Necrotizing fasciitis

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Necrotizing fasciitis
Other namesFlesh-eating bacteria, flesh-eating bacteria syndrome, [1] necrotizing soft tissue infection (NSTI), [2] fasciitis necroticans
Necrotizing fasciitis left leg.JPEG
Person with necrotizing fasciitis. The left leg shows extensive redness and tissue death.
Pronunciation
Specialty Infectious disease
Symptoms Severe pain, fever, purple colored skin in the affected area [3]
Usual onsetSudden, spreads rapidly [3]
CausesMultiple types of bacteria, [4] occasional fungus [5]
Risk factors Poor immune function such as from diabetes or cancer, obesity, alcoholism, intravenous drug use, peripheral artery disease [2] [3]
Diagnostic method Based on symptoms, medical imaging [4]
Differential diagnosis Cellulitis, pyomyositis, gas gangrene, toxic shock syndrome or toxic shock-like syndrome, pyoderma gangrenosum, deep vein thrombosis, Mucormycosis, brown recluse spider bite [6]
Prevention Wound care, handwashing [3]
Treatment Surgery to remove the infected tissue, intravenous antibiotics [2] [3]
Prognosis ~30% mortality with treatment, [2] ~100% mortality without treatment
Frequency0.7 per 100,000 per year [4]
Blackish discoloration with vesicle formation on the thigh in a case of necrotizing fasciitis Blackish discolouration with vesicle formation on the thigh NF.webp
Blackish discoloration with vesicle formation on the thigh in a case of necrotizing fasciitis

Necrotizing fasciitis (NF), also known as flesh-eating disease, is an infection that kills the body's soft tissue. [3] It is a serious disease that begins and spreads quickly. [3] Symptoms include red or purple or black skin, swelling, severe pain, fever, and vomiting. [3] The most commonly affected areas are the limbs and perineum. [2]

Contents

Bacterial infection is by far the most common cause of necrotizing fasciitis. Despite being called a "flesh-eating disease", bacteria do not eat human tissue. Rather, they release toxins that cause tissue death. Typically, the infection enters the body through a break in the skin such as a cut or burn. [3] Risk factors include recent trauma or surgery and a weakened immune system due to diabetes or cancer, obesity, alcoholism, intravenous drug use, and peripheral artery disease. [3] [2] It does not usually spread between people. [3] The disease is classified into four types, depending on the infecting organisms. [4] Medical imaging is often helpful to confirm the diagnosis. [4]

Necrotizing fasciitis is treated with surgery to remove the infected tissue, and antibiotics. [2] [3] It is considered a surgical emergency. Delays in surgery are associated with a much higher risk of death. [4] Despite high-quality treatment, the risk of death remains between 25 and 35%. [2]

Signs and symptoms

Symptoms emerge very quickly, often within hours. [7] Manifestations include:

The initial skin changes are similar to cellulitis or abscess, so diagnosis in early stages may be difficult. The redness and swelling usually blend into surrounding normal tissues. The overlying skin may appear shiny and tense as well. [8]

Later signs more suggestive of necrotizing changes (but only present in less than half of cases) are:

Rapid progression to shock despite antibiotic therapy is another indication of necrotizing fasciitis. However, those who are immunocompromised may not show typical symptoms. This includes but is not limited to patients with:

Immunocompromised persons are twice as likely to die from necrotizing infections compared to the greater population, so higher suspicion should be maintained in this group. [2]

Causes

Risk factors

Vulnerable populations are typically older with medical comorbidities such as diabetes mellitus, obesity, and immunodeficiency. [4] Other documented risk factors include:

For reasons that are unclear, it can also infect healthy individuals with no previous medical history or injury. [7] [9]

NSAIDs may increase the rates of necrotizing infections by impairing the body's immune response. NSAIDs inhibit the production of prostaglandins responsible for fever, inflammation, and pain. In theory, it also prevents white blood cells from migrating to infected areas, thus increasing the risk of soft-tissue infections. [2] [7]

Skin infections such as abscesses and ulcers can also complicate NF. A small percentage of people can also get NF when bacteria from streptococcal pharyngitis spreads through the blood. [10] For infection of the perineum and genitals (Fournier gangrene), urinary tract infection, renal stones, and Bartholin gland abscess may also be implicated. [2]

Prevention

Good wound care and handwashing reduces the risk of developing necrotizing fasciitis. [3] It is unclear if people with a weakened immune system would benefit from taking antibiotics after being exposed to a necrotizing infection. Generally, such a regimen entails 250 mg penicillin four times daily for 10 days. [7]

Bacteria

Necrotizing fasciitis is divided into four classes by the type of bacteria causing the infection. This classification system was first described by Giuliano and his colleagues in 1977. [4] [2]

Type I infection: This is the most common type of infection, and accounts for 70 to 80% of cases. It is caused by a mixture of bacterial types, usually in abdominal or groin areas. [4] These bacterial species include:

In polymicrobial (mixed) infections, Group A Streptococcus (S. pyogenes) is the most commonly found bacterium, followed by S. aureus. [10] However, when the infection is caused solely by S. pyogenes and/or S. aureus, it is classified as a Type II infection.

Gram-negative bacteria and anaerobes like Clostridia are more often implicated in Fournier gangrene. This is a subtype of Type I infections affecting the groin and perianal areas. [10] Clostridia account for 10% of overall type I infections and typically cause a specific kind of necrotizing fasciitis known as gas gangrene or myonecrosis.

Type II infection: This infection accounts for 20 to 30% of cases, mainly involving the extremities. [4] [11] This involves Streptococcus pyogenes , alone or in combination with staphylococcal infections. Methicillin-resistant Staphylococcus aureus (MRSA) is involved in up to a third of Type II infections. [4] Infection by either type of bacteria can progress rapidly and manifest as shock. Type II infection more commonly affects young, healthy adults with a history of injury. [2]

Type III infection: Vibrio vulnificus is a bacterium found in saltwater. It occasionally causes NF after entering the body through a break in the skin. [12] One in three patients with a V. vulnificus infection develop necrotizing fasciitis. [12] Disease progression is similar to type II but sometimes with few visible skin changes. [2]

Type IV infection: This type of NF accounts for less than 1% of cases. It is mostly caused by the Candida albicans fungus. Risk factors include age and immunodeficiency. [4] [13]

Diagnosis

Micrograph of necrotizing fasciitis, showing necrosis (center of image) of the dense connective tissue, i.e. fascia, interposed between fat lobules (top-right and bottom-left of image), H&E stain Necrotizing fasciitis - intermed mag.jpg
Micrograph of necrotizing fasciitis, showing necrosis (center of image) of the dense connective tissue, i.e. fascia, interposed between fat lobules (top-right and bottom-left of image), H&E stain

Early diagnosis is difficult, as the disease often first appears like a simple superficial skin infection. [4] While a number of labs and imaging can raise the suspicion for necrotizing fasciitis, none can rule it out. [14] The gold standard for diagnosis is a surgical exploration and subsequent tissue biopsy. When in doubt, a 2-cm incision can be made into the affected tissue under local anesthesia. [2] [15] If a finger easily separates the tissue along the fascia, then the finger test is positive. This confirms the diagnosis, and an extensive debridement should be performed. [2] [15]

Medical imaging

CT scan of right thigh, showing inflammatory stranding and low attenuation in vastus lateralis muscle (arrow) CT scan of right thigh, showing inflammatory stranding and low attenuation in vastus latralis (arrow).webp
CT scan of right thigh, showing inflammatory stranding and low attenuation in vastus lateralis muscle (arrow)

Necrotizing fasciitis is ideally a clinical diagnosis based on symptoms. Due to the need for rapid surgical treatment, the time delay in performing imaging is a major concern. [15] Hence, imaging may not be needed if signs of a necrotizing infection are clear. However, due to the vague symptoms associated with the earlier stages of this disease, imaging is often useful in clarifying or confirming the diagnosis. [15]

Both CT scan and MRI are used to diagnose NF, but neither are sensitive enough to rule out necrotizing changes completely. [2]

Computed tomography (CT)

Necrotizing fasciitis producing gas in the soft tissues as seen on CT scan Pnecrotisingfasc.png
Necrotizing fasciitis producing gas in the soft tissues as seen on CT scan

If available, computed tomography (CT) is the most convenient tool in diagnosing NF due to its speed and resolution (detects about 80% of NF cases). [16] CT scan may show fascial thickening, edema, or abscess formation. [2] [15] CT is able to pick up on gas within tissues better than MRI, but it is not unusual for NF to present without gas on imaging. [15] In addition, CT is helpful in evaluating complications due to NF and finding possible sources of infections. [15] Its use may be limited in pregnant patients and patients with kidney issues. [15]

Magnetic resonance imaging (MRI)

Axial T2 weighted MRI (a) and contrast-enhanced MRI (b) of left wrist showing necrotizing fasciitis. There is diffuse hyperintensity with irregular enhancement of the deep fascia (asterisks). The arrows indicate a lobulating abscess, and the triangle a skin bulla. Necrotizing fasciitis MRI.png
Axial T2 weighted MRI (a) and contrast-enhanced MRI (b) of left wrist showing necrotizing fasciitis. There is diffuse hyperintensity with irregular enhancement of the deep fascia (asterisks). The arrows indicate a lobulating abscess, and the triangle a skin bulla.

Magnetic resonance imaging (MRI) is considered superior to computed tomography (CT) in the visualization of soft tissues and is able to detect about 93% of NF cases. [15] It is especially useful in finding fluid in the deep fascia, which can distinguish between NF and cellulitis. [15] When fluid collects in the deep fascia, or thickening or enhancement with contrast, necrotizing fasciitis should be strongly suspected. However, MRI is much slower than CT and not as widely available. [15] There may also be limitations on its use in patients with kidney problems. [15]

Point-of-care ultrasonography (POCUS)

Necrotizing fasciitis as seen on ultrasound [17]
Necrotizing fasciitis with soft tissue gas seen on (b) plain radiography and (c) ultrasound Necrotizing fasciitis with soft tissue gas NF.webp
Necrotizing fasciitis with soft tissue gas seen on (b) plain radiography and (c) ultrasound

Point-of-care ultrasound (POCUS) may be useful in the diagnosis of NF if MRI and CT are not available. [18] It can also help rule out diagnoses that mimic earlier stages of NF, including deep vein thrombosis (DVT), superficial abscesses, and venous stasis. [18] Linear probes are generally preferred for the assessment, especially in the extremities. [18]

Findings characteristic of NF include abnormal thickening, air, or fluid in the subcutaneous tissue. [18] This can be summarized as the mnemonic "STAFF" (Subcutaneous irregularity or Thickening, Air, and Fascial Fluid). [18] The official diagnosis of NF using ultrasound requires "the presence of BOTH diffuse subcutaneous thickening AND fascial fluid more than 2 mm." [18] Gas in the subcutaneous tissue may show "dirty acoustic shadowing." [15] However, similar to other imaging modalities, the absence of subcutaneous free air does not definitively rule out a diagnosis of NF, because this is a finding that often emerges later in the disease process. [18]

Of note, the quality and accuracy of POCUS is highly user-dependent. It may also be difficult to visualize NF over larger areas, or if there are many intervening layers of fat or muscle. It is still unclear whether POCUS improves the speed of diagnosis of NF, or if it reduces the time to surgical intervention as a whole. [18]

Plain radiography (X-ray)

It is difficult to distinguish NF from cellulitis in earlier stages of the disease using plain radiography. [15] X-rays can detect subcutaneous emphysema (gas in the subcutaneous tissue), which is strongly suggestive of necrotizing changes. However, air is often a late-stage finding, and not all necrotizing skin infections create subcutaneous emphysema. Hence, radiography is not recommended for the initial diagnosis of NF. [15] However, it may be able to identify the source of infection, such as foreign bodies or fractures, and thus aid in subsequent treatment. [15]

Scoring system

Correlated with clinical findings, a white blood cell count greater than 15,000 cells/mm3 and serum sodium level less than 135 mmol/L are predictive of necrotizing fasciitis in 90% of cases. [3] If lab values do not meet those values, there is a 99% chance that the patient does not have NF. There are various scoring systems to determine the likelihood of getting necrotizing fasciitis. The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring system developed by Wong and their colleagues in 2004 is the most common. It evaluates people with severe cellulitis or abscess to determine the likelihood of necrotizing fasciitis.

LRINEC uses six laboratory values: C-reactive protein, total white blood cell count, hemoglobin, sodium, creatinine, and blood glucose. [2] A score of 6 or more indicates that there is a 50-75% probability of necrotizing fasciitis. A score of 8 or more represents over 75% likelihood of NF. [15] [19] [20] Patients with a LRINEC score ≥6 may have a higher rate of both death and amputation as well. [21] The scoring criteria are: [19] [22]

LRINEC Scoring System
Lab valueCriteriaPoints*
CRP≥ 15 mg/dL (150 mg/L)+4
WBC count (×103)15 - 25/mm3+1
> 25/mm3+2
Hemoglobin11 - 13.5 g/dL+1
< 11 g/dL+2
Sodium< 135 mEq/L+2
Creatinine> 1.6 mg/dL (141 μmol/L)+2
Glucose> 180 mg/dL (10 mmol/L)+1
*If the lab value does not meet the listed criteria, it is assigned 0 points.

However, this scoring system is yet to be validated. [3] A LRINEC score ≥6 is only able to detect 70% of NF cases, and a LRINEC score ≥8 has shown even poorer sensitivity. [20] Moreover, these lab values may be falsely positive if any other inflammatory conditions are present. Therefore, this scoring system should be interpreted with caution. [2]

Treatment

Necrotizing fasciitis is treated with surgical debridement (cutting away affected tissue). [3] However, antibiotics should be started as soon as this condition is suspected. Appropriate antibiotic coverage may be changed based on tissue cultures. Additional support should be initiated for those with unstable vital signs and low urine output. [2]

Surgery

Aggressive wound debridement should be performed as soon as the diagnosis is made. The affected area may need to be debrided several times, usually once every 12–36 hours. [3] Large sections of tissue and muscle may need to be removed to prevent the infection from spreading. Amputation may be needed if the infection is too severe. [3]

En bloc debridement (EBd) is most commonly employed in treating NSTIs. [23] This involves cutting away the skin overlying all diseased areas at the cost of increased scar formation and potential decreased quality of life post-operatively. [23] More recently, skin-sparing debridement (SSd) has gained traction, as it resects the underlying tissue and sources of infection while preserving skin that is not overtly necrotic. [23] However, more studies are needed to examine whether SSd actually accelerates the healing process after surgery. [23]

Fournier gangrene and subsequent VSD Fournier gangrene VSD.webp
Fournier gangrene and subsequent VSD

After the wound debridement, adequate dressings should be applied to promote wound healing. [2] Wounds are generally packed with wet-to-dry dressings and left open to heal. [3] In certain cases, vacuum-sealing drainage (VSD) may help the wound heal, especially in Fournier gangrene.

For necrotizing infection of the perineal area (Fournier's gangrene), wound debridement and wound care in this area can be difficult because of the excretory products that often render this area dirty and affect the wound-healing process. Therefore, regular dressing changes with a fecal management system can help to keep the wound at the perineal area clean. Sometimes, colostomy may be necessary to divert the excretory products to keep the wound at the perineal area clean. [2]

Antibiotics

Empiric antibiotics are usually initiated as soon as the diagnosis of NSTI has been made. They are then changed to culture-guided antibiotic therapy. In the case of NSTIs, empiric antibiotics are broad-spectrum, covering gram-positive (including MRSA), gram-negative, and anaerobic bacteria. [24] Often, a combination of clindamycin, daptomycin, IV vancomycin, and gentamicin is used. [2] Gram-negative coverage may entail the use of fluoroquinolones, piperacillin/tazobactam, or carbapenems. [3]

Despite multiple studies, there is no consensus on how long antibiotics should be given. [24] Generally, antibiotics are administered until surgeons decide that no further debridement is needed, and the patient no longer shows any systemic signs of infection from a clinical and laboratory standpoint. [3] Evidence regarding the efficacy of treatment and adverse effects is also unclear.

Add-on therapy

Epidemiology

Prevalence

Necrotizing fasciitis occurs in about 4 people per million per year in the U.S., and about 1 per 100,000 in Western Europe. [4] About 1,000 cases of necrotizing fasciitis occur per year in the United States, but the rates have been increasing. This could be due to increasing awareness of this condition and increased reporting, or increasing antibiotic resistance. [2] Both sexes are affected equally. [2] It is more common among older people and is rare in children. [4]

Anatomical location

Necrotizing fasciitis can occur at any part of the body, but it is more commonly seen at the extremities, perineum, and genitals. A small fraction of cases arise in the head/neck, chest and abdomen. [2]

History

In the fifth century BCE, Hippocrates was the first to describe necrotizing soft tissue infections.

"Erysipelas all over the body while the cause was only a trivial accident. Bones, flesh, and sinew (cord, tendon, or nerve) would fall off from the body and there were many deaths".

Necrotizing soft-tissue infections were first described in English by British surgeon Leonard Gillespie and British physicians Gilbert Blaine and Thomas Trotter in the 18th century. At that time, there was no standardized name for NSTIs. They were variably described as severe ulcers, gangrene, erysipelas, or cellulitis. [26] Later, "hospital gangrene" became more commonly used. In 1871, Confederate States Army surgeon Joseph Jones reported 2,642 cases of hospital gangrene with a mortality rate of 46%.

In 1883, Dr Jean-Alfred Fournier described necrotizing infections of the perineum and scrotum, now named after him as Fournier gangrene. The term "necrotizing fasciitis" was coined by Dr. Bob Wilson in 1952. [4] [27] Since then, its definition has broadened to include infections of fascia and soft tissue. [2] Despite being disfavored by the medical community, the term "galloping gangrene" was frequently used in sensationalistic news media to refer to outbreaks of necrotizing fasciitis. [28]

Society and culture

Notable cases

See also

Related Research Articles

<span class="mw-page-title-main">Abscess</span> Localized collection of pus that has built up within the tissue of the body

An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends beyond the swelling. Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger. A cyst is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall. Abscesses can also form internally on internal organs and after surgery.

<span class="mw-page-title-main">Necrosis</span> Unprogrammed cell death caused by external cell injury

Necrosis is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who is often regarded as one of the founders of modern pathology. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated digestion of cell components. In contrast, apoptosis is a naturally occurring programmed and targeted cause of cellular death. While apoptosis often provides beneficial effects to the organism, necrosis is almost always detrimental and can be fatal.

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enters the bloodstream, the infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<i>Vibrio</i> Genus of bacteria and the disease it can cause

Vibrio is a genus of Gram-negative bacteria, possessing a curved-rod (comma) shape, several species of which can cause foodborne infection or soft-tissue infection called Vibriosis. Infection is commonly associated with eating undercooked seafood. Being highly salt tolerant and unable to survive in freshwater, Vibrio spp. are commonly found in various salt water environments. Vibrio spp. are facultative anaerobes that test positive for oxidase and do not form spores. All members of the genus are motile. They are able to have polar or lateral flagellum with or without sheaths. Vibrio species typically possess two chromosomes, which is unusual for bacteria. Each chromosome has a distinct and independent origin of replication, and are conserved together over time in the genus. Recent phylogenies have been constructed based on a suite of genes.

<span class="mw-page-title-main">Gangrene</span> Type of tissue death by infection or lack of blood supply

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

<span class="mw-page-title-main">Epiglottitis</span> Inflammation of the epiglottis

Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate. As the epiglottis is in the upper airway, swelling can interfere with breathing. People may lean forward in an effort to open the airway. As the condition worsens, stridor and bluish skin may occur.

<span class="mw-page-title-main">Gas gangrene</span> Human bacterial infection

Gas gangrene is a bacterial infection that produces tissue gas in gangrene. This deadly form of gangrene usually is caused by Clostridium perfringens bacteria. About 1,000 cases of gas gangrene are reported yearly in the United States.

<span class="mw-page-title-main">Noma (disease)</span> Medical condition

Noma is a rapidly-progressive and often-fatal gangrenous infection of the mouth and face. Noma usually begins as an ulcer on gums and rapidly spreads into the jawbone, cheek, and soft tissues of the face. This is followed by death of the facial tissues and fatal sepsis. Survivors are left with severe facial disfigurement often with impairments in breathing, swallowing, speaking and vision. In 2023 noma was added to the World Health Organization's list of neglected tropical diseases.

<span class="mw-page-title-main">Lymphangitis</span> Inflammation or infection of the lymphatic channels

Lymphangitis is an inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel. It may present as long red streaks spreading away from the site of infection. It is a possible medical emergency as involvement of the lymphatic system allows for an infection to spread rapidly. The most common cause of lymphangitis in humans is bacteria, in which case sepsis and death could result within hours if left untreated. The most commonly involved bacteria include Streptococcus pyogenes and hemolytic streptococci. In some cases, it can be caused by viruses such as mononucleosis or cytomegalovirus, as well as specific conditions such as tuberculosis or syphilis, and the fungus Sporothrix schenckii. Other causes of Lymphangitis could be from Arthropod bites and Iatrogenic causes. Lymphangitis is sometimes mistakenly called "blood poisoning". In reality, "blood poisoning" is synonymous with sepsis.

A skin infection is an infection of the skin in humans and other animals, that can also affect the associated soft tissues such as loose connective tissue and mucous membranes. They comprise a category of infections termed skin and skin structure infections (SSSIs), or skin and soft tissue infections (SSTIs), and acute bacterial SSSIs (ABSSSIs). They are distinguished from dermatitis, although skin infections can result in skin inflammation.

<span class="mw-page-title-main">Fournier gangrene</span> Medical condition

Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the external genitalia or perineum. It commonly occurs in older men, but it can also occur both in women and children and in people with diabetes or alcoholism or those who are immunocompromised.

An open fracture, also called a compound fracture, is a type of bone fracture that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. An open fracture can be life threatening or limb-threatening due to the risk of a deep infection and/or bleeding. Open fractures are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. Other potential complications include nerve damage or impaired bone healing, including malunion or nonunion. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. This classification system can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection.

<span class="mw-page-title-main">Ecthyma gangrenosum</span> Medical condition

Ecthyma gangrenosum is a type of skin lesion characterized by vesicles or blisters which rapidly evolve into pustules and necrotic ulcers with undermined tender erythematous border. "Ecthyma" means a pus forming infection of the skin with an ulcer, "gangrenosum" refers to the accompanying gangrene or necrosis. It is classically associated with Pseudomonas aeruginosa bacteremia, but it is not pathognomonic. Pseudomonas aeruginosa is a gram negative, aerobic bacillus.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Abnormal presence of air or gas under the skin

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

<span class="mw-page-title-main">Arterial insufficiency ulcer</span> Skin sore on the hands and feet due to insufficient blood flow

Arterial insufficiency ulcers are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD).

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Anaerobic infections are caused by anaerobic bacteria. Obligately anaerobic bacteria do not grow on solid media in room air ; facultatively anaerobic bacteria can grow in the presence or absence of air. Microaerophilic bacteria do not grow at all aerobically or grow poorly, but grow better under 10% carbon dioxide or anaerobically. Anaerobic bacteria can be divided into strict anaerobes that can not grow in the presence of more than 0.5% oxygen and moderate anaerobic bacteria that are able of growing between 2 and 8% oxygen. Anaerobic bacteria usually do not possess catalase, but some can generate superoxide dismutase which protects them from oxygen.

Chronic limb threatening ischemia (CLTI), also known as critical limb ischemia (CLI), is an advanced stage of peripheral artery disease (PAD). It is defined as ischemic rest pain, arterial insufficiency ulcers, and gangrene. The latter two conditions are jointly referred to as tissue loss, reflecting the development of surface damage to the limb tissue due to the most severe stage of ischemia. Compared to the other manifestation of PAD, intermittent claudication, CLI has a negative prognosis within a year after the initial diagnosis, with 1-year amputation rates of approximately 12% and mortality of 50% at 5 years and 70% at 10 years.

<span class="mw-page-title-main">Diabetic foot infection</span> Medical condition

Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.

References

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