Postgrad Med J: first published as 10.1136/pgmj.53.619.237 on 1 May 1977. Downloaded from Postgraduate Medical Journal (May 1977) 53, 237-242. Necrotizing fasciitis M. A. TEHRANI I. McA. LEDINGHAM F.R.C.S. M.B., Ch.B. University Department ofSurgery, Western Infirmary, Glasgow Summary stated that 'the infection essentially produces a The authors' experience of fourteen patients with gangrene of the subcutaneous tissues, subsequently it necrotizing fasciitis is reviewed. The pathognomonic causes death of a part of the overlying skin'. In feature of this condition is an extensive necrosis of Meleney's report, bacterial culture showed that the subcutaneous tissue caused by a vicious cycle of infec- haemolytic streptococcus 'was the only organism tion, local ischaemia and reduced host defence invariably present'. Other organisms which were mechanisms. The diagnosis can only be confirmed by identified were fewer in number and none of them immediate exploratory incision. appeared regularly enough to be considered as the The reported mortality of 30-40%/ reflects the 'causative organism'-hence the term 'haemolytic inadequacy of conservative surgery in the treatment of streptococcus gangrene'. this serious condition. Mortality can be reduced by Wilson (1952) was the first to use the descriptive early recognition followed by radical excision of the term 'necrotizing fasciitis' because of the charac- necrotic fascia and overlying skin. The preservation teristic necrotic fascia and subsequently observed and subsequent use of the excised skin has the ad- non-specificity of the pathogenic organism involved. vantage of economy in the use of donor areas and Others in later reports (Rea and Wyrick, 1970;copyright. reduction in morbidity. Hyperbaric oxygen therapy Meade and Mueller, 1968; Ledingham and Tehrani, does not halt the spread of the necrotizing process and 1975) have confirmed the validity of this statement is not a substitute for radical surgery. and have continued to use this term in preference to other descriptive names. Definition and historical background Necrotizing fasciitis is a relentlessly destructive Bacteriology bacterial infection characterized by extensive necrosis Pathogenic organisms undoubtedly play a major of the subcutaneous tissues of the abdominal wall role in initiating and spreading the necrotizing and, less frequently, the extremities. The condition is process. The type of bacteria now encountered, http://pmj.bmj.com/ fortunately uncommon but is potentially fatal and however, seem to differ from those in earlier reports. demands early recognition in order that treatment In Wilson's series of twenty-two patients (Wilson, may be effective. Although the serious nature of this 1952), haemolytic organisms were found in pure condition was recognized as long as 100 years ago culture in 58% of cases studied bacteriologically and (Jones, 1871), confusion in the literature was com- were present along with non-haemolytic bacteria in pounded by the multiplicity of descriptive termi- an additional 26% of the patients. The majority of and data. Thus the were nology inadequate bacteriological organisms (88%) pathogenic staphylococci. on October 2, 2021 by guest. Protected condition has been referred to as 'hospital gangrene' Rea and Wyrick (1970) reported forty-four patients (Jones, 1871), 'acute infective gangrene' (Fedden, with necrotizing fasciitis seen during 15 years at 1909), 'necrotizing erysipelas' (Pfanner, 1918), Parkland Memorial Hospital in Dallas. In this 'haemolytic streptococcus gangrene' (Meleney, 1924, group, haemolytic streptococci and pathogenic 1929), and 'suppurative fasciitis' (McCafferty and staphylococci together accounted for 89% of the Lyons, 1948). wound infections with enteric Gram-negative The first large series published in the present organisms responsible for the remaining 11%. In a century was that of Meleney who, in 1924, reported recent report, Wilson and Haltalin (1973) described twenty patients from China. Meleney described the eleven children with necrotizing fasciitis. Haemolytic condition as a rapidly developing gangrene which streptococci were found in 50%/ of cases. The other occurred more frequently in males and the extremi- organisms were staphylococci and Pseudomonas ties were affected in the large majority of cases. He aeruginosa. In the report by Ledingham and Tehrani the in initial wound Correspondence: Dr lain McA. Ledingham, University (1975) predominant organisms Department of Surgery, Western Infirmary, Glasgow culture, obtained through fresh incisions in the Gil 6NT. affected areas, were coliforms in combination most Postgrad Med J: first published as 10.1136/pgmj.53.619.237 on 1 May 1977. Downloaded from 238 M. A. Tehrani and . McA. Ledingham frequently with enterococci and streptococci; in only Lyons (1948) postulated activation by streptokinase one case was the streptococcus of the a-haemolytic or staphylokinase of a serum proteolytic enzyme, variety. Other organisms included Bacteroides, present in the inflammatory exudate, causing pro- diphtheroids, Clostridium welchii, Proteus, Staphylo- gressive collagen necrosis. coccus and Ps. aeruginosa. Since colonizing bacteria Haemolytic streptococci are capable of producing rapidly invade the affected area, bacteriological haemolysin, leucocidine, fibrinolysin, erythrogenic cultures, both aerobic and anaerobic must be taken toxin and the enzyme hyaluronidase. The filtrate of from several sites at an early stage in the course ofthe pathogenic staphylococci has haemolytic, necrotic disease. and coagulating properties (Kellaway, Burnet and Williams, 1930). Other organisms such as Pseudo- Pathogenesis monas are known to produce collagenase with a Irrespective of the species of organism involved, primary effect on subcutaneous tissues and fascia the initial bacterial growth takes place in the sub- (Meade and Mueller, 1968). cutaneous tissues, i.e. the subcutaneous fat, super- Another important factor which should be con- ficial fascia and the superficial layer of the deep sidered in the pathogenesis of a major infection of fascia, most commonly of the abdominal wall and this sort is reduction in the host defence mechanisms lower extremities. The initiating injury responsible (HDM). Primarily, local reduction in tissue resis- for introduction of the infection may follow minor tance is achieved by the action of bacterial toxins trauma (abrasions, cuts, bruises, insect bites, minor added to the effect of bacterial kinases. This action is burns) or surgical incision. At times, no obvious further enhanced by the general reduction in HDM cause is found. occurring in the postoperative period, or by pre- In the series reported by Rea and Wyrick (1970), existing systemic diseases such as diabetes, arterio- minor trauma was responsible for 80% of the cases sclerosis, agamma- or hypogammaglobulinaemia, and in eight patients, no history of specific injury rheumatoid arthritis, malnutrition and gastro- could be obtained. In the present series of fourteen intestinal haemorrhage (Table 1). fasciitis following patients, necrotizing developed copyright. ischio-rectal sepsis in six, abdominal surgery in five, TABLE 1. Factors involved in the pathogenesis of necro- and fractured pelvis, diabetic peripheral vascular tizing fasciitis. HDM - host defence mechanisms disease and repeated supra-pubic aspiration of urine Infection each in one patient. Similarly in eleven children, (non-specific bacteria) reported by Wilson and Haltalin (1973), the condition Postoperative occurred in and traumatic Diabetic following surgery five, Collagenase Arteriosclerosis laceration, varicella, osteomyelitis, abscess ofbuttock Bacterial toxins Agamma/Hypo- and bone marrow aspiration, each in one patient. In Proteolytic enzymes Reduced HDM globulinaemia >. Rh. arthritis the final of this series no predisposing con- http://pmj.bmj.com/ patient Malnutrition dition was present. Gastrointestinal After the initial bacterial insult, the infection Necrosis of the haemorrhage spreads rapidly along the fascial plane causing superficial fascia massive necrosis. The presence of ischaemic tissue further facilitates spread of the necrotizing process. Ischaemia The skin remains intact initially but later develops Rapid spread along patchy necrosis and becomes gangrenous as a result avascular fascial plane of thrombotic occlusion of both venules and arte- + gross undermining on October 2, 2021 by guest. Protected rioles supplying the skin. Damage to cutaneous nerves causes numbness and subsequent anaesthesia Secondary gangrene of skin of the part. Untreated, the affected skin becomes extensively necrotic. At an early stage, histological Abele et al. (1960) reported a case of progressive examination of full thickness skin biopsies reveals no fatal cutaneous gangrene associated with hypo- abnormality. The subcutaneous fat and superficial gammaglobulinaemia. In Buchanan's patient fascia show a continuing non-specific inflammatory (Buchanan and Haserick, 1970) there was elevation reaction, with fibrinoid arteriolitis and thrombosis of of serum complement level and a slight increase in the vessels. Organisms may or may not be demon- IgA, but its significance was unknown. In six strated in specially stained preparations. patients in the present series, hypoalbuminaemia and The factors responsible for this alarming spread hypergammaglobulinaemia were found. Clearly are unknown. An anaphylactic reaction similar to more detailed studies are required to detect the the Schwartzmann or Arthus