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Idiopathic necrotizing fasciitis: recognition, incidence, and outcome of therapy
C R McHenry1, C P Brandt, J J Piotrowski
1Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Abstract:
Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.
Insights
Early recognition of idiopathic necrotizing fasciitis (NF) is crucial. This form of NF, often caused by S. pyogenes, presents with unexplained pain and tenderness, requiring prompt diagnosis and treatment for better survival outcomes.
Area of Science:
- Infectious Diseases
- Surgical Pathology
- Epidemiology
Background:
- Necrotizing fasciitis (NF) requires prompt diagnosis and treatment for patient survival.
- Idiopathic NF, lacking a clear causative factor, presents diagnostic challenges.
- Understanding idiopathic NF's characteristics is vital for clinical management.
Purpose of the Study:
- To determine the incidence, clinical features, bacteriology, and treatment outcomes of idiopathic NF.
- To compare idiopathic NF with secondary NF in terms of presentation and prognosis.
- To highlight the importance of suspecting NF in cases of unexplained soft tissue pain.
Main Methods:
- Retrospective review of 51 NF patients treated between 1989 and 1993.
- Analysis of clinical data, including demographics, comorbidities, affected sites, and symptoms.
- Bacteriological investigation and comparison of treatment delays between idiopathic and secondary NF groups.
Main Results:
- Idiopathic NF accounted for 18% of cases, predominantly affecting the lower extremities.
- Monomicrobial infections were more common in idiopathic NF (78%) versus secondary NF (21%), with S. pyogenes being a frequent cause.
- Patients with idiopathic NF experienced significantly longer delays from admission to operation (62.3 hours) compared to secondary NF (17.0 hours).
- Mortality for idiopathic NF was 33%, comparable to secondary NF.
Conclusions:
- Idiopathic NF is primarily a monomicrobial infection, often caused by S. pyogenes, typically affecting extremities.
- Despite high mortality, outcomes are similar to secondary NF.
- Clinicians must consider idiopathic NF in patients presenting with unexplained soft tissue pain and tenderness.