Limb loss due to necrotizing  fasciitis (Gas Gangrene)
Photos courtesy of Dr. Tim Best M.D.  FRCS(C)
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   The concept of necrotizing fasciitis is not new.There  have been case reports dating back over  a century.Various terms have been used including  gas gangrene, flesh eating disease, Meleney's synergistic gangerene, Cullen's ulcer, mixed aerobic/anaerobic infection, Fournier's  scrotal gangrene as well as hemolytic streptococcal  cellulitis     .Clearly the pathophysiology of these conditions  are not the same nor their clinical manifestation. .Although "lumping " of the terms may have  benefit, a clear distiction must be made particularly as it affects management.
  
   A few years ago ,
flesh eating disease gained national attention   when one of our provincial premiers was afflicted  resulting in an above the knee amputation.

   The  world wide incidence is difficult to determine as most are unreported  particulary in third world countries.The incidence is likely on the incline with the  increase in the immune compromised population (hepatitis and HIV),diabetics and transplanted patients.. However, otherwise normal healthy patients have also been afflicted.Males are affected more than females .Young children are usually spared ( young to middled aged adults  are usually affected).
Mortality in some series  is still over 50 %

    Previous surgery or trauma may not have occurred.Pain and swelling are the primary features.Spread is rapid and may occur in hours to days depending on the organisms.Spread is usually along the deep fascia and usually  varies with the  amount of subcutaneous tissue involved.The bacteria involved may be aerobic, anaerobic or mixed(synergistic).Gas may or may not be present clinically or by X-ray. 
   Organisms involved  can include  group A Strepococcus,Proteus , Klebsiella ,Bacteroides, Clostrium, E.coli.,  Enterobacter and Staph aureus



    This first case is a classic presentation of the so called"flesh eating disease" which affected our hospital.There have been various forms of necrotizing fasciitis  dealt with in the various surgical specialties. This case is unique in that it   illustrates  the virulence  of the  group A Streptococcus.

      The affected patient was a 48 year old male ,known hepatitis C ,with portal hypertension and end stage cirrhosis.He presented to the emergency department with severe pain in his (R) leg associated with a small ulcer on his lower shin.He had seen his family physician just a few days prior to this for an unrelated problem and the ulcer noted in passing.On presentation on this occasssion he complained of severe pain in this small reddened ulcer (A).The pain was felt to be out of proportion to the clinical findings.The patient became progressively more agiated and threatened to sign himself out.Over the next few hours he become hypotensive and semi-conscious.The small reddened area was now a purplish/vioalceous superficial  demarcation initially in the calf but within a few hours affected the entire limb.(C&D)It was associated as well with a small superficial  purple patch over his pupis.(E) Noticeable changes occured in the limb even from the  short time from the intial surgical consultation to the  visit to the OR

      In the OR  the patient was found to have dead  skin, fat , fascia and muscle.The muscle was grey. The tissues  did not bleed.(B)   There was  thrombosis of both arteries and veins. After surgical interrogation a decisicion was made  to  do a hip disarticulation. ( F) In this process it become obvious after  the  necrotic abdominal musculature was removed that there was  intrabdominal spread with involvementof the iliopsoas muscle.Peritoneum was clearly exposed and several hundred cc.'s of bloody fluid was visible.The patient survuived 12 hours after the surgery depite massive doses of antibiotics and pharmacologic and ventilatory support.

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