Necrotizing fasciitis symptoms treatment. Uncommon diseases: necrotizing fasciitis. Video: Necrotizing fasciitis is a dangerous disease

The causative agents are the bacteria Streptococcus pyogenes or Clostridium perfringens.

This infection destroys the tissue just under the skin. It can develop into gas gangrene.

The disease was discovered by Welch and Netall in 1892. Most often, the disease attacks the limbs and the perineal area; it occurs when the skin of these areas of the body is damaged due to injury or purulent processes.

Statistics show a frequency of 4 cases of NF per 10,000 people, with a 33% mortality rate.

Some doctors call this disease the “flesh eater” because of its ability to rapidly destroy all types of tissue in the affected area.

In other cases, among the causes that cause necrotizing fasciitis may be an internal ulcer from which bacteria penetrate into the subcutaneous tissue; with streptococcal infections, bacteria are often transferred through the bloodstream.

At the beginning, NF leads to the formation of local tissue ischemia (blood blockade), followed by necrosis this area due to the proliferation of bacteria in the wound. The infection spreads through the subcutaneous fat.

Factors that may contribute to the occurrence of NF:

age after 50 years;
excess body weight;
peripheral vascular lesions are observed;
immunodeficiency;
alcoholism in chronic form;
you suffer from diabetes;
you are undergoing treatment with corticosteroid drugs;
you are a drug addict on the needle;
postoperative complications.

Symptoms and signs

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The photo shows how dangerous necrotizing fasciitis is

Diagnosing necrotizing fasciitis in the early stages is extremely difficult, since its only manifestation is fever and local pain.

Then the skin becomes red from the blood collecting under it and swelling appears, palpation is painful.

The skin of the affected area gradually darkens to a dark red color, sometimes with a bluish tint, then blisters appear, after which the stage of skin necrosis begins - it becomes purple, less often purple or black.

Extensive thrombosis occurs in the superficial vessels, and the affected fascia acquires a dirty brown color.

From this moment on, bacteria begin to rapidly spread through the blood, lymph and fascial sheaths. Against this background, the patient’s temperature rises, the pulse increases, and the consciousness ranges from confused to complete unconsciousness.

A drop in blood pressure may occur as fluid drains into the affected area.

Modern medicine offers several treatment methods

polyarthritis of the hands

You can find them out in our material.

Slipping of the vertebrae relative to each other is called spondylolisthesis cervical spine spine. At the moment, there are several methods for treating the pathology.

Diagnostic methods

The diagnosis is made based on test results - signs of inflammation - a shift to the left of leukocytosis, the erythrocyte sedimentation rate is increased. The contents of the blisters are also further studied to determine sensitivity to antibiotics.

Treatment of the disease

Autodermoplasty operation

Surgery is used to remove dead areas of tissue, including amputation of a limb in severe cases.

Used when dressing wounds ultrasonic cavitation, together with use antiseptic ointments and proteolytic enzymes. Etiotropic treatment is actively used - the type of bacteria is determined and then targeted drugs are used.

Additionally, antibiotics are used wide range actions to reduce the risk of infection by other microorganisms.

Complications of the disease

The disease should be taken extremely seriously, since in a mild case you can get away with a scar on the skin, and if you neglect it, then everything can end very sadly - from amputation of a limb to death.

A common cause of complications is insufficient removal of affected tissue during surgery; if surgical intervention is required, surgery is repeated every 1-2 days.

Preventive measures

Thorough treatment of all abrasions and wounds, especially those contaminated with street dust or dirt. If redness or swelling appears, you should immediately consult a doctor.

In general, you should consult a doctor if the wound is deep enough and contaminated - this will avoid the risk of infection with bacteria or overcome the infection at an early stage.

People over 50 years old should also be careful about all kinds of abrasions and damage to the skin and mucous membranes, such as cracks anus for hemorrhoids.

Cases of infection can even be very exotic - American doctors in the state of Louisiana describe a case of NF, in which a 34-year-old woman contracted the infection while taking a hot salt bath, through a puncture in the skin left after an injection with a thick needle.

Remember, the later treatment is started, the worse the prognosis. It’s better to run to the doctor one more time and find out that there’s nothing wrong than to miss the real thing. dangerous infection which can lead to life disaster.

Video: Necrotizing fasciitis is a dangerous disease

Necrotizing fasciitis is considered one of the most difficult diseases. As much as I don’t want to believe it, this and other terrible diseases really exist in our world.

OsteoCure.ru

Necrotizing fasciitis- infection caused by bacteria Streptococcus pyogenes(mixed aerobic and anaerobic microflora) or Clostridium perfringens, which affect the superficial and deep fascia and subcutaneous tissue.

Diagnosing necrotizing fasciitis at an early stage, when the only symptoms are pain and fever, is quite difficult. Then pain and fever are joined by swelling and hyperemia, the skin becomes dense and painful on palpation. Later, the skin becomes dark red or bluish in color, blisters and necrotic areas of purple, purple or black appear. At this stage, extensive thrombosis develops in the vessels of the superficial plexus. The affected fascia acquires a dirty brown tint. The infection quickly spreads along the fascial sheaths, through the veins and lymphatic vessels.

On late stages the disease is accompanied by intoxication, and infectious-toxic shock and multiple organ failure often develop.

Notes

Necrotizing fasciitis (Russian). Website “Medicine and Biology” (medbiol.ru). Retrieved September 7, 2011. Archived August 28, 2012.

en.wikipedia.org

Extremely unpleasant inflammatory disease necrotizing fasciitis (photo shown below) became known back in 1871. Its causative agents are clostridia and hemolytic streptococci. They can attack the fascia by entering through open cuts or wounds. The disease is called differently: hemolytic streptococcal, hospital or acute skin gangrene, purulent fasciitis. International classification(ICD-10) designates it as M72.6.

Classification and reasons

This disease progresses very quickly, resulting in secondary necrosis of subcutaneous tissue. It can occur as a result of a surgical procedure or due to unsuitable medical conditions. Today, 3 forms of fasciitis are known:

first type (polymicrobial);
second type (streptococcal);
third type (myonecrosis).

Photo. Necrotizing fasciitis

The first type is also called “salty” necrotizing fasciitis. It received this name due to the fact that the disease appears upon contact with dirty salt water containing bacteria. Main risk groups:

drug addicts;
people over 50 years old;
obese patients;
HIV-infected;
people suffering from diabetes;
patients with complications after surgery;
chronic alcoholics;
patients with peripheral vascular disease.

Most often, the disease occurs between the ages of 38 and 44 years. This disease is diagnosed in children extremely rarely and only in countries where hygiene is low. If the child variety occurs, it is no less severe than in an adult.

The disease necrotizing fasciitis is acute and severe and requires consultation with a surgeon, because in children all the symptoms will be more pronounced. But in any case, both the child and the adult need to undergo wound sanitation.

Hospital gangrene can be triggered by many factors: fungus or infection. It happens that even an insect bite can give rise to the development of an infection, and 20–45% of patients with fasciitis simultaneously suffer from diabetes, which gave rise to the disease. Also at risk are alcoholics, people with cancer and cirrhosis.

If necrotizing fasciitis is diagnosed, the causes of the disease may be: beta-hemolytic streptococcus and pneumococcus (less commonly), surgical interventions in which tissue was injured, and the development of fasciitis.

Previously, this disease was extremely rare. It is difficult to diagnose, since before the onset of the disease the patient must have an injury or undergo surgery. It all starts simple and ordinary: a scratch, abrasion, wound, bite, injection puncture. But after some time the situation worsens, the place begins to hurt and become hot. This means that the wounds are necrotic.

Clinical picture

The pain is strong, intense, the muscle becomes sensitive, and the sensation resembles a sprain or tear. These symptoms are accompanied by fever, lethargy, and chills. The pain becomes stronger and more unbearable until the patient begins to feel numbness in the damaged area.

The process of developing the disease occurs individually for everyone. As the wound progresses, it enlarges, darkens, and then turns black. If this phenomenon is not treated, the infection affects the muscles deeper, after which myonecrosis may begin. The main signs of necrosis: darkening of the skin, sharp pain on the site, rotten discharge, it is distinguished by gangrenous areas with an inflammatory process.

To diagnose the disease, in addition to an external visual examination, you need to pass lab tests: complete blood count, arterial blood gas levels, urinalysis and blood and tissue analysis. Since they cannot give an accurate result, it is necessary to take samples of infected tissue. Surgery is inevitable.

Based on the tests and visual examination, the doctor is obliged to immediately begin treatment. Sanitation of dead tissue occurs until they are finally removed. After surgical intervention the patient's chances of survival increase.

During manipulation, incisions are made deeply to remove areas of necrosis and the area around it. During this procedure, the doctor must comply with the following conditions:

constant treatment and dressing of the wound;
all necrotic tissue is removed;
the wound is left open, maintaining homeostasis;
daily processing and analysis of the course of the disease.

When necrotic tissue is removed, dressing, debridement and antibiotics are required for a certain period of time. Not everyone benefits from surgery; after it, complications of fasciitis can develop: sepsis, limb amputation, renal failure, toxic shock syndrome.

The main thing is not to let it go and see a doctor in time.

The mortality rate is 30-35%, so the patient needs to take fasciitis extremely seriously, because it is one of the most serious diseases. Self-medication is unacceptable.

OrtoCure.com

Necrotizing fasciitis is an infectious disease in which rapidly spreading necrosis affects the subcutaneous tissue, superficial and deep fascia (connective tissue membrane). Usually caused by the gram-positive bacteria Streptococcus pyogenes or mixed aerobic and anaerobic microflora.

General information

The first case of the disease was recorded in 1871 in the USA, and the first description of the disease, made in 1892, belongs to Welch and Netall. The modern name of the disease was proposed by Nilsson in 1952.

The disease is relatively rare - since 1883, the medical literature has recorded about 500 cases of necrotizing fasciitis, but in Lately the incidence of the disease has increased. According to statistics, the current prevalence of necrotizing fasciitis is 0.4 cases per 100,000 people.

Average age patients – 38-44 years. The disease is twice as common in men as in women and is very rare in children (such cases have been reported in countries where low level hygiene).

The fatal outcome is 33% of the number of cases.

A disease caused by group A beta-hemolytic streptococci (Streptococcus pyogenes). This form is sometimes called hemolytic streptococcal gangrene.
A disease that is caused by a mixed infection. The causative agents are simultaneously non-group A hemolytic and non-hemolytic streptococcus, Escherichia coli, the rod-shaped bacterium Enterobacter, various enterobacteria and pseudomonads, as well as Citrobacter freundi, Klebsiella pneumoniae, Proteus mirabilis and others anaerobic bacteria and facultative anaerobes.

Based on the location of necrotizing fasciitis, a form is distinguished that primarily affects the perineum, scrotum and penis, in which the infectious process is likely to spread to the thighs and anterior abdominal wall (Fournier’s gangrene).

Depending on the clinical picture of the disease, necrotizing fasciitis can be:

Primary. It begins with damage to the fascia, pain and swelling at the site of the injury.
Secondary. The development of the disease occurs against the background of advanced purulent skin diseases. Symptoms of necrotizing fasciitis are superimposed on the clinical picture of the underlying disease, and necrotic manifestations are observed at the site of the primary purulent focus.

Reasons for development

The disease develops as a result of the spread of infection of the streptococcal group or aerobic and anaerobic bacteria. Infection may spread to the fascia as a complication of:

for puncture and laceration wounds, abrasions, blunt trauma;
after surgery in the area abdominal cavity, gastrointestinal tract, urinary tract and perineum;
superinfections with chickenpox;
with subcutaneous injections.

Streptococcus can spread through the bloodstream from a distant source of infection.

The causes of Fourier's gangrene are:

paraproctitis;
periurethral gland infections;
retroperitoneal infection due to perforation internal organs abdominal cavity.

In children, the infection usually spreads to the fascia with omphalitis (bacterial inflammation of the umbilical ring, subcutaneous fat around it and the bottom of the umbilical wound) and balanitis (inflammation of the glans penis that occurs during circumcision).

The disease develops in the presence of accompanying factors, which include:

Weakening of the immune system (local or general). The risk group includes people suffering from diabetes, peripheral vascular diseases, malignant neoplasms, as well as persons who have recently undergone corticosteroid immunosuppressive therapy or surgery.
Injection drug addiction and chronic alcoholism.
Immunodeficiency states.
Age over 50 years.
Excess body weight.

In some cases, the development of the disease is provoked by insect bites, taking non-steroidal anti-inflammatory drugs and fungal diseases.

Pathogenesis

The pathogenesis of necrotizing fasciitis is associated with thrombosis of the microvasculature of the skin and damage to adjacent tissues. This explains the rapid progression of necrosis, which does not involve a separate area of fascia, but a large region that corresponds to the zone of microvascular circulation.

Morphological changes in the fascia are initially gangrenous in nature - the affected tissues do not become inflamed, but die.

The destructive and rapid course of the disease is associated with polymicrobial infection - with necrotizing fasciitis, most necrotic tissues contain:

Anaerobic bacteria that grow in tissues deprived of sufficient oxygen as a result of injury, surgery, or other disorder.
Aerobic bacteria that multiply in tissues due to a decrease in the function of polymorphonuclear neutrophils (polymorphonuclear neutrophils play a key role in providing innate immunity, and their functions are reduced during wound hypoxia). The proliferation of aerobic bacteria further reduces the redox potential, and this accelerates the spread of infection.

The end products of metabolism of aerobic organisms are water and carbon dioxide. With a mixed infection, nitrogen, hydrogen, methane and hydrogen sulfide, which are poorly soluble in water, accumulate in the soft tissues.

Microorganisms spread along the fascia from the affected subcutaneous tissues. Deep infection causes vascular occlusion (obstruction), ischemia and necrosis of deep tissues. There is also damage to the superficial nerves, which manifests itself as characteristic localized numbness.

If left untreated, sepsis develops.

Symptoms

A distinctive feature of necrotizing fasciitis is local swelling, erythema, increased skin temperature and intense pain that does not correspond to local changes in the skin (often reminiscent of muscle damage or rupture).

The primary form of necrotizing fasciitis immediately begins with damage to the fascia and manifests itself:

swelling of the skin in an isolated area;
painful sensations at the site of the lesion;
hyperemia.

With streptococcal infection, the following quickly appear:

dark spots with the formation of blisters that are filled with dark liquid;
areas of superficial skin necrosis that may merge.

With non-streptococcal infections, the disease develops more slowly and the symptoms are less pronounced. The presence at the site of the lesion is observed:

swelling and woody thickening of the skin;
erythematous and pale spots at the site of compaction.

At the site of the wound, a dirty gray tint of the fascia is observed, a cloudy, often brownish exudate is present, and the subcutaneous tissue is instrumental study can be easily separated from the fascia.

Necrotizing fasciitis is accompanied by:

high temperature, at which sharp rises and falls of 3-5 C are possible;
tachycardia;
leukocytosis;
general weakness.

The muscle layer is usually not affected, but if left untreated, myositis or myonecrosis may develop.

In some cases, symptoms appear in an area that is distant from the site of injury.

Cases of fulminant progression of necrotizing fasciitis and death in the absence of changes in the color and temperature of the affected areas have also been described.

Diagnostics

The diagnosis is based on:

History of the disease. The patient's complaints, the presence of injury and other provoking factors are clarified.
General inspection. At the initial stage appearance the patient may not correspond to the degree of his discomfort, but intoxication develops quite quickly.
Laboratory tests. The main sign of inflammation is an increased erythrocyte sedimentation rate and leukocytosis with a shift of the leukogram to the left, which are detected during a detailed blood test. Arterial blood gas levels are also measured.

To clarify the diagnosis, an incisional biopsy is used, in which tissue sections obtained during the removal of necrotic areas are examined. Research is carried out on a freezing microtome, which allows you to obtain results in a short period of time.

To determine the pathogen, microscopy of a Gram-stained section is used.

Additionally, exudate is studied to determine sensitivity to antibiotics.

The only thing effective treatment necrotizing fasciitis is a surgical procedure that involves performing a necrectomy (removal of affected tissue). During surgery:

determine the boundaries of necrosis;
evaluate the nature of the affected tissues (smell, presence of gas, etc.);
affected tissues are excised.

For extensive lesions and blurred boundaries, staged necrectomies are performed.

Mechanical tissue removal is accompanied by the use of:

ultrasonic cavitation;
chemical necrectomy (sodium hypochlorite, proteolytic enzymes are used).

Antibacterial therapy is also prescribed:

benzylpenicillin every 4 hours for streptococcal infection;
broad-spectrum antibiotics and antibacterial bactericidal drugs active against anaerobic microflora (dioxidin, metrogil).

Detoxification therapy is carried out according to general principles treatment of purulent-inflammatory diseases.

Historical reference
- The disease was first described by Hippocrates in the 5th century BC. BC, the first case described in the United States dates back to 1871.
- The term “necrotizing fasciitis” was first used in 1952.
The prevalence among adults is 0.4 cases per 100,000 people.
The prevalence in children is 0.08 per 100,000 people.

The overall incidence has increased fivefold over the past decade.
Necrotizing fasciitis type 1 is the most common form of necrotizing fasciitis.

Risk factors for necrotizing fasciitis type I:
- Diabetes.

- Obesity.
- Alcoholism and cirrhosis.
- Intravenous administration medicines. - Bedsores. - Malnutrition.
- Patient after surgery or with a penetrating wound. - Abscess of the female genital organs.

Risk factors for necrotizing fasciitis type II:
- Diabetes.
- Severe peripheral vascular disease.
- Recent birth.
- Trauma.
- Muscle damage.
- Chicken pox.
- There is conflicting information about the importance of using non-steroidal anti-inflammatory drugs.

Causes and mechanisms of development of necrotizing fasciitis

Necrotizing fasciitis type I:
- Polymicrobial infection caused by aerobic and anaerobic bacteria.
Up to 15 pathogens are detected in one wound.
On average, there are five different pathogenic strains per wound.

The most common microorganisms:
Streptococci that do not belong to group A.
Enterobacteriaceae organisms.
Bacteriodes.
Peptostreptococcus.

If exposed to salt water:
A penetrating wound or open wound contaminated by salt water.
Caused by marine gram-negative organisms of the genus Vibrio, the most virulent of which is Vibrio vulnificus.

Necrotizing type II:
- Usually monomicrobial infection caused by Streptococcus pyogenes:
Occurs in combination with Staphylococcus aureus.
Methicillin-resistant Staphylococcus aureus is very rarely detected.
-Streptococcus pyogenes strains can secrete pyrogenic exotoxins that act as superantigens, stimulating the production of TNF-a, TNF-b, IL-1, IL-6 and IL-24.
For timely diagnosis and initiation of treatment, examination of the patient by an experienced surgeon plays a decisive role.

Clinic and diagnosis of necrotizing fasciitis

Rapid progression of erythema to vesicle, ecchymosis and necrosis or gangrene.
Swelling of the “stiff” subcutaneous tissues, spreading beyond the boundaries of the erythema.
Lack of response to empirical antimicrobial therapy.
Heat body and severe systemic toxicity.

Persistent severe pain, disproportionate to skin manifestations.
As the disease progresses, the pain progresses to cutaneous anesthesia.
Crepitus in necrotizing fasciitis type I.
Can occur on any part of the body.

In most cases it is observed on lower limbs
Often found on the abdominal wall and perineum.
Routine laboratory tests are nonspecific.
For culture analysis, it is better to perform a deep biopsy.

Standard radiography does not provide the necessary information, unless there is air in the tissue.
MRI helps determine the extent of the lesion, but consultation with a surgeon should not be delayed.
Macroscopic examination reveals swollen, dull, gray fascia with long and thin areas of necrosis.

Necrosis of the superficial fascia and fatty tissue leads to the formation of watery pus with an unpleasant odor.
Histological examination reveals necrosis of subcutaneous fat, vasculitis and local hemorrhages.

Differential diagnosis of necrotizing fasciitis

Cellulitis is an acute, widespread infection of the skin and soft tissues, characterized by erythema, swelling, pain and local increase in tissue temperature. Despite antibiotic therapy, the disease progresses rapidly, with systemic toxicity, severe pain, and necrosis suggestive of necrotizing fasciitis rather than cellulitis.

Pyomyositis - purulent inflammation skeletal muscles. Zero is localized to individual muscles, and the absence of systemic toxicity indicates pyomyositis rather than necrotizing fasciitis. The diagnosis is confirmed additional methods research.

Erythema induratum - painful erythematous subcutaneous nodes on the legs (especially in the area calf muscles). The absence of fever, systemic toxicity, and skin necrosis suggests erythema induratum rather than necrotizing fasciitis. Erythema induratum can become chronic, relapsing, and the patient often has a history of tuberculosis or a positive tuberculin skin test.

Clostridial myonecrosis is an acute necrotizing infection of muscle tissue caused by clostridial microorganisms. Surgical exploration and culture are required to differentiate this disease from necrotizing fasciitis.

Streptococcal or staphylococcal toxic shock syndrome is a systemic inflammatory response to toxins produced by bacteria, which is characterized by fever, hypotension, generalized erythroderma, myalgia and multisystem organ damage. Necrotizing fasciitis can develop due to toxic current. Consultation with an infectious disease specialist and surgeon is essential.

Source: jmedicalcasereports.biomedcentral.com

A young woman with leg pain and fever was admitted to the hospital - an ulcer that had been bothering her for 3 years began to increase after topical use of herbal compresses

Based on: Fulminant necrotizing fasciitis following the use of herbal concoction: a case report

Aidigun I. A., Nasir A. A., Aderibigbe A. B.

Journal of Medical Case Reports 2010, 4:326

A twenty-year-old Igbo student (Nigeria) was admitted with complaints of pain and swelling of the right leg that progressed over three days. According to the medical history, the patient has been suffering from a chronic trophic ulcer of the right leg for the last three years, for which skin grafting was performed. The ulcer began to enlarge after topical application of herbal compresses two weeks before admission.

Upon admission, in addition to pain in the leg, the patient was bothered by a feeling of thirst and shortness of breath. On examination: fever, body temperature 38.2 °C, the skin and visible mucous membranes are dry and somewhat jaundiced, swelling of both legs, more pronounced on the right and reaching the thigh. It was not possible to palpate the pulsation of the dorsal artery of the foot on the right. The pulse is regular with a frequency of up to 132 beats per minute, blood pressure = 90/50 mm. rt. Art. On the right leg there are multiple ulcers with cloudy purulent discharge.

The electrolyte composition of the blood serum was within normal limits.

Treatment started: Ceftriaxone 1 g IV drip 2 times a day, crystalloid infusions, metronidazole 500 mg 3 times a day, three units of red blood cells were transfused. A fasciotomy was performed, which, however, did not bring improvement.

During the therapy, extensive necrosis of the skin of the right leg developed; subcutaneous crepitus was detected by palpation from the foot to the upper third of the leg. On the fourth day after admission, emergency radical surgical treatment of the wounds of the anterior, lateral and back surfaces right shin. During the operation, extensive intramuscular abscesses were discovered and excised, as well as necrotic areas of the gastrocnemius and tibialis anterior muscles. In the postoperative period, dressings were performed and surgical treatment was continued, but the necrotic process spread to the large and small tibia with the development of sepsis. Due to a threatening condition, a patellar amputation of the right leg was performed.

Bacteriological examination of the wound material revealed the growth of bacteria of the genera Klebseilla and Pseudomonas. Histological examination of the tissues of the removed limb described extensive necrosis of fatty, connective and striated muscle tissue with focal accumulations of mononuclear cells.

The postoperative period proceeded without complications, the patient's condition improved after amputation, and preparations for prosthetics began.

Discussion

Necrotizing fasciitis (NF) is a rare but severe rapidly progressive soft tissue infection characterized by extensive necrosis of the superficial fascia and subcutaneous fat. NF spreads along the surface of the fascia, usually without affecting the skin and muscles, but in severe cases, all the above and underlying organs and tissues are involved in the process. Early suspicion of NF is critically important, since the survival rate for this pathology is lower the longer the time that passes from infection to the initiation of appropriate therapy. NF can develop after surgery, minor injuries, scratches, both against the background of chronic skin lesions and in previously healthy individuals. Cases of the development of this pathology after corticosteroid therapy and after intramuscular injection of NSAIDs have been described, but a case of NF after a herbal compress has been described for the first time. In developing countries, various folk remedies plant origin and unknown composition are used by the local population for many diseases, but the application of herbal compresses to open wounds is not so common.

The composition of causative agents of soft tissue infections is diverse and includes highly virulent strains of Streptococcus, Staphylococcus, or combinations of gram-negative and anaerobic bacteria. In the described case, the growth of Klebseilla and Pseudomonas bacteria was detected.

The publication of the clinical case was carried out with the consent of the patient. Copy of signed informed consent is with the editor-in-chief of the Journal of medical case reports.

The disease begins nonspecifically, the patient is bothered by fever, pain in the leg and swelling, local redness, loss of sensitivity or subcutaneous crepitus may occur. The discrepancy between the intensity of pain and minimal local changes may attract attention and alert.

At later stages, the infectious process spreads locally through the fascia, causing thrombosis and disrupting the vascularization of the skin. Once bacteria and toxins enter the bloodstream, sepsis develops. When the underlying muscles are involved, necrotizing myositis develops, which can be detected by CT and MRI studies.

The main method of treating soft tissue infections is early radical surgical debridement and resection of all necrotic tissue against the background of full antibacterial therapy. Fulminant and severe cases may require amputation of the affected limb.

Sources

Rieger U. M., et al. Prognostic factors in necrotizing fasciitis and myositis: analysis of 16 consecutive cases at a single institution in Switzerland. Ann Plast Surg. 2007, 58: 523–530.
Sonia F., Andress C. Necrotizing fasciitis due to streptococcus pneumoniae after intramuscular injection of nonsteroidal anti-inflammatory drugs: Report of cases and Review. Clin Infect Dis. 2001, 33: 740–744.
Donaldson P. M., et al. Rapidly fatal necrotizing fasciitis caused by Streptococcus pyogenes. J Clin Pathol. 1993, 46: 617–620.
Heitmann C., et al. Surgical concepts and results in necrotizing fasciitis. Chirurg. 2001, 72: 168–173.
Hashimoto N., et al. Fulminant necrotizing fasciitis developing during long term corticosteroid treatment of systemic lupus erythematosus. Ann Rheum. Dis. 2002, 61: 848–849.
Nai-Chen C., et al. Necrotizing fasciitis: clinical features in patients with liver cirrhosis. Br J Plast Surg. 2005, 58: 702–707.
Meltzer D. L., Kabongo M. Necrotizing fasciitis: a diagnostic challenge. Am Fam Physician. 1997, 56: 145–149.
Green R. J., Dafoe D. C., Raffin T. A. Necrotizing faciitis. Chest. 1996, 110: 219–229.

Necrotizing fasciitis (NF) is a rapidly progressive infection that primarily affects the subcutaneous connective tissues(fascia), where it can quickly spread to involve neighboring soft fabrics, which leads to widespread necrosis (tissue death). Several different types of flesh-eating bacteria can cause this life-threatening condition, which can affect both healthy people, and for those with underlying medical problems. Although rare, there has been an increase in the incidence of necrotizing fasciitis over the past few decades. Although apparently unreported, the annual incidence of necrotizing fasciitis is estimated to be 500–1,000 cases per year, with an overall disease prevalence of 0.40 cases per 100,000 population. Early identification and fast treatment necrotizing fasciitis are critical to managing the potentially devastating consequences of this emergency medical care.

What is the history of necrotizing fasciitis?

One of the first descriptions of necrotizing fasciitis comes from Hippocrates in the fifth century BC, when he described complications of erysipelas. Although necrotizing fasciitis has been around for centuries, several more detailed descriptions this condition was subsequently reported in the 19th and early 20th centuries. In 1952 year dr. B. Wilson first used the term necrotizing fasciitis to describe this condition, and this term remains the most common in modern medicine. Other terms that have been used to describe this same condition include flesh-eating bacteria syndrome, suppurative fasciitis, necrotizing cellulitis, necrotizing soft tissue infection, hospital gangrene, streptococcal gangrene, dermal gangrene, Melenei's ulcer and Melenei's gangrene. When necrotizing fasciitis affects the genital area, it is often called Fournier's gangrene (also called Fournier's gangrene).

What are the causes and risk factors for necrotizing fasciitis?

Necrotizing fasciitis is caused by bacteria in the vast majority of cases, although fungi can also rarely lead to this condition. Most cases of necrotizing fasciitis are caused by group A beta-hemolytic streptococci (Streptococcus pyogenes), although many different bacteria may be involved, either alone or together with other bacterial pathogens. Group A streptococcus is the same bacteria that is responsible for strep throat, impetigo (skin infection) and rheumatic fever. IN last years There has been a surge in cases of necrotizing fasciitis caused by community acquired methicillin-resistant Staphylococcus aureus (MRSA), often found in intravenous drug users. Most cases of necrotizing fasciitis are polymicrobial and include both aerobic and anaerobic bacteria. Additional bacterial organisms that may be isolated in cases of necrotizing fasciitis include Escherichia coli, Klebsiella, Pseudomonas, Proteus, Vibrio, Bacteroides, Peptostreptococcus, Clostridium, and Aeromonas hydrophila, among others.

In many cases of necrotizing fasciitis, there is a history of previous trauma, such as a cutting, scrape, insect bite, burn, or needlestick injury. These lesions may initially appear trivial or minor. Surgical incision sites and various surgical procedures can also serve as a source of infection. In many cases, however, there is no obvious source of infection or portal of entry to explain the cause (idiopathic).

Once a bacterial pathogen enters, the infection may spread from the subcutaneous tissues to involve deeper fascial planes. Progressive, rapid spread of infection will occur and can sometimes involve adjacent soft tissue, including muscle, fat and skin. Various bacterial enzymes and toxins lead to vascular occlusion, leading to tissue hypoxia (decreased oxygen) and ultimately tissue necrosis (death). In many cases, these tissue conditions allow the proliferation of anaerobic bacteria, allowing the infection to progressively spread and tissue destruction to continue.

Individuals with underlying medical problems and weakened immune systems are also at increased risk of developing necrotizing fasciitis. Various medical conditions, including diabetes, renal failure, liver disease, cancer, peripheral vascular disease, and HIV infection are often present in patients who develop necrotizing fasciitis, as well as in people undergoing chemotherapy, patients who have had organ transplants, and patients taking corticosteroids for a variety of reasons. Alcoholics and intravenous drug abusers are also at increased risk. However, many cases of necrotizing fasciitis also occur in healthy people who have no predisposing factors.

For classification purposes, necrotizing fasciitis has been divided into three distinct groups, largely based on the microbiology of the underlying infection; type 1 NF is caused by multiple bacterial species (polymicrobial), type 2 NF is caused by a single bacterial species (monomicrobial), which is usually Streptococcus pyogenes; type 3 NF (gas gangrene) is caused by Clostridium spp., and type 4 NF is caused by fungal infections, mainly Candida spp. and Zygomycetes. Infection caused by Vibrio spp. (often Vibrio vulnificus) is a species often found in people with liver disease, usually after eating seafood or exposure to skin wounds sea water contaminated by this organism.

Is Necrotizing Fasciitis contagious?

Necrotizing fasciitis is not considered an infectious disease. However, it is theoretically possible for an individual to become infected with the same organism that causes necrotizing fasciitis in someone with whom they have had direct contact (eg, MRSA infection). For a test individual to then begin to develop necrotizing fasciitis would be very rare and unlikely, although it is possible.

What are the signs and symptoms of necrotizing fasciitis?

Symptoms and signs of necrotizing fasciitis vary depending on the extent and progression of the disease. Necrotizing fasciitis often affects the extremities or the genital area (Fournier's gangrene), although any area of the body can be involved.

At the onset of the disease, patients with necrotizing fasciitis may initially present themselves deceptively, and they may not demonstrate any superficial visible signs main infection. Some people may initially complain of pain or tenderness, similar to a “pulled muscle.” However, as the infection spreads rapidly, symptoms and signs of severe illness become apparent.

Necrotizing fasciitis usually appears as an area of localized redness, warmth, swelling and pain, often resembling a superficial skin infection (cellulitis). Many times the pain and tenderness experienced by patients does not match the visible results on the skin. Fever and chills may be present. Over the course of hours and days, the redness of the skin spreads quickly and the skin may become dark, purple, or dark in color. Animating blisters, necrotic eschars (black scabs), hardening of the skin (thickening), skin breakdown, and wound drainage may develop. Sometimes a fine crackling sensation can be felt under the skin (crepitus), indicating gas within the tissues. Strong pain and tenderness may later decrease due to subsequent nerve damage, resulting in localized anesthesia of the affected area. If left untreated, persistent spread of infection and widespread involvement of the body invariably occurs, often leading to sepsis (spread of infection into the bloodstream) and often death.

Other associated symptoms seen with necrotizing fasciitis may include malaise, nausea, vomiting, weakness, dizziness and confusion.

When will someone seek medical help for necrotizing fasciitis?

Prompt identification and treatment of necrotizing fasciitis is critical to increase the likelihood of a favorable outcome. Due to the rapid progression of this condition, a high index of suspicion and early detection are necessary to immediately initiate emergency treatment. Those who have underlying medical problems or are debilitated the immune system, must be especially vigilant. Contact a healthcare professional if any of the following symptoms or signs occur:

Unexplained area of skin redness, warmth, tenderness, or swelling, with or without a history of previous skin trauma
Changes in skin color (dark, purple, mottled, black) or in skin texture (blisters, open wounds, hardening, hardening)
Drainage from any open wound
Fever or chills
Intense pain or discomfort in a body area, with or without previous injury

If a person has previously been assessed by a healthcare professional and there is progression of the above symptoms, or if the person does not improve (even with antibiotic treatment at home), a further reassessment should be undertaken. If necrotizing fasciitis is suspected, expedited surgical consultation is necessary.

Which specialists treat necrotizing fasciitis?

A multidisciplinary team of providers is needed to care for patients with necrotizing fasciitis. Most patients will go to the ward first emergency care, and therefore they will see an emergency doctor. The surgeon will begin to care for this patient early. Depending on which area of the body is involved, surgical subspecialists may also need to be consulted (for example, a urologist in the case of Fournier's gangrene). Specialist in infectious diseases often involved in antibiotic treatment.

PRACTICAL HEALTH ISSUES

UDC 616.75 - 092 - 07 - 089

NECROTIZING FACCIITIS: EARLY DIAGNOSIS AND

SURGERY

G.G.Shaginyan, M.N.Chekanov, S.G.Shtofin

Novosibirsk State Medical University, rector - doctor of medical sciences, prof. I.O. Marinkin; department general surgery, manager - Doctor of Medical Sciences, Prof.

S.G. Shtofin

Summary. In order to improve methods early diagnosis necrotizing fasciitis, an analysis of the results of clinical and laboratory research in 17 patients. As a result of the studies, it was revealed that with fascial necrosis there is always a reaction of the underlying muscles, which causes an increase in the level of

creatine phosphokinase (CPK). On average, the excess of the upper limit of the norm was 77.4 U/L. After 10 days after treatment (necrectomy and antibacterial therapy), the indicators did not go beyond the normal value of CPK activity (195 U/L).

Key words: necrotizing fasciitis, early diagnosis,

creatine phosphokinase.

Shaginyan Hrachya Henrikovich - graduate student of the department. pathological physiology and clinical pathophysiology of NSMU; e-mail: Dr. Shaginyan911 @yandex.ru.

Chekanov Mikhail Nikolaevich - Doctor of Medical Sciences, Prof. department General Surgery NSMU; e-mail: [email protected].

Shtofin Sergey Grigorievich - Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Prof., Head. Department of General Surgery, NSMU; e-shaP: Rg. 8baetpuan911 @uapeech.gi.

Necrotizing infections of the skin and soft tissues are severe, rapidly or rapidly progressing infections, accompanied by severe intoxication, predominantly affecting the fascia, fatty tissue, occurring without the formation of purulent exudate or with a disproportionately small amount of it. The mortality rate for the development of such infections ranges from 13.9% to 30%. .

Traditionally, anaerobic microorganisms play a leading role in the pathogenesis of necrotizing soft tissue infections.

A number of authors identify the following conditions as factors predisposing to the occurrence of necrotizing fasciitis: diabetes, immunodeficiency conditions, soft tissue injuries, drug injections, corticosteroid use, infectious complications in the postoperative period, the presence of excess body weight, age over fifty years, damage to peripheral vessels.

Histological studies showed that the leading factor in the occurrence of necrosis of fascial structures is the pathological formation of vascular thrombi, which disrupts the perfusion of the fascia and sharply reduces the transport of oxygen to the tissues.

As a result of the fact that pathological process begins deep in the tissues, in the initial stages of disease development clinical manifestations very scarce and manifest as the infection progresses. That is why the initial symptoms differ little from those with phlegmon and abscesses. Among others, the most common symptoms are: erythema, intense swelling, discoloration of the skin to gray with a bluish tint, the presence of bullae with hemorrhagic contents, the presence of ulcerations and necrosis of the skin.

Among the proposed methods for early diagnosis of fascial necrosis, ultrasound and MRI of soft tissues, tissue cryobiopsy followed by morphological examination can be noted.

In the presence of fascial necrosis, there is almost always a reaction of the underlying muscle tissue, which determines the increase in the level of creatine phosphokinase (CPK) activity.

Currently, the mortality rate for of this disease remains high (21.9%), which requires quick, timely diagnosis and urgent radical treatment surgical treatment.

In modern medical literature necrotizing fasciitis has received insufficient attention and terminology remains unclear.

Given the clinical similarities to initial stages NF with other soft tissue infections, the issue of early diagnosis is extremely relevant.

The purpose of the study is to develop a method for early diagnosis of necrotizing fasciitis and optimize the timing of the start of surgical treatment.

Materials and methods

The basis of this work is an analysis of the treatment of 17 patients with necrotizing fasciitis for the period from 2006 to 2010. in the clinic of general surgery of the Novosibirsk State medical university. The average age in the main study group was 57 years (from 36 to 78 years). The gender ratio was: women - 6, men - 11. Average duration from the onset of the disease to hospitalization in surgical hospital amounted to 7.5 (from 2 to 13) days.

Among the predisposing factors in 14 patients were age over 50 years, five patients abused alcohol, one patient suffered from opium drug addiction, two patients had atherosclerotic lesion lower extremities, three patients were obese and one patient had been taking corticosteroids for a long time.

For comparison, an analysis of the examination and treatment of 20 patients with abscesses and 20 patients with phlegmon of various locations was carried out. In the comparison group, similar criteria for assessing the condition of patients were used.

With the aim of differential diagnosis In the first hours upon admission, blood was drawn from all patients to determine CPK activity. To avoid false-positive results (increased CPK activity is possible in acute coronary pathology and myocardial ischemia, as well as in traumatic damage to a large muscle mass), patients were required to be examined by a cardiologist after recording an ECG. Repeated blood sampling and determination of CPK activity were carried out 10 days after necrectomy and the start of antibacterial treatment.

Results and discussion

Calculations and graphical representation The results were carried out using statistical data processing programs Statistica 7.0, SPSS 11.5, MS Excel from the MS Office 2003 and 2007 packages.

A distinctive feature of the described changes was their rapid growth. Thus, in 4 patients, less than 24 hours passed from the initial damage to the skin until the onset of the described symptoms.

Of the specific symptoms of necrotizing fasciitis, patients most often experienced various changes in skin coloration. We noted characteristic bluish or brownish spots in 14 observations. Uniform cyanosis of the skin with areas of black or dark purple necrosis - in 5 patients. Detachment of the epidermis in the form of bluish-gray bullae filled with dark turbid liquid - in 8 patients.

In terms of area, the skin changes were significantly smaller than the boundaries of inflammation of the subcutaneous tissue, the swelling of which, in turn, did not allow palpation of deeper muscle formations. At the same time, the localization of skin changes, as a rule, was quite clearly projected onto the intraoperatively identified zone of greatest

lesions of the superficial fascia. Fluctuation in necrotizing fasciitis was, as a rule, not detected in our observations. Only 2 patients in whom necrotizing fasciitis developed against the background of purulent-inflammatory diseases of soft tissues (mainly post-injection abscesses and phlegmons), who did not undergo timely surgical treatment, had a fluctuation.

Crepitus on palpation was noted in 4 cases. It is noteworthy that this sign was often determined far beyond the necrotic tissues, sometimes not even having common boundaries with them, and when making diagnostic incisions over areas with a characteristic palpation crunch, we often found visually viable tissues with single gas bubbles.

In 9 patients, body temperature remained normal, 5 had low-grade fever, one had a temperature rise above 39.2 °C, and 2 had a body temperature in the range of 38.0-39.1 °C. One patient experienced hypothermia. In 2 patients, a rise in temperature was noted during the first hours, and in 2 patients - on the first day from the onset of the disease.

For surgical treatment of necrotizing fasciitis in all patients subcutaneous tissue was swollen, dirty gray in color, saturated with cloudy, often foul-smelling exudate, sometimes with gas bubbles. Fascia is swollen, gray or black, often slimy, saturated with similar exudate. The muscles had a dull, flabby, “boiled” appearance, saturated with serous-hemorrhagic exudate.

In 8 observations, hyperemia and compaction of the underlying tissues spread to neighboring areas - the groin, buttocks, lower extremities, and also the abdominal wall.

However, in 3 patients over a long period of time (3-5 days), the only local symptom of necrotizing fasciitis was pain in the affected segment without any other physical signs of infection.

Localization of the process was observed: in upper limbs in 5 patients, in the lower extremities - in 10, in the head and neck area - in one, in the perineal area - in one.

The average area of soft tissue involvement was 5% (range 2 to 8%).

At microbiological research The following strains were verified: S. aureus - 7, S. pyogenes - 3, E. coli - 1, P. aeruginosa - 4.

All patients had leukocytosis upon admission to the hospital - an average of 18.3x109/l (from 13.6 to 23.1x109/l). In addition, they had relative lymphopenia - an average of 10% (from 4 to 16%).

In all observations, the morphological picture in preparations of skin, subcutaneous fat, skeletal muscles and fascia obtained from the site of inflammation was characterized by widespread necrotic tissue changes. The exudate contained a small amount of polymorphonuclear leukocytes (the phenomenon of “leukocyte flight”) and exfoliated necrotic tissue. Circulatory disorders manifested themselves in the form of plethora, stasis and sludge phenomenon in the vessels of the microvasculature. With fibrinoid necrosis of the arterial walls, perivascular focal hemorrhages were noted. There was always marked interstitial edema of the surrounding tissues.

During hospitalization, all patients had increased level creatinine phosphokinase activity. On average, the excess of the upper limit of the norm was 77.4 U/L. After 10 days after treatment (necrectomy and antibacterial treatment), the indicators did not go beyond the normal value of CPK activity (195 U/L).

The data obtained as a result of the study are presented in Fig. 1, where “CPK-1” is the activity of the enzyme under study upon admission of the patient to the hospital, “CPK-2” is the activity of the enzyme after 10 days, the horizontal line is the upper limit of the normal value of CPK activity = 195 U/L.

In Fig. 2 and 3 present the results of examination of patients with abscesses and phlegmon, respectively. At the same time, both upon admission and after surgical treatment, CPK indicators did not go beyond normal limits.

All patients were operated on on the first day after hospitalization. Mortality in the main study group was 11.8% (2 patients, 78 years old and 76 years old, died from multiple organ failure).

The average length of hospital stay for patients with NF was 41±3 days. All patients received combined empirical antibacterial treatment with broad-spectrum drugs before receiving the results of bacteriological analysis and the nature of microflora sensitivity. The number of necrectomies performed in one patient did not exceed three. Limb amputation was performed in one patient. All patients required autodermoplasty.

Thus, in the early stages of the disease, the diagnosis of necrotizing fasciitis cannot always be established based on an assessment of the clinical picture of the disease. The analysis of the main clinical symptoms did not reveal pathognomonic signs for necrotizing fasciitis.

In this regard, it is advisable to study the level of creatine phosphokinase activity as a marker of muscle tissue necrosis, which can provide significant support in making the diagnosis of necrotizing fasciitis.

It should be noted that the results of surgical treatment of patients with necrotizing fasciitis directly depend on the timely diagnosis.

NECROTIC FASCIITIS: EARLY DIAGNOSTICS AND SURGICAL

G.G. Shaginyan, M.N. Chekanov, S.G. Shtofin Novosibirsk state medical university

Abstract. We analyzed clinical and laboratory results of 17 patients with necrotic fasciitis for early diagnostic improvement. It was revealed that necrotic fasciitis is accompanied by creatinphosphokinase (CPK) increasing and reaction of nearby muscles. In average CPK level excess norm level to 77.4 U/L. Normal CPK activity (195U/L) was observed after 10 days of treatment (necrectomia and antibacterial therapy).

Key words: necrotic fasciitis, early diagnostics, creatinphosphokinase.

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