Necrotizing infections of the skin and fascia include necrotizing forms of cellulitis and fasciitis types I and II. These infections are characterized clinically by fulminant destruction of tissue, systemic signs of toxicity, and a high rate of mortality. NECROTIZING CELLULITIS
There are several different types of necrotizing cellulitis including clostridial and nonclostridial anaerobic infections.
Clostridial cellulitis - Clostridial cellulitis, most often due to Clostridium perfringens, is usually preceded by local trauma or recent surgery. Gas is invariably found in the skin, but the fascia and deep muscle are spared. Magnetic resonance imaging (MRI) or CT scanning and measurement of the serum creatine kinase (CK) concentration can help to determine if muscle tissue is involved.
Nonclostridial anaerobic cellulitis - Is due to infection with mixed anaerobic and aerobic organisms that produce gas in tissues. Unlike clostridial cellulitis, this infection is usually associated with diabetes mellitus and often produces a foul odor. It must be distinguished from myonecrosis and necrotizing fasciitis by surgical exploration
Necrotizing fasciitis is a deep-seated infection of the subcutaneous tissue that results in progressive destruction of fascia and fat, but may spare the skin. Two clinical types exist.
Unexplained pain, which increases rapidly over time, may be the first manifestation of necrotizing fasciitis. Whenever postoperative/posttraumatic pain is increasing in severity, the patient should be examined expeditiously to verify that a serious wound complication, such as necrotizing fasciitis, is not the source of the increasing pain. Thus the triad of incordinate pelvic pain, oedema (unilateral) and any sign af septicemia in the post partum period create a high suspision on necrotizing fasciitis and mandate imediately surgical intervention.
Erythema may be present diffusely or locally. Within 24 to 48 hours, erythema may develop or darken to a reddish-purple color, frequently with associated blisters and bullae; bullae can also develop in normal appearing skin. Once the bullous stage is reached, there is already extensive deep soft tissue destruction such as necrotizing fasciitis or myonecrosis. Crepitus is present in about 10 percent of patients. GAS production does not play a significant role in the early diagnosis. GAS is seen by X-ray, CT-scan or magnetic Imagining (MR) and should be obtain if the diagnosis is in doubt. Awaiting results of blood cultures or skin aspirates should not be done. Surgical exploration should proceed rapidly if this diagnosis is suspected. The patient can develop bakteriaemia -sepsis - sepsis shock and multiple organ dysfunction syndrome (MODS). Recommendations
(1) Nekrotiserende Fascit: Guidelines from Rigshospitalet, Copenhagen (2) www.uptodate.com 2007 UptoDate 2006. version 14.3 Se also Piper JM, West P. Necrotizing fasciitis following postpartum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet. 1995;256(1):35-8. Ozalay M, et all Necrotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality. 2006 Schroeder JL, Steinke EE. Necrotizing fasciitis--the importance of early diagnosis and debridement. 2005 Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. 2005