Necrotizing fasciitis

Case report:

In a bedridden for several weeks 73 years old patients with diabetes mellitus and chronic alcoholism evolved over several days in the area of the ischial tuberosity decubital over a massive erythema of the skin with focal necrotizing epidermolysis throughout the anogenital region. The patient in this affected skin area to considerable pain and febrile offers temperatures up to 39 � C and intermittent confusion.

Comment:

The clinical findings with an inflammatory swelling of the skin, an ill-defined erythema and a reddish livid, map-like discoloration of the skin with blackish central districts must draw attention to the diagnosis of necrotizing fasciitis is suspected. Since the differential diagnosis especially at an early stage is difficult, six other characteristics are in the relevant literature been formulated: 1. An extensive necrosis of superficial fascia with extension to the adjacent skin, 2. moderate to severe Systemintoxikation with disturbance of consciousness, 3. lack of a primary muscle involvement , 4. Absence of clostridia in the wound smear, 5. lack of a causal vascular occlusion, 6. leukocyte infiltration, focal necrosis of the fascia and the surrounding tissue and vascular thrombosis in the histological micro-examination of the excised tissue.
In the advanced stage of this disease, there is wide-scale Fasziennekrosen with extensive cutaneous necrosis. Most missing a lymphadenopathy and it develops a strong septic disease.

Etiology:

When necrotizing fasciitis is a bacterial infection, in which two types can be differentiated with respect to the excitation spectrum. The type I is characterized by a mixed infection with anaerobes, enterobacteria or non-group A streptococci, type II is caused by hemolytic streptococcus group A. The group A streptococci is pathogenetically given the greater importance. In particular, the streptococcal M proteins with type 1 and type 3 are found in such invasive disease. In addition, these bacterial pathogens are characterized by a endotoxin similar C complex, by the streptolysin S, and by so-called "spreading factors" such as hyaluronidase, streptokinase and streptodornase. Epidemiologically is expected in the United States of 10,000 cases of illness annually and the disease has recently been drawn as streptogenes, toxic shock syndrome.

Therapy:

Are the clinical features of necrotizing fasciitis, there is the indication for immediate surgery. All necrotic tissue must be excised consistently. Especially with septic disease intensive medical therapy and monitoring is necessary. The antibiotic treatment is not a priority of the therapeutic efforts, however, should definitely also be initiated. Although the streptococcal comes pathogenetically to the highest value, frequently it is but to mixed infections with Gram-positive, Gram-negative and anaerobic pathogens. Antimicrobial therapy with a broad-spectrum penicillin in combination with a beta-Laktamaseinhibitor detects the germ spectrum adequately. Thus, ampicillin plus sulbactam (UNACID) in a daily dose of three 3 g, amoxicillin plus clavulanic acid (Augmentin) four 2 g daily, mezlocillin (BAYPEN) three times 4 g daily plus three 1 gSulbactam (sulbactam) daily or piperacillin plus tazobactam (TAZOBAC ) three to four times 5 g iv are recommended daily.

Forecast:

The lethality of this serious infection is dependent on how fast the surgical care. With age, the mortality rate of necrotizing fasciitis increases. This can achieve when there is inadequate or delayed treatment up to 70%.