Necrotizing Fascitis

This patient is presenting with the classic findings of necrotizing fasciitis with systemic toxicity and minimal to marked skin changes. The site of inoculation, often resulting from simple trauma, usually is somewhat distant. While staphylcocci, Bacteroides spp., or anaerobic streptococci also can cause a similar syndrome, group A streptococci account for about 60% of these cases. Rare cases secondary to Vibrio (shellfish and seafood exposure) have also been described in coastal states like Texas and Louisiana and should be kept in the differential diagnosis of hemorrhagic bullae.

As this infection progresses, the marked tenderness of the involved skin may progress into anesthesia as a result of infarction of cutaneous nerves. Surgery is required for both diagnosis and therapy. These infections typically require extensive debridement and antibiotics (penicillin g or erythromycin if PCN allergic) are adjunctive therapy.

It is also important to keep in mind that the gram stain may not show the classic textbook images of streptococci in "chains".

References:

  1. Working Group on Severe Streptococcal Infection: Defining the Group A streptococcal toxic shock syndrome. JAMA 269:390, 1993
  2. Monnickendam MA. McEvoy MB. Blake WA. Gaworzewska ET. Hallas G. Tanna A. Efstratiou A. George RC. Necrotising fasciitis associated with invasive group A streptococcal infections in England and Wales. Advances in Experimental Medicine & Biology. 418:87-9, 1997.
  3. Swanston WH. Woo J. Murphy A. Efstratiou A. Tanna A. Reid HF. Invasive group A streptococcal infections. Serotype newly associated with toxic shock-like syndrome in Trinidad. Advances in Experimental Medicine & Biology. 418:71-3, 1997.
  4. Majeski J. Majeski E. Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. Southern Medical Journal. 90(11):1065-8, 1997 Nov.
  5. Weiss KA. Laverdiere M. Group A Streptococcus invasive infections: a review. Canadian Journal of Surgery. 40(1):18-25, 1997 Feb
  6. Francis KR, Lamaute HR, Davis JM, Pizzi WF:Implications of Risk Factors in Necrotizing Fascitis. The American Surgeon 1993:59:304-308.
  7. Stevens DL: Invasive Group A Streptococcus Infections. Clin Infect Dis 1992; 14:2-13.

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