Dr. Shirish SilwalHouse OfficerDept. of General Surgery & UrologyB & B Hospital Pvt. Ltd.
Case 1Mr BKB, 54 years presented in the Emergency on 2070/3/31.Swelling and Pain in left lower leg .Watery discharge with skin blisters.H/O small wound due to insect bite a month ago.H/O Fever on and off for 3 days, not associated with chills or rigor.Primary management done in other center took antibiotic for 1 day and Hot water bath taken.K/C/O HTN, NO PREVIOUS H/O DIABETES.
GENERAL EXAMINATIONGeneral condition- Fair JALCCOD - Nil , Vitals T 97 F, BP 110/80 mm of Hg
SYSTEMIC EXAMINATIONPer Abdominal FindingsSoft & non tender, bowel sound (+),No organomegaly
Respiratory system FindingsB/L vesicular breathe sound, No added sound
Other systemic findings NAD
LOCAL EXAMINATION OF LEFT LEG
InspectionDiscoloration of skin (+)Redness and swelling up to knee region Bulla with serous discharge present at the dorsum of foot and ankleMovement of distal joint (+)
PalpationTenderness presentIncreased local temperatureNeurovascular system not assessable due to edema
INVESTIGATION CBCWBC- 8400/CummNeutrophils - 85%Lymphocyte- 15%Platelets - 153000RFTUrea- 75mg/dlCreatinine- 1mg/dlNa+ 125mmol/L,K+ 2.5mmol/LBlood sugar- 230 mg/dlLIVER FUNCTION TEST Billirubin Total-1.0 mg/dlBillirubin Direct- 1.0 mg/dlSGPT/ALT- 39 IU/LSGOT/AST- 50 IU/LAlkalinePhosphatase- 128 IU/LURINE RME - NADVENOUS DOPPLER - NORMAL
CULTUREWound/pus culture: No growth (2070/3/31)No growth (2070/4/16)Heavy growth of pseudomonas sp.(2070/4/22) Pseudomonas aeroginosa(2070/4/24) national reference lab.No growth after 48 hours(2070/4/28)
(2070/4/5) After Fasciotomy
(2070/4/11)- Continuous Debridement and hot water bath
(2070/5/2)- After Skin Grafting
Treatment Diagnosed as uncontrolled diabetics with Cellulitis with Necrotizing fasciitis Insulin on sliding scaleIV antibiotics GentamycinMetronidazolePenicillinClindamycinBlood transfusion VIII bag
Surgery Fasciotomy done on (2070/4/2)Daily debridement, dressing and foot bath.Debridement with povidone iodine, washing powder, Neosporin powder, placentex.Skin grafting on (2070/4/31)
Requirement of survivalBed must be well vascularized.The contact between graft and recipient must be fully immobile.Low bacterial count at the site.Cause of failureSystemic FactorsMalnutritionSepsisMedical Conditions (Diabetes)MedicationsSteroidsAntineoplastic agentsVasoconstrictors (e.g. nicotine)
Post-operative statusPatient is stable and afebrile.Skin grafting 90% accepted.No foul smell from wound.Diabetes and Blood Pressure under control.
Patients flexor tendons were excised. So range of movement is restricted.20
Past history Hippocrates in the 5th century BC noted known as malignant ulcer, gangrenous ulcer , putrid ulcer, and hospital gangrene in the 18th centuryIn 1871 after the Civil War was called hospital gangrene by a war surgeonIn 1924 called hemolytic streptococcal gangreneIn 1952 called necrotizing fasciitis
DefinitionCharacterized by fulminant destruction of tissue, systemic signs of toxicity, and a high mortality rate.Pathologic features include extensive tissue destruction, thrombosis of blood vessels, abundant bacterial spread along fascial planes, and unimpressive infiltration of acute inflammatory cells.
Risk FactorsDrug useDiabetes mellitusObesityImmunosuppressionRenal failure
Types of Necrotizing InfectionNecrotizing cellulitisClostridial cellulitisNonclostridial anaerobic cellulitisMeleneys synergistic gangreneSynergistic necrotizing cellulitis
Necrotizing fasciitisType IType II
Type I Necrotizing FasciitisMixed aerobic and anaerobic infectionBacteria almost always isolatedStaphylococcus aureus, Streptococci, Enterococci, E.coli, Peptostreptococcus species, Prevotella, Porphyromonas, bacteroides fragilis and Clostridium species.More common in diabetics, post op patients, and patients with peripheral vascular disease.
Type I Cervical necrotizing fasciitisLudwigs angina
Fourniers gangreneCaused by penetration of the GI or urethral mucosa by enteric organisms
Type II Necrotizing FasciitisMonomicrobialGroup A StrepORSACan occur in any age group and in healthy patientsRisk factorsH/o blunt trauma or lacerationVaricellaInjection drug usePost operative Post partumBurnsExposure to a case?NSAIDs
Type II Can result from hematogenous translocation from GAS in throatNSAIDs thought to inhibit neutrophil function or mask symptoms and delay diagnosis
Pathophysiology"Flesh-eating bacteria" is a misnomer, as the bacteria do not actually "eat" the tissue. They cause the destruction of skin and muscle by releasing toxins (virulence factors), which include streptococcal pyogenic exotoxins.Streptococcus pyogenes produces an exotoxin known as a superantigen. This toxin is capable of activating T-cells non-specifically, which causes the overproduction of cytokines and severe systemic illness (Toxic shock syndrome).
Unexplained/disproportionate painBlister and bullae formationSigns of systemic toxicity fever tachycardia hypotensionTense edema outside the involved skinCrepitus/subcutaneous gas
Why it is so aggressive?Toxins-host releases cytokines, including interleukin-2, tumor necrosis factor and gamma-interferon. resulting in shock substances cause vascular thrombosis and ischemic gangrenetissue is consumed at 1 inch per hourinoculation from subcutaneous tissuehematogenous spread from distant site found in post op complications of fecal contaminated woundshock & multi system organ failure, ARDS
Risk ScoreSerum CRP >= 150mg/L (4 pt)WBC 15K-25K (1 pt) or > 25K (2 pt)Hb 11-13.5 (1 pt) or 1.6 (2 pt)Glucose >180 (1 pt)
Score >/= 6 should raise suspicion for NF>/= 8 highly predictive of NF
DiagnosisImagingSoft tissue X-rays, CT, MRICan reveal gas in the tissues, but not as good as direct surgical exploration
Role of Doppler these techniques showed changes in subcutaneous adipose tissue , fascia and muscle.CulturesBlood Culture positive in 60% with type II, 20% with type ISurgical wound cultures almost always positive
Nf causing air in soft tissue36
TreatmentEarly and aggressive surgical exploration and debridementRe exploration should be performed with in 24 hrsAntibiotic therapyType I: Ampicillin or Unasyn(Ampicillin + Sulbactam) with clindamycin or metronidazoleIf recent hospitalization, use Zosyn (Piperacillin and Tazobactam Injection)or Timentin (Ticarcillin and Clavulanate) instead of Unasyn.Type II: Penicillin G and clindamycin; vancomycinHemodynamic supportIntravenous immunoglobulin (currently under investigation, but not recommended) well an attempt to reduce hyper proliferation of T cells inhibit production of tumor necrosis factorHyperbaric oxygen therapy
Role of SurgeryNecrotizing fasciitis is a surgical emergency, the patient should be admitted immediately to a surgical intensive care unit in a setting such as a regional burn center or trauma center, where the surgical staff is skilled in performing extensive debridement and reconstructive surgery.
PrognosisAggressive treatment- mortality 30%Delayed treatment- mortality 92%Patient with predisposing factor- mortality 80%Ineffective debridement- mortality 83%Death cause by sepsis and multi organ failurePredictor for mortality WBC >30k,Creatinine>2 Clostridia infection Presence of heart disease during admission
ConclusionNecrotizing fasciities is a aggressive disease.Rapid identification and rapid treatment is essential for recovery from this aggressive disease.Aggressive disease should be treated aggressively. Tit For Tat.