| 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.