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Necrotizing Fasciitis

Necrotizing Fasciitis

Necrotizing

WnLAm J. REA, M.D., WALTER J. WYRICK, JR., M.D. From the Department of , Division of Thoracic and Cardiovascular Surgery, The University of Texas Southwestern Medical School at DaUas, Dallas, Texas 75235

NECROTIZING fasciitis is a specific clinical patients had both streptococci and staphy- which is relatively rare. Since it is lococci present in significant quantity and a clinical entity of varied bacteriological one of the organisms was always of a he- etiology, it has doubtless been diagnosed molytic type. Eleven patients had strepto- in the older literature under such names as cocci or staphylococci along with enteric acute streptococcal , gangrenous pathogens. Five patients had only gram , necrotizing erysipelas and hos- negative organisms isolated, including two pital gangrene. "" is the hemolytic , two preferred terminology when the most sig- Paracolon intermedium and one had only nificant manifestation of the infection is . Therefore, hemolytic strep- extensive of the superficial tococci and pathogenic staphylococci each with resultant widespread undermining of predominated in 44.5% of the with surrounding and extreme systemic enteric gram negative organisms in the re- toxicity, regardless of the specific bacterial maining 1%. etiology. Experience with 44 patients at Fourteen patients received Parkland Memorial Hospital in Dallas, drugs before or during the development of Texas, during the past 15 years stimulated this clinical entity. In ten the hemolytic a review and re-evaluation of this ex- streptococci were not found and one might tremely serious type of infection. speculate that this organism was inhibited by the antibiotic agents. However, in four Methods and Materials patients who received antibiotic drugs he- The records of all patients with necrotiz- molytic streptococci were cultured and in ing fasciitis at Parkland Hospital were some who received no antibiotic drugs only evaluated as to age, sex, race, location of pathogenic staphylococci were cultured. primary infection and type of initiating in- jury. and blood cultures as well as B. Initiating Injury pathologic slides were reviewed. An analy- The initiating injuries leading to infec- sis of and the modes tions were minor traumas in 80% of pa- of therapy was evaluated. tients (Table 2). These included minor abrasions, cuts, and in 17 patients Results and in eight no history of specific injury A. Bacterial Etiology could be obtained. Two patients had his- The hemolytic was the ma- tories of falling, but denied any resultant jor organism cultured from the wounds in injury. These patients and those with no 19 patients. Pathogenic was histories of injury, probably became in- the predominant organism in another 19 fected through small and unnoticed breaks patients (Table 1). Fourteen of these 38 in the skin. Two diabetics who had in- fected toes denied any specific injury. In Submitted for publication January 24, 1970. two patients the initial infection resulted 957 REA AND \ Annals 958 NYRICK Decemberof Surgery1970 TABLE 1. Bacteriology subcostal area and two in the area of the back and buttocks. I. Hemolytic Streptococcus 19 1. Hemolytic streptococcus-alone 5 D. Diagnosis 2. Hemolytic streptococcus & enteric 2 organisms Necrotizing fasciitis occurred at all ages 3. Hemolytic streptococcus & staphylo- 12 (Table 4), from 9 months to 81 years, coccus a. 4 of these had enteric pathogens mostly in patients over 40 years of age. b. 2 of these staphylococci were There was no statistical difference in race hemolytic or sex. II. Staphylococcus 19 The signs and symptoms of necrotizing 1. Hemolytic staphylococcus 3 fasciitis varied, but the sine qua non for 2. Coagulase positive staphylococcus- 6 alone diagnosis, superficial and widespread fas- 3. Coagulase positive staphylococcus & 2 cial necrosis, was predominant (Table 5). nonhemolytic streptococcus was present in all but three pa- 4. Coagulase positive staphylococcus & 6 enteric pathogen tients and two of these had erysipelas. Six- 5. Gram positive cocci 2 teen patients had blue to brown ecchymotic a. 1 also had E. coli and skin discoloration and 15 had cutaneous III. Gram Negative Group 5 gangrene. The number of patients with 1. Hemolytic Pseudomonas aeruiginosa 2 cutaneous gangrene is small probably be- 2. Paracolon intermediuim 2 of early diagnosis and therapy. Skin 3. Escherchia coli 1 anesthesia was present in 12 patients (27%), IV. No Growth 1 although it was not tested in many patients. Skin vesicles were less common, being from and in another two from inlfec- present in only five patients (11%o). tions following bites. Mild to massive edema was present in Necrotizing fasciitis developed following 81%o of the patients. This along with calf surgical procedures in nine patients. Thtree tenderness (9%o) may simulate deep vein followed appendectomies, (one , and two patients were given each following gastrectomy, inguinal Iher- drugs and managed conserv- niorrhaphy, hip nailing, an explorat;ory atively because the true condition was not laparotomy for multiple stab wounds, -and diagnosed. a muscle biopsy in an outpatient MNvith TABLE 2. Initial Injury dermatomyositis taking large doses of ster- oids. The ninth patient developed necroitiz- Those occurring outside the hospital 35 ing fasciitis following aorto-iliac enda:rte- a) Abrasions 9 b) Cuts 4 rectomy at another hospital and was re- c) Bruises 4 ferred to Parkland Hospital for treatmient d) Boils 3 of this infection. s) Insect bite 2 f) Diabetic toe with no history or trauma 2 g) Fall but no evidence of cuts, abrasions 2 C. Location or any visible skin break h) No history of injury 8 Of the 44 patients with necrotizing ffas- i) 1 ciitis, in 33 the lesions were on the extre:mi- ties (Table 3), 22 on the lower extremiltlies Post-Surgical 9 a) Appendectomy 3 and 11 on the upper extremities. Five in- b) Inguinal herniorrhaphy 1 fections originated on the abdomen aLnd c) Gastrectomy 1 d) Exploratory laparotomy for stab of 1 three in the inguinal area, all but one oc- e) Aorto-iliac endarterectomy 1 curring in surgical wounds. Of the thiree f) Hip nailing 1 remaining infections, one originated in the g) Muscle biopsy 1 Volume 172 NECROTIZING FASCIITIS Number 6 959 Crepitation has been thought to be TABLE 3. Location pathognomonic of clostridial infections. Lower extremity 22 However, it is known that other organisms Upper extremity 11 can create crepitation, as do E. coli infec- Abdomen 5 tions in diabetics. Two patients had sub- Inguinal region 3 Back & buttocks 2 cutaneous crepitation, and in one subcu- Subcostal region 1 taneous gas was demonstrated on roent- genograms and yet smears and cultures served. Deficiencies were corrected with failed to grow out clostridial organisms. intravenous calcium gluconate. Although not a predominant sign, jaundice White cell counts, serum electrolytes, occurred in eight patients (18%). This BUNs, and other laboratory studies showed may be a result of either or non-specific changes of other serious acute hepatocellular dysfunction and is not spe- infections. cific with necrotizing fasciitis. Because of the possibility of hemolysis and anemia, F. Management the need for blood transfusions may arise. Once the diagnosis was suspected, aero- Symptoms varied with the severity of bic and anaerobic blood and wound cul- the , with mental disorientation or tures were obtained. The patient was given apathy in 18 or nearly half of the patients. several million units of penicillin and one The cause was difficult to assess, but bac- gram of chloramphenicol intravenously and terial toxicity and extracellular fluid shifts 500 mg. kanomycin intramuscularly. Cor- are two major considerations. The average rections of the fluid, electrolyte and red temperature was 38.5° C. with a range of cell mass deficiencies were carried out and 370 C. to 40.5° C., and it was usually of the treated by antipyretics and cool- a spiking or septic pattern. ing blankets. After resuscitation and under E. Laboratory Data anesthesia, incisions were made down to the superficial fascia for thorough inspec- levels were monitored be- tion. If a serosanguineous along cause the red cell mass was frequently with a swollen, stringy, dull grey and ne- diminished by thrombosis, ecchymoses, se- crotic fascia with extensive undermining in questration by the reticuloendothelial sys- this plane predominated, the clinical diag- tem and hemolysis. Production of red cells nosis of necrotizing fasciitis was confirmed. by the is often depressed by Multiple linear incisions were made over infection and toxemia in these patients. In the affected area and carried beyond the 68% the hemoglobin level was below 10 Gm./100 ml. In one patient, the hemoglo- TABLE 4. Age bin dropped from 12 Gm./100 ml. to 3.9 Extreme-Youngest-9 mos.-Oldest-81 Gm./100 ml. in 24 hours. Thirty-two pa- tients required up to nine units of blood 0-20 - 5 during the period of active infection with 20-29 3 30-39 2 an average of 3.6 units for each patient. 40-49 7 Serum calcium levels frequently fell dur- 50-59 9 60-69 5 ing the acute phase. Presumably fat is split 70-79 - 3 into fatty acids by bacterial lipase and the 80-89 1 ionic calcium combines with the fatty acids Sex Race to form insoluble soaps in the subcutaneous tissues. Most patients showed a mild drop Male 25 - 18 Negro Female 19 - 26 White in serum calcium, but no tetany was ob- WYRICK Annals of Surgery 960 REA AND ' December 1970 TABLE 5. Clinical Features for autografting. Seventeen patients re- quired split-tlhickness skin grafts, two had Subcutaneous and fascial necrosis 44 100.0% Cellulitis 41 93.0% delayed primary closures and four under- Edema 39 81.0% went . The wounds of the re- Disorientation or apathy 18 41.0% maining eight patients who survived healed Skin discoloration 16 36.0% Gangrene 15 34.0% by secondary intention. Skin anesthesia 12 27.0% Jaundice 8 18.0% G. Morbidity and Mortality Vesicles 5 11.0% Lung involvement 5 11.0% The average period of hospitalization Septic 5 11.0% was 45 days. The shortest period was in an Calf tenderness 4 9.0% Erysipelas 2 4.5% elderly woman who was transferred in a Crepitation 2 4.5% moribund condition and expired on the Bone involvement 2 4.5% second hospital day; the shortest period of Stress bleeding 2 4.5% hospitalization for a survivor was 8 days. The longest period of hospitalization was fascial extension as determined by finger 119 days. dissection in that plane (Fig. 2). Fenes- The in the 44 patients was trated catheters and fine mesh gauze were 30%o. However, if three deatlhs that oc- placed in the wound, the gauze placed curred after the fasciitis was arrested are loosely so that anaerobic pockets would excluded, the mortality rate was 23%. not be created. Neomycin 100 mg., baci- There appears to be several factors which tracin 100,000 units and polymixin 100 lead to in patients with necrotizing mg./I. of normal saline was dripped into fasciitis (Table 6). One of the most strik- the wound at the rate of one liter each 8 ing is mellitus, as five of eight dia- hours (Fig. 3). (Active zinc peroxide or betics died. The second factor was arterio- silver nitrate was used in the first 20 cases.) sclerosis. All non-diabetic patients over 50 The fine mesh gauze was removed and re- years of age had vascular disease and seven placed every 6 to 8 hours. This allowed of the ten died. There was poor vascular frequent mechanical as ne- perfusion in all but one patient who suc- crotic material adhered to the gauze and cumbed. With the exception of one child, was removed as the packing was changed. At each change of the gauze, a sterile gloved finger checked all areas of the wound to determine whether further dis- section required extension of the surgical wound for adequate drainage. The infec- tion may progress rapidly, requiring thor- ough re-evaluation several times a day to control the disease. Many survivors were re-operated upon because of extension of the infection discovered at the dressing change examinations. After the infection was controlled and granulation tissue covered the wound, the sides of the wound were loosely approxi- mated. This reduced the healing area and the number of skin grafts required to close the defect. Recently, heterografts have FiG. 1. Extensive undermining in a case of been used to cover and prepare the wound staphyloccal necrotizing fasciitis. Volume 172 Number 6 NECROTIZING FASCIITIS

FiG. 2. Extensive de- bridement required in necrotizing fasciitis.

all were in patients over 50 years of veloped in nine surgical wounds 1 to 4 days age with either diabetes mellitus or arterio- postoperatively (Table 2). When the red sclerosis, a 67%o mortality rate in patients inflamed wounds were opened, there was over 50 years of age. little or no , but serosanguineous fluid The most important factor in survival with marked fascial necrosis. Three infec- was related to rapidity of diagnosis and in- tions followed appendectomies and one stitution of therapy (Table 7). The average each followed gastrectomy, inguinal her- time from the onset of the disease to the niorraphy, hip nailing, muscle biopsy, and diagnosis and institution of therapy was 5 exploratory laparotomy for abdominal stab days. However, this period averaged only wounds. One patient developed the dis- 4 days in survivors as compared to 7 days ease at another hospital following aorto- in those who died. iliac endarterectomy and was referred for Post-surgical. Necrotizing fasciitis de- treatment. One infection followed an interval ap- pendectomy 6 weeks after drainage of an appendiceal . This patient was in in the postoperative period and the entire anterior rectus fascia was necrotic. from the infected wound were the same as those from the previous appendiceal abscess. Another appendectomy wound infection derived from a small pu- rulent abrasion of the patient's ankle. The etiology of the inguinal herniorraphy and the other appendectomy infection was traced to the anesthesiologist who had an active nasal lesion caused by the same or- ganism. Gross contamination at the time of injury accounted for infection in the pa- tient who was FIG. 3. Fine mesh gauze packing and irrigation stabbed and the muscle bi- catheters in debrided wound. opsy was performed in a patient with der- ND WYRICK Annals of Surgery 962 December 1970 complications; two had Kimmelstiel-Wilson disease with blood urea nitrogens over 50 mg./100 ml., another had chronic brain syndrome and refused to eat, and the fourth had vascular disease and . The other diabetic who died had and hepatic cirrhosis. He was 81 days postsurgical treatment of fas- ciitis and almost totally recovered when he had a fatal myocardial during a hypoglycemic episode. Arteriosclerosis. There were 18 patients over 50 years of age, and all either had diabetes mellitus or arteriosclerosis. In the overall "over 50 group," 12 of the 18 died. Excluding diabetics, seven of ten patients with arteriosclerosis died. This latter group includes an elderly patient with broncho- pulmonary disease and complete hemi- plegia from a previous stroke who survived 119 days following surgical debridement and had three grafting procedures before FIG. 4. Healed wound shown in Figures 2 and 3. he died from aspiration pneumonitis. Another patient had metastatic carcinoma matomyositis taking large doses of steroids of the cervix and was not seen until the in the out-patient clinic. The sources of the fourteenth day of the infection; she was fasciitis in the gastrectomy and the hip operated upon the third hospital day, but nailing were never found. died 20 days later. A 56-year-old man with There were two deaths in the postsurgi- generalized arteriosclerosis and cirrhosis cal patients. One who developed fasciitis was treated with antibiotic and anticoagu- following the aorto-iliac procedure died on the day after admission. The other death TABLE 6. Factors Relating to Mortality was in a 4-year-old boy operated upon for acute . No disease was found No. Died at operation. He developed a fulminant Diabetics 8 5 wound infection 24 hours following opera- Arteriosclerosis 10 7 tion and cultures grew coagulase positive All deaths, except one child, were over 50 years of age. staphylococcus and B-hemolytic streptococ- cus, the same organisms cultured from a TABLE 7. Average Time for Diagnosis small purulent abrasion on his ankle. De- After onset of disease before admission - 5.72 days spite early recognition and aggressive ther- Earliest admission-12 hours apy, infection progressed to involve the en- Latest admission-21 days tire anterior abdomen and lower thorax and From onset of disease to diagnosis & he died in septic shock. treatment - 5 days Diabetics. There were eight diabetics For those who died from onset of disease and five of these died, a 63%o mortality. to diagnosis & treatment - 7 days Four of the five diabetics died during the From onset of disease to diagnosis & treatment in survival - acute phase of infection and had diabetic group 4 days Volume 172 Number 6 NECROTIZING FASCIITIS 963 lant drugs for 4 days before the diagnosis minor lacerations, abrasions, or minor in- of necrotizing fasciitis was made. He sur- juries not detected." 13 14 25 This was true vived 38 days following debridement be- in 80%o of our patients. Although many ear- fore succumbing to an extension of necro- lier reports were of scrotal gangrene, re- tizing fasciitis, stress ulcers and liver fail- cent incidence is predominantly on the ex- ure. Four other patients in this group, tremities and on the abdomen.3' 6, 8,19,22 including two transferred from other hos- Treatment has changed little and remains pitals, were critically ill on admission and surgical debridement and drainage.15' 18, 20, died within 48 hours. 23, 24 Antibiotic drugs have not significantly altered mortality rate." 23 Discussion Necrotizing fasciitis must be differenti- Necrotizing fasciitis was probably de- ated from erysipelas, progressive bacterial scribed for the first time as "hospital gan- synergistic gangrene, anaerobic streptococ- grene" by Joseph Jones, a Confederate cal gangrene, streptococcal myositis and Army Surgeon in the Civil War, who stated clostridial myositis or . Ery- "the skin of an affected part melts away." 10 sipelas is a spreading cellulitis and lym- Meleney first described "hemolytic strepto- phangitis with raised sharply defined ir- coccal gangrene" when he reported 20 regular reddish borders. In necrotizing fas- cases from Peking, China.14 The infections ciitis the involved skin is pale red without he described were similar to what is now distinct borders and with or bullae. called necrotizing fasciitis, and most of Pale red areas progress to a distinct purple these patients probably had streptococcal color. There is little swelling of the soft necrotizing fasciitis. tissues in erysipelas, whereas there may be It has been advocated that necrotizing mild to massive edema in necrotizing fas- fasciitis is not due solely to B-hemolytic ciitis. Progressive bacterial synergistic gan- streptococci, but can be caused by a num- grene usually develops more slowly, with ber of different organisms.4 13 25 Kellaway fewer signs of toxicity, and frequently in- in 1930 and Jandl in 1960 showed that volves the edges of a previous wound. staphylococcus causes intravascular Characteristically the wound demarcates hemolysis and tissue necrosis seen in necro- into three zones, a wide peripheral zone tizing fasciitis.9 11 Subsequently it has been of erythemia surrounding a tender purple reported that the streptococcus is not the zone, the center of which becomes black sole etiological organism. Crosthwait et al. and necrotic with subsequent ulceration, cultured the streptococcus in either pure or i.e., Meleney's . mixed cultures in 58%o of their patients,' Aerobic streptococcal gangrene develops whereas Wilson found streptococci to be rapidly and the affected skin is hot, red, in only 35%o of his patients.25 Our demon- swollen and painful. Blebs and eventually stration of streptococci in 44.5%o of pa- gangrene may occur. There is usually foul tients probably indicates that this disease odor and dark serous drainage. Infection is a clinical entity and not a specific bac- involves the , but may terial infection. Although a few bacterial extend downward to the fascia or muscle. types may predominate (streptococcus and If the fascia is primarily infected, the diag- staphylococcus) necrotizing fasciitis may nosis is necrotizing fasciitis, if the muscle result from different bacteria or combina- is principally infected, diagnosis is strepto- tions thereof. coccal myositis. Streptococcal myositis and The initiating injuries in Meleney's pa- clostridial myositis are infections of muscle tients and in reports by McCafferty and tissue although clinical manifestations, with Lyons, Wilson, and Crosthwait et al. were the exception of tetanus, may mimic necro- Annals 964 964 REA AND WYRICK ~~~~~~~~~~~~~~~~~~~~~~~Decemberof Surgery1970 tizing fasciitis. Severe local pain, foul odor, 7. Gage, A.: Streptococcal Subcutaneous Necro- sis with Gangrene of Skin. Med. Progress, and pus formation are more pronounced in 45:30, 1929. myositis and there is a greater incidence 8. Hawkins, J. A.: Spontaneous Gangrene of the . Milit. Surg., 50:419, 1922. of crepitation. is not 9. Jandl, C. H. and Kaplan, M.: The Destruc- important as both infections require wide tion of Red Cells by Antibodies in Man. J. Clin. Invest., 39:1145, 1960. surgical debridement. Observation of t-he 10. Jones, J.: Investigation upon the Nature, predominant area of involvement along Causes and Treatment of Hospital Gangrene as It Prevailed in the Confederate Armies with a gram stain of the pus or fluid should 1861-1865. New York, U. S. Sanitary Com- establish the diagnosis.2 5 7, 12, 10, 17, 21 mission, Surgical Memoirs of the War of Rebellion, 1871. 11. Kellaway, C. H., Burnet, F. M. and Williams, Summary F. E.: Pharmacological Action of of . J. Path. Bact., Necrotizing fasciitis is uncommon, occur- 33:889, 1930. ring in two to three patients a year over 12. Mainzer, F. S.: Acute Streptococci Hemolytic Gangrene. Penn. Med. J., 34:784, 1931. the past 15 years at a large city-county hos- 13. McCafferty, E. L., Jr. and Lyons, C.: Sup- pital. Etiological agents were usually B- purative Fasciitis as an Essential Feature of Hemolytic Streptococcus Gangrene, with hemolytic streptococci or coagulase posi- Notes on Fasciotomy and Early Wound tive staphylococci, although a few infec- Closure as Treatment of Choice. Surgery, 24:438, 1948. tions were associated with gram negative 14. Meleney, F. L.: Hemolytic Streptococcus Gan- organisms. A minor extremity injury was grene. Arch. Surg., 9:317, 1924. the most common pre-disposing 15. Meleney, F. L. and Stevens, F. A.: Postopera- factor, al- tive Hemolytic Streptococcus Wound Infec- though nine infections occurred in post- tions and Their Relation to Hemolytic operative wounds. Treatment consisted of Streptococcus Carriers among Operating Personnel. Surg. Gynec. Obstet., 43:338, extensive surgical debridement, triple anti- 1926. biotic solutions locally and specific par- 16. Meleney, F. L.: Hemolytic Streptococcus Gan- grene: Importance of Early Diagnosis and enteral antibiotic drugs with a 307%o mor- Early Operation. JAMA, 92:2009, 1929. tality. Ten of 13 deaths followed minor in- 17. Meleney, F. L.: Hemolytic Streptococcus Gan- grene Following the Administration of Scar- juries. Two deaths followed post-surgical let Fever Antitoxin. Ann. Surg., 91:287, infections and one was secondary to an in- 1930. 18. Meleney, F. L.: Bacterial Synergism in Dis- fected burn. With the exception of one ease Processes, with Confirmation of Syner- child, all deaths occurred in patients who gistic Bacterial Etiology of Certain Types of Progressive Gangrene of the Abdominal were over 50 years of age and had poor Wall. Ann. Surg., 94:961, 1931. vascular perfusion, as a result of either dia- 19. Meleney, F. L.: A Differential Diagnosis be- tween Certain Types of Infectious Gangrene betes mellitus or severe arteriosclerosis. of the Skin with Particular Reference to Hemolytic Streptococcus Gangrene and Bac- References terial Synergistic Gangrene. Surg. Gynec. Obstet., 56:847, 1933. 1. Andrews, E. C. and Cruz, A. B., Jr.: Necro- 20. Meleney, F. L.: In A Textbook of Surgery. tizing Fasciitis: Diagnosis and Treatment. Edited by Frederick Christopher, 5th Edi- Texas Med., 65:50, 1969. tion, Philadelphia & London, W. B. Saun- 2. Bettmnan, A. G.: Hemolytic Streptococcal Gan- ders Co., 1949, pp. 708-718. grene. Northwest Med., 30:28, 1931. 21. Shires, G. T.: In Care of the Trauma Patient. 3. Campbell, M. F.: Streptococcus Scrotal and New York, McGraw-Hill Co., 1966, pp. Penile Gangrene. Surg. Gynec. Obstet., 34: 137-151. 780, 1922. 22. Stirling, W. C.: Gangrene of Scrotum and 4. Crosthwait, R. W., Jr., Crosthwait, R. W. and Penis. JAMA, 80:622, 1923. Jordan, G. L.: Necrotizing Fasciitis. J. 23. Webb, H. E., Hoover, N. W., Nichols, D. R. Trauma, 4:149, 1964. and Weed, L. A.: Streptococcal Gangrene. 5. Fallon, J.: Hemolytic Streptococcal Subcu- Arch. Surg., 85:969, 1962. taneous Gangrene. Arch. Surg., 18:1817, 24. White, W. L.: Hemolytic Streptococcus Gan- 1929. grene; Report of 7 Cases. Plast. Reconstr. 6. Fedden, W. F.: Six Cases of Acute Infective Surg., 11:1, 1953. Gangrene of the Extremities. Proc. Roy. Soc. 25. Wilson, B.: Necrotizing Fasciitis. Amer. Surg., Med., 2:213, 1909. 18:416, 1952.

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