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Clinical Summary

This uncommon, severe infection involves the subcutaneous soft tissues, including the superficial and deep fascial layers. It is usually seen in the lower extremities, abdominal wall, and perianal or groin area. It is commonly spread from a trauma site, surgical wound, abscess, or decubitus ulcer. Alcoholism, parenteral drug abuse, and diabetes are predisposing factors. Pain, tenderness, erythema, swelling, warmth, shiny skin, lymphangitis, and lymphadenitis are early findings. Later, there is rapid progression of bullae with clear pink or purple fluid and cutaneous necrosis; the skin becomes anesthetic, and subcutaneous gas may be present. Systemic toxicity may be manifest by fever, dehydration, leukocytosis, and frequently positive blood cultures. Type I is polymicrobial and includes anaerobic species. Type II includes group A streptococci.

FIGURE 12.10

Necrotizing Fasciitis. Markedly swollen, dusky, erythematous arm with necrotizing fasciitis in an IV drug user. (Photo contributor: Alexis Lawrence, MD.)

FIGURE 12.11

Necrotizing Fasciitis. Radiograph of the forearm in Fig. 12.10 showing extensive subcutaneous gas. (Photo contributor: Alexis Lawrence, MD.)

FIGURE 12.12

Necrotizing Fasciitis. Large cutaneous bullae on the leg of this patient with necrotizing fasciitis. Note the dark purple fluid in the bullae. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 12.13

Necrotizing Fasciitis. Necrotizing fasciitis with cutaneous necrosis in the inner thigh. (Photo contributor: Lawrence B. Stack, MD.)

Management and Disposition

Prompt diagnosis is critical; if made within 4 days from symptom onset, the mortality rate is reduced from approximately 50% to approximately 10%. Initial treatment involves resuscitation with volume expansion, operative debridement, and prompt initiation of broad-spectrum antibiotics.

Pearls

  1. Plain radiographs or computed tomography (CT) imaging may detect nonpalpable subcutaneous gas.

  2. Hemolysis and disseminated intravascular coagulation may be present.

FIGURE 12.14

Necrotizing Fasciitis. Involvement of the abdominal wall and genitals. (Photo contributor: Kevin J. Knoop, MD, MS.)

FIGURE 12.15

Necrotizing Fasciitis. Lower extremity CT demonstrating extensive soft tissue gas. (Photo contributor: Lawrence B. Stack, MD.)

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