Potentially life-threatening emergency
Necrotizing fasciitis in Adult
See also in: Cellulitis DDx,External and Internal EyeAlerts and Notices
Synopsis
Necrotizing fasciitis can occur without a clear portal of entry, although predisposing risk factors include major penetrating trauma (eg, crush injury, deep penetrating wound), minor nonpenetrating trauma (eg, muscle strain, sprain, or contusion), and breaches in the skin and mucosa (eg, lacerations, varicella vesicles, insect bites, injection drug use, hemorrhoids, episiotomies, and other surgical wounds). Vibrio vulnificus is associated with necrotizing fasciitis infections in cirrhotic patients with exposure to ingestion of raw oysters and with exposure of lacerations to salt water. Aeromonas hydrophila is part of the Vibrionaceae family and can cause necrotizing fasciitis in both immunocompromised and immunocompetent patients. Unlike V vulnificus sepsis, where exposure is usually to seawater, in A hydrophila infection, contact with brackish water, soil, wood, or dirty ditches is typically the common exposure. Infections can follow any trauma, fracture, or injury where there was exposure to fresh water. Infection has also occurred in the setting of debris or floodwater after a hurricane. Both V vulnificus and Aeromonas infections can present with lower leg hemorrhagic bullae, purpura, and skin necrosis. Aeromonas hydrophila infection, in contrast to infection with V vulnificus, is marked by more myonecrosis and a distinctive foul odor when the wound is debrided. Most patients with A hydrophila had exposure to wet soil or dirty ditches.
Patients with necrotizing fasciitis are acutely ill. They are often thought to have cellulitis that is not responding to standard antibiotic therapy. There is commonly a paucity of cutaneous findings in the early course of the disease. Pain is out of proportion to physical findings. There may be associated skin necrosis and bullae formation. While necrotizing fasciitis most commonly involves the lower extremities, other sites may also be involved. Signs of systemic illness such as fever, lethargy, hypotension, and tachycardia are present; these may progress to multiorgan failure.
The mortality of necrotizing fasciitis is high. Treatment includes broad-spectrum intravenous (IV) antibiotics and immediate surgical debridement of infected and devitalized tissue. Therefore, if you are considering this diagnosis, stop reading this and contact a surgeon now.
When necrotizing fasciitis is localized to the lower abdominal wall, perineum, or genitals, it is known as Fournier gangrene. Diabetic patients are particularly susceptible to Fournier gangrene, which is often polymicrobial with mixed anaerobic organisms.
Codes
ICD10CM:M72.6 – Necrotizing fasciitis
SNOMEDCT:
52486002 – Necrotizing fasciitis
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
It can sometimes be difficult to differentiate necrotizing fasciitis from pyoderma gangrenosum (PG). This is especially true in the pustular variant of PG that may not develop into frank ulceration. Relatively rapidly progressing soft-tissue inflammation not responding to broad-spectrum antibiotics and surgical debridement should be promptly evaluated by a dermatologist to rule out PG.Also consider:
- Cellulitis
- Calciphylaxis
- Subcutaneous acute febrile neutrophilic dermatosis (subcutaneous Sweet syndrome)
- Ecthyma gangrenosum
- Erysipelas
- Deep vein thrombosis
- Purpura fulminans complicating varicella
- Insect bite (eg, brown recluse spider)
- Vasculitis
- Disseminated intravascular coagulation
- Staphylococcal scalded skin syndrome
- Toxic shock syndrome
- Vibrio vulnificus infection
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:04/29/2019
Last Updated:05/12/2019
Last Updated:05/12/2019
Potentially life-threatening emergency
Necrotizing fasciitis in Adult
See also in: Cellulitis DDx,External and Internal Eye