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Multifocal necrotising fasciitis: an overlooked entity?
Ussamah El-Khani1, Jean Nehme, Ammar Darwish
1Mountbatten Department of Plastic and Reconstructive Surgery, Queen Alexandra Hospital, Curie Road, Cosham, Portsmouth PO6 3LY, UK. ussamah.elkhani@doctors.org.uk
Objective:
The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management.
Context:
Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities.
Design:
A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.
Data Sources:
A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms.
Data Extraction:
All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted.
Data Synthesis:
A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis.
Conclusions:
Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.
Insights
Multi-focal necrotising fasciitis, a rare condition, is often associated with type II disease and may benefit from early imaging. Establishing regional registers could improve management of this severe infection.
Area of Science:
- Infectious Diseases
- Surgical Pathology
- Medical Research Methodology
Background:
- Necrotising fasciitis is a severe, life-threatening soft tissue infection.
- Multi-focal necrotising fasciitis (multiple non-contiguous necrotic areas) is rarely reported.
- Lack of specific guidelines and under-reporting hinder effective management.
Purpose of the Study:
- Report a case of multi-focal necrotising fasciitis.
- Review literature to identify etiological factors.
- Suggest improvements for managing multi-focal necrotising fasciitis.
Main Methods:
- Systematic literature review following PRISMA protocol.
- Searched MEDLINE, OLD MEDLINE, and Cochrane Collaboration (1966-2011).
- Extracted data on demographics, injury, timeline, microbes, sites, scores, treatment, and outcomes for 33 cases.
Main Results:
- 31 studies and 33 cases of multi-focal necrotising fasciitis analyzed.
- 52% of cases were type II necrotising fasciitis.
- Identifiable inciting injuries in 42%; 21% developed non-synchronous lesions (86% type II).
- Objective assessment scores were incomplete in 94% of cases.
Conclusions:
- Multifocality in necrotising fasciitis is linked to type II disease.
- Validated objective tools may aid in identifying high-risk patients for early imaging.
- Recommends adopting regional multi-focal necrotising fasciitis registers for improved management.
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