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Necrotizing Fasciitis

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Necrotizing fasciitis (NF) is an infection that can occur following a minor injury or major surgery. It is often referred to by the media as "Man-eating flesh disease". Necrotizing fasciitis has a long history. It was originally called "hospital gangrene" during the Civil War, when confederate surgeon Joseph Jones began recording the incidents of hospital gangrene. Although NF has become increasingly common in the United States since the late 1980s, intensive surveillance efforts for the disease in our country have not been conducted since 1991.

Necrotizing fasciitis has also been called "acute infective gangrene," "streptococcal toxic shock syndrome," and "hemolytic streptococcal gangrene."

No matter what it is called, a diagnosis of NF should be understood by every healthcare provider to be a potentially life-threatening infection.

Necrotizing fasciitis is a bacterial infection. The most common type of bacteria causing necrotizing fasciitis is Streptococcus pyogenes, this Group A Strep is the same bacteria that causes strep throat. However, there are various strains of the bacteria, some of which are more powerful than others (with stronger m-protein serotypes). If the right set of conditions is present, necrotizing fasciitis can occur.

This rapidly progressive disease attacks the soft tissue and the fascia, which is a sheath of tissue covering the muscle. NF can occur in an extremity following a minor trauma, or after some other type of opportunity for the bacteria to enter the body such as surgery.

Because the onset often resembles flu-like symptoms, it is often dismissed until the infection has advanced. Early signs and symptoms of necrotizing fasciitis include fever, severe pain and swelling, and redness at the wound site. If the infection is deep in the tissue, signs of inflammation may not develop right away.

A person may have pain from an injury that gets better over 24 to 36 hours and then suddenly gets worse. Often the pain is much worse than would be expected from the size of the wound or injury. Other early symptoms may include chills, nausea and vomiting or diarrhea and the skin usually becomes hot to the touch.

The symptoms often start suddenly over a few hours or a day (for example a tiny black dot or purplish bruise may become a large pustule in the span of an hour). The infection may spread rapidly and can quickly become life-threatening. Serious illness and shock can develop in addition to tissue damage. Necrotizing fasciitis can lead to organ failure and death.

While early diagnosis and treatment is the key to preventing devastating tissue destruction, physicians often fail to recognize necrotizing fasciitis and its severity.

After several days, the skin develops a dusky blue coloring, fluid-containing blisters called bullae may form and the skin may become anesthetic. This loss of feeling is due to the damage to nerve endings.

There is an elevated white blood cell count and the heart rate will be faster than the patient's normal. This is called Tachycardia and can result in a sustained heart rate as high as 175 beats per minute. As the disease progresses, skin necrosis develops and then sloughing of the skin occurs. Fat and fascial necroses occur simultaneously. Reduction of the pain and the presence of numbness can be an indication that the infection has destroyed subcutaneous nerves.

If the wound is opened, the fascia appears gray or grayish green. The exudate is watery thin "dishwater pus" and of significant foul odor in the presence of anaerobic microorganisms.

The patient's condition can rapidly deteriorate into hypoxia, altered level of consciousness, septic shock, disseminated intravascular coagulopathy (DIC), and multisystem organ failure.

Treatment of necrotizing fasciitis is most effective if the infection is recognized in time. Antibiotics and surgical removal of dead tissue are required. If the tissue destruction is widespread, extensive surgery or amputation might be the only way to prevent death.

NF must be treated in the hospital with antibiotic IV therapy and aggressive debridement (removal) of affected tissue. Other treatments will take place depending upon the level of toxicity or organ failure being experienced by the patient. Medications to raise blood pressure, blood, chemotherapy and a new medicine called intravenous immunoglobulin (IVIG) are also used. A hyperbaric oxygen chamber is sometimes used in certain cases involving a mixed bacterial infection. The hyperbaric chamber is also recommended for post-discharge healing of the chronic wounds created by multiple debridements or amputation.

Be sure to ask that in addition to a skilled surgeon, your medical team include an Infectious Disease Specialist and an oncologist. The nurses attending to your daily monitoring and wound dressing changes should include a Certified Wound, Octomy and Continence Nurse (CWOCN). This person should see you for more than just a singular consult and periodically check to insuring that your regular dressing changes are done in a manner to best prevent secondary infections from occurring. Because survivors of NF experience a great deal of tissue destruction, large wounds or amputation it is imperative to seek out a Wound Care Specialists or clinic in your area for a second opinion on the healing and follow-up treatment of your wounds.

Patients should also take the initiative to notify their local Department of Public Health, the CDC and the Joint Commission if their case of Necrotizing Fasciitis is hospital-acquired.

Necrotizing Fasciitis Video
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