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Average 4.3 of 43 Ratings
A 16-year-old male presents to the emergency department one day after scratching his leg on a piece of scrap metal. He reports a progressive rash on his leg that has advanced over the last several hours. In the emergency room his temperature is 102.8 degrees and his systolic blood pressure is 98 mmHg. On physical exam the clinical finding shown in Figure A is found. What would be the most appropriate next step in treatment.
Biopsy with urgent frozen section in the operating room
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The clinical presentation is consistent with early necrotizing fasciitis. A biopsy with a frozen section is effective at rapidly confirming an early diagnosis. If the biopsy is performed in the operating room, and is positive, then their will be minimal time delays in performing the required radical debridement.
Necrotizing fasciitis is characterized by hypotension, ascending rash, bullae and fevers. Skin abrasions, prior surgical intervention, and any cause of open wounds in the skin are all risk factors for the condition. The most common cultures are polymicrobial. The management consists of immediate IV antibiotics and emergent surgical debridement. Initial IV antiobiotics should be broad-spectrum to include penicillin, an aminoglycoside, clindamycin, and metronidazole.
Ozalay et al. analyzed the clinical presentation and factors associated with mortality in a retrospective study of 22 patients with necrotizing fasciitis. They noted that chronic liver disease and diabetes are common risk factors and they reiterate that early and aggressive debridement is the primary treatment.
McCarthy et al. review the etiology, presentation, diagnosis, and treatment of necrotizing fasciitis, noting that biopsy is the only method to definitively diagnose the condition.
Figure A is a clinical radiograph showing early necrotizing fasciitis. Illustration A is a clinical photograph of a lower extremity with necrotizing fasciitis and the classic signs of bullae, tracking erythema, and swelling.
Answer 1 and 4: Although MRI and CT scans are useful adjuncts to demonstrate edema in the soft tissue it does not provide the definitive diagnosis.
Answer 3: Needle aspiration has no use in the diagnosis of necrotizing fasciitis.
Answer 5: Ultrasound would be helpful if an abscess was suspected.
Ozalay M, Ozkoc G, Akpinar S, Hersekli MA, Tandogan RN
Foot Ankle Int. 2006 Aug;27(8):598-605. PMID: 16919212 (Link to Abstract)
Ozalay, FAI 2006
McCarthy JJ, Dormans JP, Kozin SH, Pizzutillo PD.
Instr Course Lect. 2005;54:515-28. PMID: 15948476 (Link to Abstract)
McCarthy, JBJS 2005
Stamenkovic I, Lew PD
N. Engl. J. Med.. 1984 Jun;310(26):1689-93. PMID: 6727947 (Link to Abstract)
Stamenkovic, NEJM 1984
Please rate question.
Average 2.0 of 53 Ratings
Poor outcomes with necrotizing fasciitis have been associated with which of the following factors?
Pre-existing cardiac dysfunction
Use of hyperbaric oxygen
Intravenous drug abuse
Delay in time to diagnosis
Necrotizing fasciitis is a uncommon soft-tissue infection, characterized by widespread fascial necrosis. It is most commonly a polymicrobial infection, with group A ß-hemolytic streptococci the most common bacteria reported. Treatment includes emergent aggressive debridement of all involved tissues and immediate empiric antibiotics covering aerobic, anaerobic, gram positive and gram negative bacteria.
The two referenced studies are excellent review articles on diagnosis and treatment of this entity. Bellapianta et al discuss that the key to treatment involve timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement.
Bellapianta JM, Ljungquist K, Tobin E, Uhl R.
J Am Acad Orthop Surg. 2009 Mar;17(3):174-82. PMID: 19264710 (Link to Abstract)
Bellapianta, JAAOS 2009
Green RJ, Dafoe DC, Raffin TA.
Chest. 1996 Jul;110(1):219-29. PMID: 8681631 (Link to Abstract)
Average 3.0 of 34 Ratings
A 52-year-old diabetic male sustained minor blunt trauma to his left thigh 10 hours prior to presentation. He initially complained of extreme thigh pain with erythema and swelling but rapidly developed bullae and worsening erythema over the affected area along with fever and tachycardia. A clinical photo is shown in Figure A. What clinical factor has been shown to reduce mortality when treating this pathology?
Presence of MRI findings
Administration of pressors
Decreasing time from admission to surgery
Immediate identification of causative organism
Location of injury
The clinical presentation and image shown in Figure A are consistent with necrotizing fasciitis. The most common pathogen is group A Streptococcus, but polymicrobial infection with Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is not uncommon. Necrotizing fasciitis is a surgical emergency and prompt aggressive débridement of all necrotic tissue is critical for survival.
Wong et al demonstrated that early operative debridement (<24 hours) improved the survival rate. The mortality associated with this condition has remained high, with a reported cumulative mortality rate of about 20% in this particular study.
Fontes et al suggest in their review article that early diagnosis and treatment are imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death.
Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO
J Bone Joint Surg Am. 2003 Aug;85-A(8):1454-60. PMID: 12925624 (Link to Abstract)
Wong, JBJS 2003
Fontes RA Jr, Ogilvie CM, Miclau T.
J Am Acad Orthop Surg. 2000 May-Jun;8(3):151-8. PMID: 10874222 (Link to Abstract)
Fontes, JAAOS 2000
Average 3.0 of 22 Ratings
A 56-year-old diabetic male presents to the emergency department by ambulance after developing high-grade fevers, malaise, and altered mental status. Upon presentation, he is found to be hypotensive and initial labs show an elevated WBC with a profound left shift. Figure A shows skin manifestations confined to the foot at initial presentation. He is started on broad spectrum antibiotics. Upon follow-up exam 3 hours later his clinical condition deteriorates (Figure B) and he is taken to the operating room for surgical debridement. In a bacterial culture, what would be the most common single isolate for this condition?
Group A streptococcus
The above clinical vignette is describing necrotizing fasciitis. Necrotizing fasciitis is a rare and often fatal soft-tissue infection that requires high clinical suspicion and prompt administration of broad-spectrum antibiotics and aggressive surgical debridement (illustrations A). Fontes et al found that although polymicrobial infections including gram-positive, gram-negative, aerobic, and anaerobic bacteria were found most commonly in necrotizing fasciitis, Group A streptococcus was the most common bacterial isolate. Wong et al also found the most isolated organism to be group A streptococcus. In their study, the highest associated medical comorbidity was diabetes mellitus (71%). They found that delay in surgery of more than 24 hours was correlated with increased risk of death.
Average 4.0 of 30 Ratings
Necrotizing fasciitis treatment