Symptoms include red or purple or black skin, swelling, severe pain, fever, and vomiting.<!-- Quote = Imaging is very useful to confirm the diagnosis -->

<!-- Treatment -->

Necrotizing fasciitis is treated with surgery to remove the infected tissue, and antibiotics. Manifestations include:

  • Redness and swelling
  • Induration (hardening of the skin and soft tissue)
  • Excessive pain
  • Systemic symptoms, including high fever > 102&nbsp;°F/39&nbsp;°C, fatigue, muscle pains

Later signs more suggestive of necrotizing changes (but only present in less than half of cases) are:

  • Bullae (blisters)
  • Crepitus (palpable gas in tissues)
  • Reduced or absent sensation over the skin of the affected area

NSAIDs may increase the rates of necrotizing infections by impairing the body's immune response. NSAIDs inhibit the production of prostaglandins responsible for fever, inflammation, and pain. In theory, it also prevents white blood cells from migrating to infected areas, thus increasing the risk of soft-tissue infections. For infection of the perineum and genitals (Fournier gangrene), urinary tract infection, renal stones, and Bartholin gland abscess may also be implicated. This involves Streptococcus pyogenes, alone or in combination with staphylococcal infections. Methicillin-resistant Staphylococcus aureus (MRSA) is involved in up to a third of Type II infections. One in three patients with a V. vulnificus infection develop necrotizing fasciitis.

Diagnosis

thumb|[[Micrograph of necrotizing fasciitis, showing necrosis (center of image) of the dense connective tissue, i.e., fascia, interposed between fat lobules (top-right and bottom-left of image), H&E stain]]

Early diagnosis is difficult, as the disease often first appears like a simple superficial skin infection. The gold standard for diagnosis is a surgical exploration and subsequent tissue biopsy. When in doubt, a 2-cm incision can be made into the affected tissue under local anesthesia. If a finger easily separates the tissue along the fascia, then the finger test is positive. This confirms the diagnosis, and an extensive debridement should be performed. CT scan may show fascial thickening, edema, or abscess formation.]]

thumb|Necrotizing fasciitis with soft tissue gas seen on (b) plain radiography and (c) ultrasound

Point-of-care ultrasound (POCUS) may be useful in the diagnosis of NF when MRI and CT are unavailable. It can also help rule out diagnoses that mimic earlier stages of NF, including deep vein thrombosis (DVT), superficial abscesses, and venous stasis. Patients with a LRINEC score ≥6 may have a higher rate of both death and amputation as well. The scoring criteria are:

{| class="wikitable"

|+LRINEC Scoring System

!Lab value

!Criteria

!Points*

|-

|CRP

|≥ 15 mg/dL (150 mg/L)

| +4

|-

| rowspan="2" |WBC count (×10<sup>3</sup>)

|15 - 25/mm<sup>3</sup>

| +1

|-

|> 25/mm<sup>3</sup>

| +2

|-

| rowspan="2" |Hemoglobin

|11 - 13.5 g/dL

| +1

|-

|< 11 g/dL

| +2

|-

|Sodium

|< 135 mEq/L

| +2

|-

|Creatinine

|> 1.6&nbsp;mg/dL (141 μmol/L)

| +2

|-

|Glucose

|> 180&nbsp;mg/dL (10&nbsp;mmol/L)

| +1

|-

| colspan="3" |*If the lab value does not meet the listed criteria, it is assigned 0 points.

|}

However, this scoring system is yet to be validated. This involves cutting away the skin overlying all diseased areas at the cost of increased scar formation and potential decreased quality of life post-operatively. Often, a combination of clindamycin, daptomycin, IV vancomycin, and gentamicin is used. However, studies have failed to find any effect on patient mortality. Later, "hospital gangrene" became more commonly used. In 1871, Confederate States Army surgeon Joseph Jones reported 2,642 cases of hospital gangrene with a mortality rate of 46%.

In 1883, Dr Jean-Alfred Fournier described necrotizing infections of the perineum and scrotum, now named after him as Fournier gangrene. The term "necrotizing fasciitis" was coined by Dr. Bob Wilson in 1952. Since then, its definition has broadened to include infections of fascia and soft tissue.

It is sometimes confused for eripheral symmetrical gangrene and acute rhabdomyolysis, and all three are sometimes incorrectly referred to as "flesh-eating virus".

Society and culture

Notable cases

  • 1994: Lucien Bouchard, future premier of Québec, Canada, who was infected while leader of the federal official opposition Bloc Québécois party, lost a leg to the illness.
  • 1994: A cluster of cases occurred in Gloucestershire, in the west of England. Of five confirmed and one probable infection, two died. The cases were believed to be connected. The first two had acquired the Streptococcus pyogenes bacteria during surgery; the remaining four were community-acquired. The cases generated much newspaper coverage, with lurid headlines such as "Flesh Eating Bug Ate My Face".
  • 1997: Jeff Moorad, former agent and partial owner of the San Diego Padres and Arizona Diamondbacks, contracted the disease. He had seven surgeries in a little more than a week and later fully recovered.
  • 2004: Don Rickles, American stand-up comedian, actor, and author, known especially for his insult comedy, contracted the disease in his left leg. He had six operations and later recovered. The condition confined him in his later years to performing comedy from a chair.
  • 2004: Eric Allin Cornell, winner of the 2001 Nobel Prize in Physics, lost his left arm and shoulder to the disease.
  • 2005: Alexandru Marin, an experimental particle physicist, professor at MIT, Boston University, and Harvard University, and researcher at CERN and JINR, died from the disease.
  • 2006: Alan Coren, British writer and satirist, announced in his Christmas column for The Times that his long absence as a columnist had been caused by his contracting the disease while on holiday in France.
  • 2009: R. W. Johnson, British journalist and historian, contracted the disease in March after injuring his foot while swimming. His leg was amputated above the knee.
  • 2011: Jeff Hanneman, guitarist for the thrash metal band Slayer, contracted the disease. He died of liver failure two years later, on May 2, 2013, and it was speculated that his infection was the cause of death. However, on May 9, 2013, the official cause of death was announced as alcohol-related cirrhosis. Hanneman and his family had apparently been unaware of the extent of the condition until shortly before his death.
  • 2011: Peter Watts, Canadian science fiction author, contracted the disease. On his blog, Watts reported, "I'm told I was a few hours away from being dead&nbsp;... If there was ever a disease fit for a science-fiction writer, flesh-eating disease has got to be it. This&nbsp;... spread across my leg as fast as a Star Trek space disease in time-lapse."
  • 2013: British actress Georgie Henley revealed in 2022 that she had contracted the disease several weeks after starting at Cambridge University and that it had almost claimed her life.
  • 2014: Daniel Gildenlöw, Swedish singer and songwriter for the band Pain of Salvation, spent several months in a hospital after being diagnosed with necrotizing fasciitis on his back in early 2014. After recovering, he wrote the album In the Passing Light of Day, a concept album about his experience during the hospitalization.
  • 2014: Ricky Bartlett, SAG-AFTRA actor & S.O.V.A.S. voiceover artist, lost both legs to 'NF'. He contracted the disease during a trip to Wyoming and South Dakota.
  • 2015: Edgar Savisaar, Estonian politician, had his right leg amputated. He got the disease during a trip to Thailand.
  • 2018: Alex Smith, an American football quarterback for the Washington Football Team of the National Football League (NFL), contracted the disease after being injured during a game. He suffered an open compound fracture in his lower leg, which became infected. Smith narrowly avoided amputation and eventually returned to playing professional football in October 2020. Smith's injury and recovery is the subject of the ESPN documentary E60 Presents: Project 11.
  • 2019: OG Maco contracted NF after an untreated rash.
  • 2021: Irish actor Barry Keoghan revealed in 2024 that he contracted NF shortly before filming The Banshees of Inisherin and nearly had his arm amputated.

See also

  • Capnocytophaga canimorsus
  • Gangrene
  • Mucormycosis, a rare fungal infection that can resemble necrotizing fasciitis (See type IV NF listing above)
  • Noma (disease)
  • Toxic shock syndrome
  • Vibrio vulnificus

Footnotes

References

  • LRINEC Score Online
  • Necrotizing Fasciitis Foundation
  • The Lee Spark Necrotizing Fasciitis Foundation