjolin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003;37:333-40.
  7. Yong JM. Necrotising fasciitis. Lancet 1994;343:1427. 
  8. Demello FJ, Haglin JJ, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973;73:936-41.
  9. Roth RN, Weiss LD. Hyperbaric oxygen and wound healing. Clin Dermatol 1994;12:141-56.
  10. Stevens DL. Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome? Clin Infect Dis 1995;21:977-80.
  11. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996;334:240-5.
  12. Bouza E, Bernaldo de Quiros JC, Rodriguez Creixems M, Quintans A. Fulminant myonecrosis due to Streptococcus pyogenes in a previously healthy patient. Eur J Clin Microbiol Infect Dis 1988;7:205-6.
  13. Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore) 2003;82:225-35.