Necrotizing fasciitis

Last Updated: 2019-08-27

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

ICD11: -

Wilson 1952.

Erysipelas gangraenosum, necrotizing fasciitis, necrotizing fasciitis, streptococcal gangrene.

Severe, very rare, deep, necrotizing infection of the tissue (the skin, subcutaneous tissue, fascia, partly also the musculature) with high lethality.


  • Mostly Streptococcus group A (Streptococcus pyogenes), in 10% common occurrence with Staphylococcus aureus or S. epidermidis.
  • Rare mixed infections (e.g. Bacteroides, Peptostreptococcus spp., Non-A-Streptococcus and Enterococcus, E. coli, Enterobacter, Klebsiella, Proteus, Acinobacter baumannii).

  • Necrotizing myositis is rare. Only 21 cases were documented between 1900 and 1985.
  • Predisposing factors: diabetes mellitus, steroid-containing exteriors, alcoholism, drug abuse, liver cirrhosis, neoplasia, childhood (even without underlying disease, but often after a VZV infection), possibly NSAID.

This can be caused by injuries, surgical wounds, needle bites, bruises, burns and sometimes even insect bites.

  • In the initial stage (first 3-7 days), severe pain (often unjustifiable with local findings) is characteristic. In some cases even no skin changes are visible. In the course of the disease, there is an extensive, oedematous, partly hard redness with plaques and sometimes subcutaneous nodules.
  • Hemorrhagic infarction causes the skin, subcutis and fascia to die. Since nerves also die, clinical painlessness occurs. However, systemic signs of infection often appear at this stage.

  • Clinic.
  • Differential-Bood Count (leukocytosis), CRP, CK, kidney parameters, electrolytes, blood cultures, blood gas analysis and several bacterial smears with antibiogram.
  • Sonography of muscles.
  • CT, MRT.

  • Neck or extremities (lower leg), abdomen and genital area (gangraena acuta genitalium).

  • Joint involvement 
  • coagulopathy of consumption 
  • 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.