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Necrotizing Fasciitis Clinical Presentation

  • Author: Richard F Edlich, MD, PhD, FACS, FACEP; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Aug 09, 2016
 

History

Diagnosis of necrotizing fasciitis can be difficult and requires a high degree of suspicion. In many cases of necrotizing fasciitis, antecedent trauma or surgery can be identified. Surprisingly, the initial lesion is often trivial, such as an insect bite, minor abrasion, boil, or injection site. Idiopathic cases are not uncommon, however.

Olafsson et al indicate that the hallmark symptom of necrotizing fasciitis is intense pain and tenderness over the involved skin and underlying muscle.[47] The intensity of the pain often causes suspicion of a torn or ruptured muscle. This severe pain is frequently present before the patient develops fever, malaise, and myalgias.

In some cases, the symptoms may begin at a site distant from the initial traumatic insult. Pain may be out of proportion to physical findings. Over the next several hours to days, the local pain progresses to anesthesia.

Other indicative findings include edema extending beyond the area of erythema, skin vesicles, and crepitus. McHenry et al and others have noted that the subcutaneous tissue demonstrates a wooden, hardened feel in cases of necrotizing fasciitis.[28] The fascial planes and muscle groups cannot be detected by palpation.

A history of comorbid factors, including diabetes mellitus, should be sought in all cases of suspected necrotizing fasciitis. A retrospective, multicenter study by van Stigt et al of 58 patients with necrotizing fasciitis found cardiovascular disease to be the most common comorbidity (39.7% of patients).[39]

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Physical Examination

Physical findings may not be commensurate with the degree of patient discomfort. Early in the disease course, the patient may look deceptively well; unfortunately, this may interfere with early detection, which is key to a favorable outcome. Soon, however, the patient will usually begin to appear moderately to severely toxic.

Typically, the infection begins with an area of erythema that quickly spreads over a course of hours to days. The redness quickly spreads, and its margins move out into normal skin without being raised or sharply demarcated. As the infection progresses, the skin near the site of insult develops a dusky or purplish discoloration. Multiple identical patches expand to produce a large area of gangrenous skin, as the erythema continues to spread.

Iwata et al reported that 2 of 3 patients who lacked inflammatory signs such as redness and heat experienced fulminant progression of necrotizing fasciitis and death.[48]

The initial necrosis appears as a massive undermining of the skin and subcutaneous layer. If the skin is open, gloved fingers can pass easily between the 2 layers and may reveal yellowish-green necrotic fascia. If the skin is unbroken, a scalpel incision will reveal it.

The normal skin and subcutaneous tissue become loosened from the rapidly spreading deeper necrotic fascia that is a great distance from the initiating wound. Fascial necrosis is typically more advanced than the appearance suggests.

Anesthesia in the involved region may be detected, and it usually is caused by thrombosis of the subcutaneous blood vessels, leading to necrosis of nerve fibers.

Without treatment, secondary involvement of deeper muscle layers may occur, resulting in myositis or myonecrosis. Normally, however, the muscular layer remains healthy red with normal bleeding muscle under the yellowish-green fascia.

Usually, the most important signs are tissue necrosis, putrid discharge, bullae, severe pain, gas production, rapid burrowing through fascial planes, and lack of classical tissue inflammatory signs.

Usually, some degree of intravascular volume loss is detectable on clinical examination. Other general signs, such as fever and severe systemic reactions, may be present.

Local crepitation can occur in more than one half of patients. This is an infrequent finding, specific but not sensitive, particularly in cases of nonclostridial necrotizing fasciitis.

Fournier gangrene in males begins with local tenderness, itching, edema, and erythema of the scrotal skin. This progresses to necrosis of the scrotal fascia. The scrotum enlarges to several times its normal diameter. If the process continues beyond the penile-scrotal region to the abdomen or the upper legs, the normal picture of necrotizing fasciitis can be seen.

In males, the scrotal subcutaneous layer is so thin that most patients present after the skin is already exhibiting signs of necrosis. In 2-7 days, the skin becomes necrotic, and a characteristic black spot can be seen. Early on, this infection may resemble acute orchitis, epididymitis, torsion, or even a strangulated hernia.

In women, Fournier gangrene acts more like necrotizing fasciitis because of the thicker subcutaneous layers involving the labia majora and the perineum.

Complications

Complications may include the following:

  • Renal failure
  • Septic shock with cardiovascular collapse
  • Scarring with cosmetic deformity
  • Limb loss
  • Sepsis
  • Toxic shock syndrome

Metastatic cutaneous plaques may occur in necrotizing fasciitis. Septicemia is typical and leads to severe systemic toxicity and rapid death unless appropriately treated.

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Contributor Information and Disclosures
Author

Richard F Edlich, MD, PhD, FACS, FACEP FASPS, Distinguished Professor Emeritus of Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health Care System

Richard F Edlich, MD, PhD, FACS, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Burn Association, American College of Emergency Physicians, American College of Surgeons, American Society of Plastic Surgeons, American Spinal Injury Association, Plastic Surgery Research Council, Society of University Surgeons, Surgical Infection Society, American Surgical Association, American Trauma Society

Disclosure: Nothing to disclose.

Coauthor(s)

William B Long, III, MD, FACS President, Trauma Specialists, LLP; President, Pacific Surgical, PC; Trauma Medical Director, Legacy Emanuel Trauma Center, Legacy Emanuel Hospital

William B Long, III, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Thoracic Society, American Trauma Society, Society of Thoracic Surgeons, Pacific Coast Surgical Association, Western Trauma Association, North Pacific Surgical Association

Disclosure: Nothing to disclose.

K Dean Gubler, DO, MPH Assistant Clinical Professor, Department of Surgery, Oregon Health Sciences University; Consulting Surgeon, Department of Surgery, Pacific Surgical, PC, Mount Hood Medical Center, Good Samaritan Hospital, Legacy Emanuel Hospital Trauma Program

K Dean Gubler, DO, MPH is a member of the following medical societies: American College of Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Joseph U Becker, MD Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Shahin Javaheri, MD Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The authors wish to thank Research Assistants Julie Garrison and Jennifer Nearants for their assistance with this Medscape Reference article.

References
  1. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014. 1:36. [Medline]. [Full Text].

  2. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug. 51 (8):344-62. [Medline]. [Full Text].

  3. Federman DG, Kravetz JD, Kirsner RS. Necrotizing fasciitis and cardiac catheterization. Cutis. 2004 Jan. 73(1):49-52. [Medline].

  4. Chan HT, Low J, Wilson L, Harris OC, Cheng AC, Athan E. Case cluster of necrotizing fasciitis and cellulitis associated with vein sclerotherapy. Emerg Infect Dis. 2008 Jan. 14(1):180-1. [Medline]. [Full Text].

  5. Bharathan R, Hanson M. Diagnostic laparoscopy complicated by group A streptococcal necrotizing fasciitis. J Minim Invasive Gynecol. 2010 Jan-Feb. 17(1):121-3. [Medline].

  6. Akcay EK, Cagil N, Yulek F, et al. Necrotizing fasciitis of eyelid secondary to parotitis. Eur J Ophthalmol. 2008 Jan-Feb. 18(1):128-30. [Medline].

  7. Anwar UM, Ahmad M, Sharpe DT. Necrotizing fasciitis after liposculpture. Aesthetic Plast Surg. 2004 Nov-Dec. 28(6):426-7. [Medline].

  8. Bisno AL, Cockerill FR 3rd, Bermudez CT. The initial outpatient-physician encounter in group A streptococcal necrotizing fasciitis. Clin Infect Dis. 2000 Aug. 31(2):607-8. [Medline].

  9. Gibbon KL, Bewley AP. Acquired streptococcal necrotizing fasciitis following excision of malignant melanoma. Br J Dermatol. 1999 Oct. 141(4):717-9. [Medline].

  10. Sewell GS, Hsu VP, Jones SR. Zoster gangrenosum: necrotizing fasciitis as a complication of herpes zoster. Am J Med. 2000 Apr 15. 108(6):520-1. [Medline].

  11. Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, Hung-An C. Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg. 2000 Dec. 58(12):1347-52; discussion 1353. [Medline].

  12. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol. 2006 Apr. 20(4):365-9. [Medline].

  13. Quirk WF Jr, Sternbach G. Joseph Jones: infection with flesh eating bacteria. J Emerg Med. 1996 Nov-Dec. 14(6):747-53. [Medline].

  14. Fournier A. Gangrene foudroyante de la verge. Semaine Med. 1883. 3:345.

  15. Meleney FL. Hemolytic streptococcus gangrene. Arch Surg. 1924. 9:317-364.

  16. Wilson B. Necrotizing fasciitis. Am Surg. 1952 Apr. 18(4):416-31. [Medline].

  17. Smith AJ, Daniels T, Bohnen JM. Soft tissue infections and the diabetic foot. Am J Surg. 1996. 7S:172(Suppl.6A).

  18. Lewis RT. Soft tissue infections. World J Surg. 1998 Feb. 22(2):146-51. [Medline].

  19. Edlich RF, Cross CL, Dahlstrom JJ, Long WB 3rd. Modern concepts of the diagnosis and treatment of necrotizing fasciitis. J Emerg Med. 2010 Aug. 39(2):261-5. [Medline].

  20. Rausch J, Foca M. Necrotizing fasciitis in a pediatric patient caused by lancefield group g streptococcus: case report and brief review of the literature. Case Rep Med. 2011.

  21. Vayvada H, Demirdover C, Menderes A, Karaca C. [Necrotizing fasciitis: diagnosis, treatment and review of the literature]. Ulus Travma Acil Cerrahi Derg. 2012 Nov. 18(6):507-13. [Medline].

  22. Swain RA, Hatcher JC, Azadian BS, et al. A five-year review of necrotising fasciitis in a tertiary referral unit. Ann R Coll Surg Engl. 2013 Jan. 95(1):57-60. [Medline]. [Full Text].

  23. Bratdorff D, Roemmele J. National Necrotizing Fasciitis Foundation (NNFF) 1997-2009. Available at http://www.nnff.org. Accessed: April 17, 2013.

  24. Bahebeck J, Sobgui E, Loic F, Nonga BN, Mbanya JC, Sosso M. Limb-threatening and life-threatening diabetic extremities: clinical patterns and outcomes in 56 patients. J Foot Ankle Surg. 2010 Jan-Feb. 49(1):43-6. [Medline].

  25. Stone DR, Gorbach SL. Necrotizing fasciitis. The changing spectrum. Dermatol Clin. 1997 Apr. 15(2):213-20. [Medline].

  26. Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: a preventable disaster. Surgery. 1982 Oct. 92(4):765-70. [Medline].

  27. Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001 Apr 1. 107(4):1025-35. [Medline].

  28. McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg. 1995 May. 221(5):558-63; discussion 563-5. [Medline]. [Full Text].

  29. Morgan WR, Caldwell MD, Brady JM, Stemper ME, Reed KD, Shukla SK. Necrotizing fasciitis due to a methicillin-sensitive Staphylococcus aureus isolate harboring an enterotoxin gene cluster. J Clin Microbiol. 2007 Feb. 45(2):668-71. [Medline]. [Full Text].

  30. Cheng NC, Chang SC, Kuo YS, Wang JL, Tang YB. Necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus resulting in death. A report of three cases. J Bone Joint Surg Am. 2006 May. 88(5):1107-10. [Medline].

  31. Olsen RJ, Sitkiewicz I, Ayeras AA, et al. Decreased necrotizing fasciitis capacity caused by a single nucleotide mutation that alters a multiple gene virulence axis. Proc Natl Acad Sci U S A. 2010 Jan 12. 107(2):888-93. [Medline]. [Full Text].

  32. Lehman D, Tseng CW, Eells S, et al. Staphylococcus aureus Panton-Valentine leukocidin targets muscle tissues in a child with myositis and necrotizing fasciitis. Clin Infect Dis. 2010 Jan 1. 50(1):69-72. [Medline].

  33. Kim HJ, Kim DH, Ko DH. Coagulase-positive staphylococcal necrotizing fasciitis subsequent to shoulder sprain in a healthy woman. Clin Orthop Surg. 2010 Dec. 2(4):256-9. [Medline]. [Full Text].

  34. Hung TH, Tsai CC, Tsai CC, et al. Liver cirrhosis as a real risk factor for necrotising fasciitis: a three-year population-based follow-up study. Singapore Med J. 2014 Jul. 55(7):378-82. [Medline].

  35. Tang WM, Ho PL, Yau WP, Wong JW, Yip DK. Report of 2 fatal cases of adult necrotizing fasciitis and toxic shock syndrome caused by Streptococcus agalactiae. Clin Infect Dis. 2000 Oct. 31(4):E15-7. [Medline].

  36. Sendi P, Johansson L, Dahesh S, et al. Bacterial phenotype variants in group B streptococcal toxic shock syndrome. Emerg Infect Dis. 2009 Feb. 15(2):223-32. [Medline]. [Full Text].

  37. Parcell BJ, Wilmshurst AD, France AJ, Motta L, Brooks T, Olver WJ. Injection anthrax causing compartment syndrome and necrotising fasciitis. J Clin Pathol. 2011 Jan. 64(1):95-6. [Medline].

  38. Tang WM, Fung KK, Cheng VC, Lucke L. Rapidly progressive necrotising fasciitis following a stonefish sting: a report of two cases. J Orthop Surg (Hong Kong). 2006 Apr. 14(1):67-70. [Medline].

  39. van Stigt SF, de Vries J, Bijker JB, et al. Review of 58 patients with necrotizing fasciitis in the Netherlands. World J Emerg Surg. 2016. 11:21. [Medline]. [Full Text].

  40. Simsek Celik A, Erdem H, Guzey D, et al. Fournier's gangrene: series of twenty patients. Eur Surg Res. 2011. 46(2):82-6. [Medline].

  41. Hsiao CT, Weng HH, Yuan YD, Chen CT, Chen IC. Predictors of mortality in patients with necrotizing fasciitis. Am J Emerg Med. 2008 Feb. 26(2):170-5. [Medline].

  42. Lee CY, Kuo LT, Peng KT, Hsu WH, Huang TW, Chou YC. Prognostic factors and monomicrobial necrotizing fasciitis: gram-positive versus gram-negative pathogens. BMC Infect Dis. 2011 Jan 5. 11:5. [Medline]. [Full Text].

  43. Cheng NC, Su YM, Kuo YS, Tai HC, Tang YB. Factors affecting the mortality of necrotizing fasciitis involving the upper extremities. Surg Today. 2008. 38(12):1108-13. [Medline].

  44. Mao JC, Carron MA, Fountain KR, et al. Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome. Am J Otolaryngol. 2009 Jan-Feb. 30(1):17-23. [Medline].

  45. Friederichs J, Torka S, Militz M, Buhren V, Hungerer S. Necrotizing soft tissue infections after injection therapy: higher mortality and worse outcome compared to other entry mechanisms. J Infect. 2015 Jun 3. [Medline].

  46. Light TD, Choi KC, Thomsen TA, et al. Long-term outcomes of patients with necrotizing fasciitis. J Burn Care Res. 2010 Jan-Feb. 31(1):93-9. [Medline].

  47. Olafsson EJ, Zeni T, Wilkes DS. A 46-year-old man with excruciating shoulder pain. Chest. 2005 Mar. 127(3):1039-44. [Medline].

  48. Iwata Y, Sato S, Murase Y, et al. Five cases of necrotizing fasciitis: lack of skin inflammatory signs as a clinical clue for the fulminant type. J Dermatol. 2008 Nov. 35(11):719-25. [Medline].

  49. Simonart T, Simonart JM, Derdelinckx I, et al. Value of standard laboratory tests for the early recognition of group A beta-hemolytic streptococcal necrotizing fasciitis. Clin Infect Dis. 2001 Jan. 32(1):E9-12. [Medline].

  50. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15. 59(2):147-59. [Medline]. [Full Text].

  51. Drake DB, Woods JA, Bill TJ, et al. Magnetic resonance imaging in the early diagnosis of group A beta streptococcal necrotizing fasciitis: a case report. J Emerg Med. 1998 May-Jun. 16(3):403-7. [Medline].

  52. Fugitt JB, Puckett ML, Quigley MM, Kerr SM. Necrotizing fasciitis. Radiographics. 2004 Sep-Oct. 24(5):1472-6. [Medline].

  53. Chao HC, Kong MS, Lin TY. Diagnosis of necrotizing fasciitis in children. J Ultrasound Med. 1999 Apr. 18(4):277-81. [Medline].

  54. Sharif HS, Clark DC, Aabed MY, Aideyan OA, Haddad MC, Mattsson TA. MR imaging of thoracic and abdominal wall infections: comparison with other imaging procedures. AJR Am J Roentgenol. 1990 May. 154(5):989-95. [Medline].

  55. Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D. Cervical Necrotizing Fasciitis-The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter. J Oral Maxillofac Surg. 2015 Jun 5. [Medline].

  56. Namias N, Martin L, Matos L, Sleeman D, Snowdon B. Symposium: necrotizing fasciitis. Contemp Surg. 1996. 49:167-78.

  57. Lille ST, Sato TT, Engrav LH, Foy H, Jurkovich GJ. Necrotizing soft tissue infections: Obstacles in diagnosis. J Am Coll Surg. 1995. 182(1):7-11.

  58. Ramirez-Schrempp D, Dorfman DH, Baker WE, Liteplo AS. Ultrasound soft-tissue applications in the pediatric emergency department: to drain or not to drain?. Pediatr Emerg Care. 2009 Jan. 25(1):44-8. [Medline].

  59. Wronski M, Slodkowski M, Cebulski W, Karkocha D, Krasnodebski IW. Necrotizing fasciitis: early sonographic diagnosis. J Clin Ultrasound. 2011 May. 39(4):236-9. [Medline].

  60. Parenti GC, Marri C, Calandra G, Morisi C, Zabberoni W. [Necrotizing fasciitis of soft tissues: role of diagnostic imaging and review of the literature]. Radiol Med. 2000 May. 99(5):334-9. [Medline].

  61. Beltran J, McGhee RB, Shaffer PB, et al. Experimental infections of the musculoskeletal system: evaluation with MR imaging and Tc-99m MDP and Ga-67 scintigraphy. Radiology. 1988 Apr. 167(1):167-72. [Medline].

  62. Tang JS, Gold RH, Bassett LW, Seeger LL. Musculoskeletal infection of the extremities: evaluation with MR imaging. Radiology. 1988 Jan. 166(1 Pt 1):205-9. [Medline].

  63. Rahmouni A, Chosidow O, Mathieu D, et al. MR imaging in acute infectious cellulitis. Radiology. 1994 Aug. 192(2):493-6. [Medline].

  64. Craig JG. Infection: ultrasound-guided procedures. Radiol Clin North Am. 1999 Jul. 37(4):669-78. [Medline].

  65. Arslan A, Pierre-Jerome C, Borthne A. Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis. Eur J Radiol. 2000 Dec. 36(3):139-43. [Medline].

  66. Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002 Feb. 68(2):109-16. [Medline].

  67. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med. 1984 Jun 28. 310(26):1689-93. [Medline].

  68. Bakleh M, Wold LE, Mandrekar JN, Harmsen WS, Dimashkieh HH, Baddour LM. Correlation of histopathologic findings with clinical outcome in necrotizing fasciitis. Clin Infect Dis. 2005 Feb 1. 40(3):410-4. [Medline].

  69. Uman SJ, Kunin CM. Needle aspiration in the diagnosis of soft tissue infections. Arch Intern Med. 1975 Jul. 135(7):959-61. [Medline].

  70. Francis J, Warren RE. Streptococcus pyogenes bacteraemia in Cambridge--a review of 67 episodes. Q J Med. 1988 Aug. 68(256):603-13. [Medline].

  71. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug. 51 (8):344-62. [Medline]. [Full Text].

  72. Crew JR, Thibodeaux KT, Speyrer MS, et al. Flow-through Instillation of Hypochlorous Acid in the Treatment of Necrotizing Fasciitis. Wounds. 2016 Feb. 28 (2):40-7. [Medline].

  73. Chelsom J, Halstensen A, Haga T, Hoiby EA. Necrotising fasciitis due to group A streptococci in western Norway: incidence and clinical features. Lancet. 1994 Oct 22. 344(8930):1111-5. [Medline].

  74. Edlich RF, Wind TC, Heather CL, Thacker JG. Reliability and performance of innovative surgical double-glove hole puncture indication systems. J Long Term Eff Med Implants. 2003. 13(2):69-83. [Medline].

  75. Wang KC, Shih CH. Necrotizing fasciitis of the extremities. J Trauma. 1992 Feb. 32(2):179-82. [Medline].

  76. Kaufman JL. Clinical problem-solving: necrotizing fasciitis. N Engl J Med. 1994 Jul 28. 331(4):279; author reply 280. [Medline].

  77. Adams EM, Gudmundsson S, Yocum DE, Haselby RC, Craig WA, Sundstrom WR. Streptococcal myositis. Arch Intern Med. 1985 Jun. 145(6):1020-3. [Medline].

  78. Edlich RF, Wind TC, Heather CL, Thacker JG. Reliability and performance of innovative surgical double-glove hole puncture indication systems. J Long Term Eff Med Implants. 2003. 13(2):69-83. [Medline].

  79. Edlich RF, Woodard CR, Pine SA, Lin KY. Hazards of powder on surgical and examination gloves: a collective review. J Long Term Eff Med Implants. 2001. 11(1-2):15-27. [Medline].

  80. Gear AJ, Hellewell TB, Wright HR, et al. A new silver sulfadiazine water soluble gel. Burns. 1997 Aug. 23(5):387-91. [Medline].

  81. Frame JD, Still J, Lakhel-LeCoadou A, et al. Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg. 2004 Apr 15. 113(5):1330-8. [Medline].

  82. Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995 Jun. 21(4):243-8. [Medline].

  83. Stevens DL, Yan S, Bryant AE. Penicillin-binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: an explanation for the inoculum effect. J Infect Dis. 1993 Jun. 167(6):1401-5. [Medline].

  84. Yan S, Bohach GA, Stevens DL. Persistent acylation of high-molecular-weight penicillin-binding proteins by penicillin induces the postantibiotic effect in Streptococcus pyogenes. J Infect Dis. 1994 Sep. 170(3):609-14. [Medline].

  85. Gemmell CG, Peterson PK, Schmeling D, et al. Potentiation of opsonization and phagocytosis of Streptococcus pyogenes following growth in the presence of clindamycin. J Clin Invest. 1981 May. 67(5):1249-56. [Medline]. [Full Text].

  86. Stevens DL, Bryant AE, Yan S. Invasive group A streptococcal infection: New concepts in antibiotic treatment. Int J Antimicrob Agent. 1994. 4:297-301.

  87. Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis. 1995 Jun. 20 Suppl 2:S154-7. [Medline].

  88. Edlich RF, Winters KL, Woodard CR, Britt LD, Long WB 3rd. Massive soft tissue infections: necrotizing fasciitis and purpura fulminans. J Long Term Eff Med Implants. 2005. 15(1):57-65. [Medline].

  89. Lota AS, Altaf F, Shetty R, Courtney S, McKenna P, Iyer S. A case of necrotising fasciitis caused by Pseudomonas aeruginosa. J Bone Joint Surg Br. 2010 Feb. 92(2):284-5. [Medline].

  90. Barry W, Hudgins L, Donta ST, Pesanti EL. Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA. 1992 Jun 24. 267(24):3315-6. [Medline].

  91. Yong JM. Necrotising fasciitis. Lancet. 1994 Jun 4. 343(8910):1427. [Medline].

  92. 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 Aug 1. 37(3):333-40. [Medline].

  93. 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(3):166-72. [Medline].

  94. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb. 208(2):279-88. [Medline].

  95. Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol Suppl. 2000. 7-36. [Medline].

  96. Korhonen K, Kuttila K, Niinikoski J. Tissue gas tensions in patients with necrotising fasciitis and healthy controls during treatment with hyperbaric oxygen: a clinical study. Eur J Surg. 2000 Jul. 166(7):530-4. [Medline].

  97. Krenk L, Nielsen HU, Christensen ME. Necrotizing fasciitis in the head and neck region: an analysis of standard treatment effectiveness. Eur Arch Otorhinolaryngol. 2007 Aug. 264(8):917-22. [Medline].

  98. Sugihara A, Watanabe H, Oohashi M, et al. The effect of hyperbaric oxygen therapy on the bout of treatment for soft tissue infections. J Infect. 2004 May. 48(4):330-3. [Medline].

  99. Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest. 1996 Jul. 110(1):219-29. [Medline].

  100. Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery. 1990 Nov. 108(5):847-50. [Medline].

  101. Brown DR, Davis NL, Lepawsky M, Cunningham J, Kortbeek J. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg. 1994 May. 167(5):485-9. [Medline].

  102. Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. 2015 Jan 15. 1:CD007937. [Medline].

  103. Monestersky JH, Myers RA. Hyperbaric oxygen treatment of necrotizing fasciitis. Am J Surg. 1995 Jan. 169(1):187-8. [Medline].

 
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Left upper extremity shows necrotizing fasciitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.
Necrotizing fasciitis at a possible site of insulin injection in the left upper part of the thigh in a 50-year-old obese woman with diabetes.
Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis.
Sixty-year-old woman who had undergone postvaginal hysterectomy and repair of a rectal prolapse has a massive perineal ulceration with foul-smelling discharge. Cultures revealed Escherichia coli and Bacteroides fragilis. The diagnosis was perineal gangrene.
Necrotizing fascitis of entire thoracolumbar posterior area in 20-year-old patient with chronic myelogenous leukemia and neutropenia (WBC count, 680/uL). Cultures revealed gram-negative Pseudomonas species and Bacteroides fragilis.
 
 
 
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