Two Types of Necrotizing Fasciitis

1Drexel–College of Medicine, Philadelphia, PA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 368

Case Presentation:

Case 1 is a 62‐year‐old woman with a history of end‐stage renal disease and poorly controlled diabetes mellitus who presented with confusion, fever, and an abscess on the posteromedial aspect of the left thigh. The abscess was drained in the operating room. The surrounding skin and underlying fascia were found to be necrotic. In the next week, she underwent multiple debridements of the necrotic fascia and received broad‐spectrum antibiotics, after which she improved significantly. Cultures of the wound grew Enterococcus faecalis, Enterococcus faecium, Proteus mirabilis, andPseudomonas aeruginosa. After 2 weeks, the patient was discharged home on oral antibiotics. Case 2 is a 59‐year‐old woman with a chronic nonhealing ulcer at left ankle presented with worsening cellulitis of the left lower extremity. On examination, she was febrile and hypotensive and had a cutaneous bulla on the left leg. She was taken to the operating room and was found to have extensive necrosis of the fascia and the muscle, all of which were debrided. She received broad‐spectrum antibiotics. The organism isolated from both the wound culture and blood culture was Streptococcus pyogenes. The biopsy of her chronic non‐healing ulcer showed moderately differentiated squamous cell carcinoma. The patient improved transiently, but the hospital course was complicated by a pulmonary embolism and Clostridium difficile colitis, and she died 2 weeks later.

Discussion:

Necrotizing fasciitis (NF) is necrosis of subcutaneous tissue that carries a high mortality rate of 30%. The most common types of NF are polymicrobial (type 1), caused by mixed aerobic and anaerobic bacteria, and monomicrobial (type 2), caused by Streptococcus pyogenes. Type I is usually seen in patients with underlying diseases such as diabetes mellitus. Type 2, on the other hand, tends to occur in healthy individuals. NF is a rapidly progressive condition that requires prompt diagnosis, timely surgical intervention, and appropriate antibiotics. Patients classically present with crepitus, bullae, and pain disproportionate to the expected clinical findings. However, the absence of these features should not deter a clinician in making a firm diagnosis of NF. Initial medical therapy consists of broad‐spectrum antibiotics to cover for gram‐negative, anaerobic, and gram‐positive bacteria. It is important to consider Four‐nier's gangrene, which is NF of the perineum when the infection approaches these anatomic sites, as seen in our first case. Fournier's gangrene has much higher mortality, reaching up to 88%. The second case is unusual, as the patient was found to have a Marjolin's ulcer, an aggressive squamous cell carcinoma that arises from a chronic nonhealing wound, which we believe was the port of entry for Streptococcus pyogenes.

Conclusions:

The purpose of this clinical vignette is to provide an up‐to‐date review of NF and to highlight the differences between type 1 and type 2 NF with the examples of 2 diverse cases.

Disclosures:

H. Pham ‐ none; P. Kaushik ‐ none; B. Palermo ‐ none

To cite this abstract:

Pham H, Kaushik P, Palermo B. Two Types of Necrotizing Fasciitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 368. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/two-types-of-necrotizing-fasciitis/. Accessed November 12, 2019.

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