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| Year : 1985 | Volume
: 31
| Issue : 3 | Page : 170-2 |
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Necrotising fasciitis (a report of 5 cases).
SD Deodhar, RG Shirahatti, AA Sareen, MA Bharucha, GG Bhave
Correspondence Address:
S D Deodhar
How to cite this article:
Deodhar S D, Shirahatti R G, Sareen A A, Bharucha M A, Bhave G G. Necrotising fasciitis (a report of 5 cases). J Postgrad Med 1985;31:170-2
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How to cite this URL:
Deodhar S D, Shirahatti R G, Sareen A A, Bharucha M A, Bhave G G. Necrotising fasciitis (a report of 5 cases). J Postgrad Med [serial online] 1985 [cited 2023 Sep 25 ];31:170-2
Available from: https://www.jpgmonline.com/text.asp?1985/31/3/170/5400 |
Full Text
INTRODUCTION
Necrotising fasciitis is an uncommon surgical condition characterised by rapidly spreading necrosis of the skin, subcutaneous tissue and adjoining fascial structures associated with gas formation. Early diagnosis and extensive surgical excision are essential to save the patient's life.
The series reported in the literature have had a maximum of 18-20 cases spread over 10-12 years.[5],[6],[7] We had, under our care at the K.E.M. Hospital, Bombay, a series of five cases over a five month period from February 1984 to June 1984. The sudden crop of patients with this relatively rare condition and the .relentless progress towards death in the majority prompted us to present this paper.
MATERIAL AND METHODS
Five patients with features of necrotising fasciitis were admitted from February 1984 to June 1984. They were studied for the etiology, bacteriology, treatment given and the final outcome.
RESULTS
All the five patients were young, otherwise healthy males, their ages varying from 24 to 40 years.
There was no history of any predisposing trauma in three cases. Case 3 had undergone anal stretching for relief of acute fissure-in-ano, 48 hours prior to the appearance of symptoms. Case 5 had undergone disarticulation of the gangrenous left great toe due to thromboangiitis obliterans. None of our patients was a known drug addict, diabetic or an alcoholic, nor was a history of homosexual practice available.
All the five patients had involvement of the lower limbs, confined to the thigh. In addition, case 3 had involvement of the perineum, scrotum and the anterior abdominal wall, while two patients (Cases 2 and 3) had involvement of the upper limbs. The affected parts were grossly edematous and tender; and patches of skin gangrene were seen in case 3. All were in shock due to septicaemia. One patient (Case 4) was in acute respiratory failure.
After aggressive resuscitation with intravenous fluids and blood transfusions and dopamine, aspiration of tissue fluid in the involved areas was performed and blood was collected for bacteriological studies, While waiting for the reports, patients were put on a combination of broad spectrum antibiotics and metronidazole. Suitable changes in the antibiotic therapy were made on receiving the sensitivity reports. One patient (Case 4) needed ventilatory support for three days. The condition of two patients was bad enough to preclude surgical treatment. In 3 patients, extensive incisions upto the deep fascia were made over the affected parts. The subcutaneous space contained foul smelling serosanguinous fluid, the fat was discoloured, but the deer fascia was not involved. The wounds were lightly packed with acriflavin-hydrogen peroxide combination.
The fluid collected from the lesions in all five cases was cultured aerobically as well as anaerobically. Coagulase positive Staphylococci were isolated in three cases. In one case, E. colt and B. fragilis were grown while in the other, only E. colt was isolated. These organisms were sensitive to gentamicin, ampicillin and chloramphenicol. Blood culture was negative in all five patients. Three patients expired within 48 hours of admission. Post mortem revealed evidence of severe toxaemia in all three cases, with petechial haemorrhages on serosal surfaces, adrenals and stomach. In two cases, there was bronchopneumonia and adult hyaline membrane in the lungs.
DISCUSSION
Necrotising fasciitis was first described by Joseph Jones[6] during the American civil war as 'hospital gangrene', and then by Meleny[5] as 'haemolytic streptococcal gangrene'. Since then various terminologies have been used.
Necrotising fasciitis is commonly seen in males over 40 years.[6] But the peculiar feature of our series is that all the patients were young males, below the age of 40, and there was no history of any predisposing factor in the majority. It is known to follow minor trauma, insect bite, pustule or operations like appendicectomy, herniorrhaphy, muscle biopsy, hip nailing and aorto-iliac endarterectomy.[6],[7] It is associated with diabetes mellitus or occlusive vascular disease. However, none of our patients had diabetes whereas only one had TAO. The lower limbs are predominantly affected. The clinical features include fascial necrosis, cellulitis, edema, skin discolouration, gangrene and severe toxaemia. Loss of sensation of the skin of the involved area has been reported to be associated with high fever, severe toxicity, tachypnoea and hypotension.[1] The laboratory investigations may reveal anaemia, leucocytosis and hypocalcaemia.[6] X-rays of the affected part may show presence of gas in the soft tissue which was evident in two of our patients.
Treatment consists of correction of shock by infusion of fluids and whole blood transfusion. Antimicrobial to be selected initially should be effective against multiple organisms; the combination of aminoglycoside and penicillin seems to be ideal. Subsequent change of antibiotics may be necessary after the availability of sensitivity reports. Wide opening of the affected tissue planes with ruthless debridement is called for; excision of the deep fascia is not indicated unless the deeper structures are involved. The wound should be packed lightly so as to permit frequent examination; any extension of the necrotising process requires deroofing of the infected compartment. After the infection is controlled, free skin grafts may become necessary.
The mortality of necrotising fascitis, varies from 3.7 to 46%.[6],[7] Higher mortality has been reported among patients over 50 years of age and among those having atherosclerosis or diabetes. Fischer et al[2] found no increase in mortality in patients with diabetes. Mortality of 60% in our series was probably due to admission at a very late stage with septic shock. Sheagren[8] has described four different mechanisms of septic shock syndrome in staphylococcal infection.
Necrotising fasciitis is usually caused by streptococci and staphylococci and rarely by Gram negative bacilli and anaerobic organisms.[7] In one case of our series, synergistic infection with E. coli and B. fragilis has been responsible to break the immune barrier as stated by Guliano et al.[3] Coagulase positive staphylococci were responsible for the infection in three cases. Ketona et al[4] attributed the increased incidence of staphylococcal infection to T cell defect in presence of high levels of IgE. High levels of IgE due to parasitic infestations which are common in our country, with resultant T cell defect and minor, unnoticed trauma might have been responsible for the three staphylococcal infections in our cases. However, as the patients died within a short period of admission, there was no opportunity to corroborate this statement.
ACKNOWLEDGEMENT
We thanks the Dean, K.E.M. Hospital and Seth G.S. Medical College, Bombay, for allowing us to publish this data.
References
| 1 | Baxter, C. R.: Surgical management of soft tissue infections. Surg. Clin. North Amer., 52: 1483-1499, 1972. |
| 2 | Fischer, J. R., Conway, M. J., Takeshita, R. T. and Sandoval, M. R.: Necrotising fasciitis-importance of roentgenographic studies for soft tissue gas. J. Amer. Med. Assoc., 241: 803-.806, 1979. |
| 3 | Guiliano, A., Lewis, F'., Hadley, K. and Blaisdel, F. W.: Bacteriology of necrotising fasciitis. Amer. J. Surg., 134: 5256, 1977. |
| 4 | Katona, I. M., Tata, G., Scanlon, R. T. and Bellanti, J. A.: Hyper IgE syndrome; a disease with suppressor T cell deficiency. Ann. Allerg., 45: 295-300, 1980. |
| 5 | Meleney, F. L.: Hemolytic streptococcal gangrene. Arch. Surg., 9: 317-364, 1924. |
| 6 | Miller, J. D.: The importance of early diagnosis and surgical treatment of necrotising fasciitis. Surg. Gynaecol. and Obstet., 157: 197-200, 1983. |
| 7 | Rea, W. J. and Wyrick, W. J.: Necrotizing fasciitis. Ann. Surg., 172: 957-964, 1970. |
| 8 | Sheagren, J. N.: Staphylococcus aureus, the persistent pathogen. Part I . New Engl. J. Med., 310: 1368-1373, 1984. |
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