Materiały źródłowe

• #1 Necrotizing Fasciitis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK430756/

  Necrotizing fasciitis is a subset of aggressive skin and soft tissue infections that cause muscle fascia and subcutaneous tissue necrosis. The infection typically travels along the fascial plane, which has a poor blood supply. The overlying tissues are initially unaffected, potentially delaying diagnosis and surgical intervention. […] The diagnosis of NSTIs is still primarily clinical. Imaging may be useful in providing data when the diagnosis is uncertain. The most common plain film finding is similar to cellulitis with increased soft tissue thickness and opacity. Computed tomography has greater sensitivity than plain film in identifying necrotizing soft tissue infections. […] Any rapidly progressing skin or soft tissue infection should be managed aggressively due to the difficulty in differentiating non-necrotizing from necrotizing skin and soft tissue infections.

• #1 Necrotizing Fasciitis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK430756/

  The Laboratory Risk Indicator for Necrotizing Infection Score was developed in a 2004 report to distinguish necrotizing soft tissue infections (NSTIs) from other severe soft tissue infections. […] A score of 6 has a positive predictive value of 92% and a negative predictive value of 96%. A score of 8 or greater represents a 75% risk of necrotizing infection. […] It should be understood that no lab or imaging test should delay surgical intervention.

• #2 Necrotizing Fasciitis: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/2051157-overview

  Necrotizing fasciitis is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. The speed of spread is directly proportional to the thickness of the subcutaneous layer. Necrotizing fasciitis moves along the fascial plane. […] Laboratory tests, along with appropriate imaging studies, may facilitate the diagnosis of necrotizing fasciitis. […] Sonography may reveal subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections, allowing for early surgical debridement and parenteral antibiotics. […] Computed tomography (CT) scanning can pinpoint the anatomic site of involvement by demonstrating necrosis with asymmetrical fascial thickening and the presence of gas in the tissues.

• #2 Necrotizing Fasciitis: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/2051157-overview

  Magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection because of its unsurpassed soft tissue contrast and sensitivity in detecting soft tissue fluid, its spatial resolution, and its multiplanar capabilities. […] In addition, the finger test should be used in the diagnosis of patients who present with necrotizing fasciitis. […] Although some necrotizing infections may still be susceptible to penicillin, clindamycin is the treatment of choice for necrotizing infections. […] Surgery is the primary treatment for necrotizing fasciitis. The authors recommend wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure.

• #3 Necrotizing fasciitis: strategies for diagnosis and management

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1988793/

  Necrotizing fasciitis (NF) is uncommon and difficult to diagnose, and it cause progressive morbidity until the infectious process is diagnosed and treated medically and surgically. […] A delay in diagnosis is associated with a grave prognosis and increased mortality. The main goal of the clinician must be to establish the diagnosis and initially treat the patient within the standard of care. […] The diagnosis of primary or idiopathic NF may be challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. […] In terms of early diagnosis and management, it is important to consider that idiopathic NF exists, and that it is a distinct clinical entity. […] NF a challenging and potentially lethal disease; early diagnosis is of principal importance and aggressive multidisciplinary treatment is mandatory. Early recognition and treatment by extensive debridement and antibiotics can prevent its fulminant course with a fatal outcome.

• #4 Necrotising fasciitis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/821

  Necrotising fasciitis is a life-threatening subcutaneous soft-tissue infection that requires a high index of suspicion for diagnosis. […] Always suspect necrotising fasciitis in a patient with a rapidly progressing soft-tissue infection and any of the following: severe pain (disproportionate to the clinical findings) or anaesthesia over the site of infection; oedema and erythema (oedema will typically extend beyond the erythema); systemic signs of infection. However, necrotising fasciitis can be easily missed because the patient may present earlier in the disease process with non-specific signs and symptoms. […] If you suspect necrotising fasciitis, immediately refer the patient for urgent surgical debridement; do not wait for the results of investigations before referral. Necrotising fasciitis is a clinical diagnosis. However, investigations can support the diagnosis if this is unclear.

• #5 Necrotizing Fasciitis – Diagnosis : Emergency Care BC

  https://emergencycarebc.ca/clinical_resource/clinical-summary/necrotizing-fasciitis-diagnosis/

  Necrotizing fasciitis is a clinical diagnosis. […] The hallmark is pain out of proportion to findings. The clinician should have a high level of suspicion and low threshold for surgical consultation in cases of severe pain, swelling, and fever. Furthermore, the physician should have a high index of suspicion for patients who present with severe pain in an anatomic area, with no other cause; necrotizing fasciitis may have severe pain as the ONLY symptom early on in the presentation. […] Early necrotizing fasciitis may present with no marks/lesions on the skin, and non-specific symptoms. […] Necrotizing fasciitis may follow minor trauma to the skin or varicella skin infection. A high index of suspicion is essential. Blood tests (elevated WBC, C-Reactive Protein, or CK) are non-specific. Typical labs drawn are CBC, eclectrolytes, BUN, CR (GFR), C Reactive Protein, INR, LFTs and an ECG. […] MRI has reasonable sensitivity for detecting necrotizing fasciitis, but surgical consultation should not be delayed for imaging for suspected necrotizing fasciitis. It is better to refer early, and have it be a false positive!

• #6

  https://journals.lww.com/jtrauma/fulltext/2012/03000/necrotizing_fasciitis__classification,_diagnosis,.3.aspx

  Necrotizing fasciitis (NF), a life-threatening rare infection of the soft tissues, is a medical and surgical emergency. […] Once suspected, immediate and extensive radical debridement of necrotic tissues is mandatory. Appropriate antibiotics and intensive general support avoid massive systemic diffusion of the infective process and are the key for successful treatment. […] However, early diagnosis is missed or delayed in 85% to 100% of cases in large published series: because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. […] This review covers the literature published in MEDLINE in the period 1970 to December 31, 2010. Particular attention is given to the clinical and laboratory elements to be considered for diagnosis. A wide variety of diagnostic tools have been described to facilitate and hasten the diagnosis of NF, but the most important tool for early diagnosis still remains a high index of clinical suspicion.

• #7 How do we misdiagnose and mismanage necrotizing fasciitis? – emDocs

  https://www.emdocs.net/misdiagnose-mismanage-necrotizing-fasciitis/

  Just as surgical exploration is the lone means to conclusively diagnose necrotizing fasciitis, surgical debridement is the only treatment demonstrated to decrease mortality. Multiple studies have shown that mortality increases greater than 9-fold when debridement is delayed more than 24 hours. Thus, high suspicion for necrotizing fasciitis should prompt early surgical management for both definitive diagnosis and treatment. […] Early diagnosis is essential but difficult to separate from more common diagnoses such as cellulitis. Key early findings include: Tenderness and edema that spreads beyond the apparent boundaries of infection, Pain out of proportion to skin findings, Ill-defined margins of involvement, Rapid progression of infection.

• #7 How do we misdiagnose and mismanage necrotizing fasciitis? – emDocs

  https://www.emdocs.net/misdiagnose-mismanage-necrotizing-fasciitis/

  How do we misdiagnose and mismanage necrotizing fasciitis? […] This post will evaluate pitfalls in the diagnosis and management of necrotizing fasciitis, discussing common mistakes. A little knowledge of these potential pitfalls can go a long way towards improving care. […] The diagnosis of necrotizing fasciitis requires a high degree of suspicion and clinical acumen. Our surgical consultants are invaluable in the ultimate management of patients with this infection; however, they can succumb to the same difficulties with diagnosis as others. The definitive diagnosis of necrotizing fasciitis requires surgical exploration, thus one must have a more detailed discussion with their surgical consultants if there is a high index of suspicion. […] Surgical exploration is the lone means to conclusively diagnose necrotizing fasciitis. Surgical findings include malodourous, ‘dishwater’ appearing discharge, lack of bleeding from necrotic tissue, and limited resistance to finger dissection of fascia.

• #8 Clinical Guidance for Type II Necrotizing Fasciitis | Group A Strep | CDC

  https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/necrotizing-fasciitis.html

  Diagnosing necrotizing fasciitis can be difficult due to non-specific early symptoms. […] The following symptoms should heighten suspicion for necrotizing fasciitis: Areas of decreased sensation, Bullae, Crepitation, Profound pain, Skin necrosis. […] Imaging may be helpful but should never delay surgical exploration. […] Healthcare providers should expeditiously obtain: Prompt surgical exploration, Gram stain, Culture. […] Gram stain can be highly informative to determine whether the etiology is group A strep. […] Laboratory results such as leukocytosis, thrombocytopenia, and azotemia are common.

• #9 The Diagnosis And Management Of Necrotising Fasciitis : Virtual Library

  https://resources.wfsahq.org/atotw/the-diagnosis-and-management-of-necrotising-fasciitis-anaesthesia-tutorial-of-the-week-298/

  Initial signs and symptoms usually include pain, swelling, erythema, pyrexia, and tachycardia. However it is only once the disease progresses that the typical more advanced skin changes are observed. These include tense oedema, pain disproportionate to skin changes and dusky blue/purple plaques that progress to haemorrhagic bullae and necrosis. […] A definitive diagnosis of NF is established surgically with visualization of fascial planes and subcutaneous tissue in theatre. However, clinical clues and diagnostic tools should be used in combination to help make an early diagnosis. […] The earliest clinical feature common to all types of NF is exquisite pain, often out of proportion to any visible skin changes. This is due to occlusion of perforating nutrient vessels with resultant nerve infarction.

• #9 The Diagnosis And Management Of Necrotising Fasciitis : Virtual Library

  https://resources.wfsahq.org/atotw/the-diagnosis-and-management-of-necrotising-fasciitis-anaesthesia-tutorial-of-the-week-298/

  Blood cultures are positive in approximately 60% of patients with type II NF due to GAS but the yield is lower in patients with synergistic NF around 20%. […] The LRINEC (Laboratory Risk Indicator for Necrotising Fasciitis) is a tool developed to help distinguish NF from other types of soft tissue infections based on laboratory investigations. […] Frozen section biopsies that include the advancing edge and central necrotic areas have been found to be useful in diagnosing NF early. […] Radiological tests should never delay surgery if there is crepitus on examination or evidence of advancing soft-tissue infection. […] A variety of tools are available to aid the diagnosis of NF but a high index of suspicion and early surgical referral remains essential for both diagnostic confirmation and for effective treatment.

• #10 Necrotising fasciitis

  https://dermnetnz.org/topics/necrotising-fasciitis

  A thorough history and clinical examination are crucial in arriving at the diagnosis of necrotising fasciitis. Special care should be taken when examining immunocompromised patients, as the presentation of symptoms/signs may be atypical. […] A positive finger test is highly pathognomic for necrotising fasciitis. A 2cm vertical incision is made in the affected skin and an index finger is pushed into the tissue. The test is positive if the finger passes through the subcutaneous tissue without resistance. […] There is poor adherence of tissue to the fascia on incising the site. […] Necrotic tissue/pus oozes out of the fascial planes. […] Dishwater-coloured fluid seeps out of the skin. […] Typically, necrotising fasciitis does not bleed. […] Blood culture, deep tissue biopsy, and Gram stain help in identifying the culprit organism(s) and guide the choice of antibiotic.

• #11 Necrotizing Fasciitis Workup: Approach Considerations, Imaging Studies, Finger Test and Biopsy

  https://emedicine.medscape.com/article/2051157-workup

  Nonetheless, a retrospective study by El-Menyar et al suggested that the LRINEC score is not only useful as a diagnostic tool but also as a prognostic one. […] The finger test should be used in the diagnosis of patients who present with necrotizing fasciitis. […] Tissue biopsies are then sent for frozen section analysis. The characteristic histologic findings are obliterative vasculitis of the subcutaneous vessels, acute inflammation, and subcutaneous tissue necrosis. […] If either the finger test or rapid frozen section analysis is positive, or if the patient has progressive clinical findings consistent with necrotizing fascia, immediate operative treatment must be initiated.

• #11 Necrotizing Fasciitis Workup: Approach Considerations, Imaging Studies, Finger Test and Biopsy

  https://emedicine.medscape.com/article/2051157-workup

  In addition, these studies permit visualization of the location of the rapidly spreading infection. More importantly, MRI- or CT-scan delineation of the extent of necrotizing fasciitis may be useful in directing rapid surgical debridement. […] However, when the patient is seriously ill, necrotizing fasciitis is a surgical emergency with high mortality. Therefore, laboratory tests and imaging studies should not delay surgical intervention. […] Most fluid collections in the tissue, especially in the musculoskeletal system, can be localized and aspirated under ultrasonographic guidance. […] Whether fluid is infected cannot be determined on the basis of its ultrasonographic characteristics; however, laboratory analysis of the aspirated fluid can help in identifying the pathogen. […] In a study of 13 patients with thoracic and abdominal wall infections, Sharif et al reported that CT scanning and MRI were superior to sonography, scintigraphy, and plain radiography in providing useful information about the nature and extent of infections.

• #11 Necrotizing Fasciitis Workup: Approach Considerations, Imaging Studies, Finger Test and Biopsy

  https://emedicine.medscape.com/article/2051157-workup

  Laboratory tests, along with appropriate imaging studies, may facilitate the diagnosis of necrotizing fasciitis. […] Laboratory evaluation should include the following: Complete blood count with differential, Serum chemistry studies, Arterial blood gas measurement, Urinalysis, Blood and tissue cultures. […] Skin and superficial tissue cultures may be inaccurate because samples may not contain the infected tissue. Deeper tissue samples, obtained at the time of surgical debridement, are needed to obtain proper cultures for microorganisms. […] New techniques include rapid streptococcal diagnostic kits and a polymerase chain reaction (PCR) assay for tissue specimens that tests for the genes for streptococcal pyrogenic exotoxin (SPE; eg, SPE-B) produced by group A streptococci. […] B-mode and possibly color Doppler ultrasonography, contrast-enhanced computed tomography (CT) scanning, and magnetic resonance imaging (MRI) can promote early diagnosis of necrotizing infections.

• #11 Necrotizing Fasciitis Workup: Approach Considerations, Imaging Studies, Finger Test and Biopsy

  https://emedicine.medscape.com/article/2051157-workup

  A study by Sandner et al indicated that the laboratory risk indicator for necrotizing fasciitis (LRINEC) is an effective tool for early detection of cervical necrotizing fasciitis. […] The investigators, who used a cutoff score of 6, reported that the LRINEC had a sensitivity and specificity for cervical necrotizing fasciitis of 94%, as well as a positive predictive value of 29% and a negative predictive value of 99%. […] A retrospective study by Narasimhan et al reported that an LRINEC score of 5 or above had a sensitivity of 76.3% and a specificity of 93.1% in the diagnosis of necrotizing fasciitis, with positive and negative predictive values being 95.5% and 88.1%, respectively. […] In contrast, however, a literature review by Fernando et al indicated that an LRINEC score of 6 or above has a sensitivity and specificity of 68.2% and 84.8%, respectively, in the detection of necrotizing soft tissue infection, while a score of 8 or above has a sensitivity and specificity of 40.8% and 94.9%, respectively.

• #12 Necrotizing Soft-Tissue Infection – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/necrotizing-soft-tissue-infection

  Diagnosis of NSTI, made by history and examination, is supported by leukocytosis, elevated C-reactive protein, soft-tissue gas on x-ray, positive blood cultures, and deteriorating metabolic and hemodynamic status. […] CT and MRI can be used to delineate disease, but treatment should not be delayed while awaiting imaging results. […] During surgical exploration, there is a gray exudate, friable superficial fascia, and absence of pus. […] Differentiation from clostridial myonecrosis is made using microbiologic testing, but because treatment should occur immediately, it is aimed at both NSTI and clostridial myonecrosis.

• #13 Necrotising Fasciitis – RCEMLearning

  https://www.rcemlearning.co.uk/reference/necrotising-fasciitis/

  Necrotising fasciitis is a rare but life threatening bacterial soft tissue infection. […] A high index of clinical suspicion, prompt administration of broad-spectrum antibiotics and emergency surgery to debride affected tissues, are key to improving survival. […] Mortality is directly proportional to delay in diagnosis and treatment. […] Necrotising fasciitis is rare but associated with significant morbidity and mortality. It represents a time critical pathology where patient outcome is directly influenced by time to diagnosis and treatment. A high index of suspicion is required to make the diagnosis at the earliest opportunity. […] Necrotising fasciitis is a clinical diagnosis and as such the gold standard investigation is surgical exploration and tissue biopsy. […] Necrotising fasciitis is difficult to diagnose early due to the non-specific nature of its early features. It is often misdiagnosed for cellulitis and requires a high index of suspicion to identify. […] Necrotising fasciitis is ultimately a clinical diagnosis results of other investigations are supportive only. If you suspect necrotising fasciitis prompt treatment should be instituted without delay!

• #14 Necrotizing fasciitis – Symptoms, diagnosis and treatment | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/821

  Necrotizing fasciitis is a life-threatening subcutaneous soft-tissue infection that requires a high index of suspicion for diagnosis. […] No laboratory or imaging studies, alone or in combination, are sufficiently sensitive and specific to definitively diagnose or rule out necrotizing fasciitis. […] An urgent surgical consultation should be obtained as soon as the diagnosis is suspected. […] Diagnostic tests include surgical exploration, blood and tissue cultures, gram stain, complete blood count and differential, serum electrolytes, serum BUN and creatinine, serum CRP, serum creatine kinase (CK), serum lactate, clotting screen, and arterial blood gas. […] Tests to consider include radiography, CT/MRI, and ultrasound.

• #15 Necrotizing Fasciitis Diagnoses and Therapy – ACEP Now

  https://www.acepnow.com/article/necrotizing-fasciitis-diagnoses-and-therapy/

  While clinical decision tools, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score that includes CRP, white blood cell count, hemoglobin, sodium, creatinine, and glucose, might help raise your suspicion for necrotizing fasciitis, validation studies showed that a LRINEC cutoff of six points only had a negative predictive value of 92.5 percent. […] While these lab findings and imaging findings of subcutaneous air and fascial thickening on X-ray, CT, and MRI can help support the diagnosis, they should not delay definitive treatment in the operating room in clinically obvious cases and should never override clinical judgment. […] Findings on point-of-care ultrasound, which has the advantage of speed over other imaging modalities, may help support the diagnosis but again cannot rule it out.

• #16 Necrotising Fasciitis: Classification, Diagnosis, & Treatment

  https://www.theplasticsfella.com/necrotising-fasciitis/

  Necrotising fasciitis is a severe infection causing tissue death. […] Diagnostic Workup of Necrotising Fasciitis: Clinical evaluation and suspicion, although routine blood work and CT imaging can be supportive. […] Diagnosis is based on clinical findings, aided by lab results and radiological investigations. […] A score 6 increases the likelihood of a necrotising infection, rather than other cutaneous manifestations. […] LRINEC score – should not replace clinical acumen as it has been heavily criticized for its low specificity and sensitivity. […] Radiological investigations may aid the diagnosis of necrotising fasciitis. […] Diagnosis is based on clinical findings, aided by lab results and radiological investigations. […] The patient is acutely critically unwell. Initial clinical presentation is non-specific requires a high index of suspicion. […] The symptoms and signs of necrotising fasciitis are non-specific, especially in the early stages of the disease, and given its rarity and high mortality a high index of suspicion is vital for prompt diagnosis. […] Necrotising fasciitis is a clinical diagnosis confirmed intra-operatively.

• #17 Necrotizing fasciitis – EMCrit Project

  https://emcrit.org/ibcc/necfas/

  Obtaining a fresh frozen section of the fascia for histopathology with urgent Gram stain may improve diagnostic performance. […] The presence of gas proves the diagnosis of necrotizing fasciitis, within the appropriate clinical setting. […] The fascia can be seen, most easily on flat areas of skin. Necrotizing fasciitis is suggested by thickening, distortion, or fluid in the fascia. […] Pain out of proportion to exam is usually the key early finding.

• #18 Necrotizing fasciitis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/necrotizing-fasciitis-1?lang=us

  CT is the most commonly used imaging modality for evaluation of suspected necrotizing fasciitis owing to its speed and sensitivity for gas in the soft tissues, which is present in 50% of cases. The sensitivity of CT is 80%, but the specificity is low given overlapping features with non-necrotizing fasciitis. […] MRI is the gold standard imaging modality for the investigation of necrotizing fasciitis with high sensitivity (93%) but low specificity. MRI has a high negative predictive value.

• #19

  https://link.springer.com/article/10.1007/s00256-013-1813-2

  Necrotizing fasciitis (NF) is a rare, life-threatening soft-tissue infection and a medical and surgical emergency, with increasing incidence in the last few years. […] Necrotizing fasciitis is often underestimated because of the lack of specific clinical findings in the initial stages of the disease. […] Many adjuncts such as laboratory findings, bedside tests e.g., the finger test or biopsy and imaging tests have been described as being helpful in the early recognition of the disease. […] Imaging is very useful to confirm the diagnosis, but also to assess the extent of the disorder, the potential surgical planning, and the detection of underlying etiologies. […] The main finding is thickening of the deep fasciae due to fluid accumulation and reactive hyperemia, best seen on magnetic resonance imaging.

• #20

  https://link.springer.com/article/10.1007/s40477-022-00761-5

  Although the use of ultrasonography in diagnosing NF was published in several papers with promising results, more studies are required to investigate its diagnostic accuracy and potential to reduce time delay before surgical intervention, morbidity, and mortality. […] The literature review identified many research articles, case reports, and case series that illustrate the usefulness of POCUS in helping physicians establish the diagnosis of NF. NF is a life-threatening medical emergency that requires urgent treatment. Any delay in the treatment of NF is associated with increased morbidity and mortality. […] POCUS has also been reported to diagnose non-infective necrotizing fasciitis. […] The summary of Ultrasonography findings in diagnosing Necrotizing fasciitis is as follows: Subcutaneous thickening, Air collection, Fascial fluid, Irregularity thickening of fascia, Role in assessing for deep vein thrombosis, foreign bodies, and abscesses, Role in monitoring the progression of necrotizing fasciitis. […] Although the use of ultrasonography in diagnosing necrotizing fasciitis was published in several papers with promising results, more studies are required to investigate its diagnostic accuracy and potential to reduce time delay before surgical intervention, morbidity, and mortality.

• #21 BrownSound POCUS for Diagnosis of Necrotizing Fasciitis — BROWN EMERGENCY MEDICINE BLOG

  http://brownemblog.com/blogposts/2023/5/29/brownsound-pocus-for-diagnosis-of-necrotizing-fasciitis

  Necrotizing fasciitis is often diagnosed clinically, but imaging may be helpful in early stages of the disease and to help differentiate from cellulitis. […] CT, or less commonly MRI, is the mainstay imaging modality for this condition, but time to transport and lack of availability in some emergency departments are limiting factors. […] Furthermore, using CT exposes patients to ionizing radiation and intravenous contrast. Point-of-care ultrasound (POCUS) is faster and has shown efficacy in diagnosing soft tissue infections. […] Several studies have specifically evaluated the sensitivity and specificity of POCUS in diagnosing necrotizing fasciitis. […] Two prospective studies demonstrated a sensitivity of 88-100% and specificity of 93-98% for POCUS diagnosis compared to CT and/or surgical impression.

• #22 Necrotising fasciitis pathology

  https://dermnetnz.org/topics/necrotising-fasciitis-pathology

  A deep biopsy is generally required for the diagnosis and shows an extensive acute inflammatory reaction involving the subcutaneous fat. […] Gram stain confirms the overwhelming colonisation by the micro-organism. […] Correct diagnosis is critical for appropriate surgical management of this aggressive disease.

• #23 Frozen sections are unreliable for the diagnosis of necrotizing soft tissue infections | Modern Pathology

  https://www.nature.com/articles/modpathol2017173

  Necrotizing soft tissue infections are rare but are associated with high rates of morbidity and mortality. […] The use of bedside or intraoperative frozen sections has been reported to be associated with faster diagnosis and better outcomes; however, to date no large studies have been published to determine the sensitivity and specificity of frozen sections in this setting. […] No histological feature or combination of features was found to be both sensitive and specific for necrotizing soft tissue infection. […] Combined with the risk of false negatives, these results suggest that frozen sections are likely to be of limited clinical utility due to lack of sensitivity and specificity, and risk for delayed diagnosis and treatment. […] Histological findings associated with necrotizing soft tissue infection include necrosis of the superficial fascia, neutrophilic infiltration, fibrin thrombi within blood vessels, and the presence of microorganisms.

• #24 Triple diagnostics for early detection of ambivalent necrotizing fasciitis | World Journal of Emergency Surgery | Full Text

  https://wjes.biomedcentral.com/articles/10.1186/s13017-016-0108-z

  Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. […] In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis. […] In these early stages of necrotizing fasciitis, triple diagnostics is suggested to be a useful adjunct in obtaining a diagnosis. […] When necrotizing fasciitis is suspected, an incisional biopsy over the most suspected area is obtained via an longitudinal or incision in the Langer lines.

• #24 Triple diagnostics for early detection of ambivalent necrotizing fasciitis | World Journal of Emergency Surgery | Full Text

  https://wjes.biomedcentral.com/articles/10.1186/s13017-016-0108-z

  In ambivalent cases microbiological findings by urgent Gram staining and histopathological analysis by fresh frozen section of soft tissue should be obtained. […] Especially in cases with only peri-fascial oedema and absence of macroscopic necrosis, a fresh frozen section is of the upmost importance. […] Clinical suspicion can be supported by fresh frozen section and Gram staining during incisional biopsy and might result in more timely identification of this life threatening condition. […] Therefore, triple diagnostics which include a fresh frozen section and Gram staining might be an important adjunct in early ambivalent stages of suspected necrotizing fasciitis.

• #25 Necrotising Fasciitis: Causes, Symptoms, and Treatment

  https://patient.info/doctor/necrotising-fasciitis-pro

  Necrotising fasciitis is difficult to diagnose in its initial stages, as it mimics cellulitis. […] Important early clues are pain, tenderness and systemic illness out of proportion to the localised physical signs. […] A high index of suspicion is necessary and suspected cases should be referred immediately. Prompt surgical debridement is essential. […] The diagnosis is clinical – if there is strong clinical suspicion of NF, exploratory surgery is required regardless of test results. […] A high index of suspicion is needed when a patient presents with cutaneous infection causing swelling, pain and erythema, particularly if the patient also has diabetes, malignancy, alcohol abuse, or chronic liver or kidney disease. […] The presence of bullae or gas on plain X-ray can be diagnostic. Early surgical exploration is advised when there is any uncertainty. […] During surgery, the diagnosis of NF is made on its macroscopic features, which include: grey necrotic tissue, lack of bleeding, thrombosed vessels, 'dishwater pus’, lack of resistance to finger dissection and non-contracting muscle.

• #26 Necrotizing soft tissue infections – UpToDate

  https://www.uptodate.com/contents/necrotizing-soft-tissue-infections

  Necrotizing soft tissue infections (NSTIs) include necrotizing forms of fasciitis, myositis, and cellulitis. These infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. […] The degree of suspicion should be high since the clinical presentation is variable and prompt intervention is critical. […] Surgical management of NSTI is discussed separately. […] NSTI can involve the epidermis, dermis, subcutaneous tissue, fascia, and muscle. Necrotizing infection may be categorized based on microbiology and presence or absence of gas in the tissues.

• #27 Necrotising soft tissue infection: A diagnosis not to be missed

  https://www1.racgp.org.au/ajgp/2021/august/necrotising-soft-tissue-infection

  A woman aged 19 years sustained a minor puncture wound to her left inner thigh while travelling in remote outback Australia. […] A diagnosis of necrotising fasciitis (necrotising soft tissue infection [NSTI]) was made. […] An NSTI is a clinical diagnosis; when suspected, urgent debridement should be performed. […] The triad of NSTI symptoms includes disproportionate local pain, swelling and erythema/skin changes. […] Clinicians should have a high index of suspicion for presentations of subcutaneous infection that seem not quite right. […] As NSTIs progress, the affected region will often swell and may develop a purpuric rash that is due to thrombosis of the perforating blood vessel that supplies that area of the skin. […] Differential diagnoses based on localised signs include cellulitis, superficial abscesses, pyoderma gangrenosum, arterial insufficiency and compartment syndrome.

• #28 Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study | BMC Infectious Diseases | Full Text

  https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-018-3355-7

  Necrotizing soft tissue infection is the most serious of all soft tissue infections. The patients life is dependent on prompt diagnosis and aggressive treatment. Diagnostic delays are related to increased morbidity and mortality, and the risk of under- or missed diagnosis is high due to the rarity of the condition. […] Our study adds to the understanding of the lived experience of NSTI by providing in-depth description of antecedent signs and symptoms precipitating NSTI-diagnosis. We have described diagnostic delay as patient-related, primary care related, or hospital related and recommend that patient and family narratives should be considered when diagnosing NSTI to decrease diagnostic delay. […] Typical signs and symptoms of NSTI are first of all pain, with other responses including localized edema, erythema, fever, hypotension, perspiration, skin necrosis and crepitus. In the early stages, the risk of under-diagnosis is high since the condition is rare. For example, one study demonstrated that only 14% of patients with NSTI were properly diagnosed on admission. Delays in diagnosis increase the rates of morbidity and mortality.

Zobacz więcej