Necrotizing Fasciitis: A Comparative Analysis of 56 Cases

2 Dec
2009

INTRODUCTION

In 1952, Wilson coined the term necrotizing fasciitis (NF) to describe a rapidly progressive inflammation and necrosis of subcutaneous tissue and fascia. Before then, the disease had been described under various nomenclature, such as hemolytic gangrene, acute streptococcal gangrene, gangrenous erysipelas, necrotizing erysipelas, suppurative fasciitis and hospital gangrene, just to mention a few. However, the term is now used in a generic sense to include all diffuse necrotizing soft-tissue infections except gas gangrene. Unlike in clostridial myonecrosis, the muscle is frequently unaffected and in the early stages, the skin stays intact. Contrary to the earlier belief that it was caused solely by hemolytic streptococci, NF is now known to be a clinical entity of polymicrobial and synergistic nature without any particular combination. The resultant effect is usually far more fulminant than the regular effect attributable to the individual pathogen.

The actual incidence of the disease has not been elucidated, although most reviews reported 2-3 cases being seen in most major centers per year. Considered a rare entity, NF has been known to affect more adults than children and can be observed in a wide variety of clinical settings in both age groups. The disease may start spontaneously or follow local infections, minor wounds or surgical procedures. Although it has been reported in healthy individuals, it is more likely in patients with underlying diseases, such as diabetes mellitus, hepatorenal disease, HIV/AIDS or those undergoing organ transplantation. The diagnosis of NF is mainly clinical. It has a varied spectrum of presentation, ranging from simple cellulitis to septic shock and multiple organ dysfunction/failure. Pain, fever or toxemia, which is out of proportion to the local signs (type and size of wound) is a hallmark in diagnosis. However, most cases run a fulminant course and are often associated with severe systemic inflammatory response syndrome (SIRS).

The keys to successful patient treatment of NF rest on early recognition, adequate resuscitation, broad-spectrum antibiotic therapy, radical surgical debridement and supportive care. The goal of surgery is to debride all necrotic soft tissue and fascia in order to halt the progression of the disease and aid speedy recovery. NF is associated with high morbidity and mortality if appropriate treatment is not offered in good time. It results in prolonged hospital stay and multiple surgical procedures. This has financial consequences, especially in countries where healthcare services are on a cash-and-carry basis, the cost being borne solely by the patients. Over 50% mortality has been reported. Sporadic case reports and a few case series have been documented worldwide on NF. In this report, we present our experience in managing 56 consecutive children and adults in a Nigerian Teaching Hospital over a four-year period. The modes of presentation and outcome of management are compared and contrasted. This report represents one of the largest single series ever presented on NF. cialis UK

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