• 1

    Descamps V, Aitken J, Lee MG: Hippocrates on necrotising fasciitis. .Lancet 344::556. ,1994. .

  • 2

    Jones J: “Investigations upon the Nature, Causes, and Treatment of Hospital Gangrene as it Prevailed in the Confederate Armies, 1861–1865,” in Surgical Memoirs of Rebellion, Sanitary Commission, New York. ,1871. .

  • 3

    Wilson B: Necrotizing fasciitis. .Am J Surg 18::416. ,1952. .

  • 4

    Centers for Disease Control and Prevention: Active Bacterial Core Surveillance (ABCs) report: emerging infections program network: group A streptococcus, 2001—provisional. Available at: http://www.cdc.gov/ncidod/dbmd/abcs/survreports/gas01_provis.pdf. Accessed December 7. ,2005. .

  • 5

    Cha JY, Releford BJ, Marcarelli P: Necrotizing fasciitis: a classification of necrotizing soft tissue infections. .J Foot Ankle Surg 33::148. ,1994. .

  • 6

    File TM Jr, Tan JS, DiPersio JR: Group A streptococcal necrotizing fasciitis: diagnosing and treating the “flesh-eating bacteria syndrome.”. Cleve Clin J Med 65::241. ,1998. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    File TM Jr, Tan JS: Group A streptococcus necrotizing fasciitis. .Compr Ther 26::73. ,2000. .

  • 8

    Leitch HA, Palepu A, Fernandes CM: Necrotizing fasciitis secondary to group A streptococcus: morbidity and mortality still high. .Can Fam Physician 46::1460. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Aronoff DM, Bloch KC: Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. .Medicine (Baltimore) 82::225. ,2003. .

    • Search Google Scholar
    • Export Citation
  • 10

    Muqim R: Necrotizing fasciitis: management and outcome. .J Coll Physicians Surg Pak 13::711. ,2003. .

  • 11

    Norton KS, Johnson LW, Perry T, et al: Management of Fournier’s gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. .Am Surg 68::709. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Elliott D, Kufera JA, Myers RA: The microbiology of necrotizing soft tissue infections. .Am J Surg 179::361. ,2000. .

  • 13

    Stone DR, Gorbach SL: Necrotizing fasciitis: the changing spectrum. .Dermatol Clin 15::213. ,1997. .

  • 14

    Headley AJ: Necrotizing soft tissue infections: a primary care review. .Am Fam Physician 68::323. ,2003. .

  • 15

    Chapnick EK, Abter EI: Necrotizing soft-tissue infections. .Infect Dis Clin North Am 10::835. ,1996. .

  • 16

    Stevens DL, Bryant AE: The role of clostridial toxins in the pathogenesis of gas gangrene. .Clin Infect Dis 35::S93. ,2002. .

  • 17

    Stevens DL, Bryant AE: Pathogenesis of Clostridium perfringens infection: mechanisms and mediators of shock. .Clin Infect Dis 25::S160. ,1997. .

  • 18

    Stevens DL: The pathogenesis of clostridial myonecrosis. .Int J Med Microbiol 290::497. ,2000. .

  • 19

    Stevens DL, Bryant AE: Role of theta toxin, a sulfhydryl-activated cytolysin, in the pathogenesis of clostridial gas gangrene. .Clin Infect Dis 4::S195. ,1993. .

    • Search Google Scholar
    • Export Citation
  • 20

    Awad MM, Ellemor DM, Boyd RL, et al: Synergistic effects of alpha-toxin and perfringolysin O in Clostridium perfringens–mediated gas gangrene. .Infect Immun 69::7904. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Bryant AE: Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. .Clin Microbiol Rev 16::451. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Brook I, Frazier EH: Clinical and microbiological features of necrotizing fasciitis. .J Clin Microbiol 33::2382. ,1995. .

  • 23

    Miller JH, Nath RL, Stoughton J, et al: Streptococcal toxic shock syndrome from a puncture wound to the foot. .J Foot Ankle Surg 35::578. ,1996. .

  • 24

    Vincent JM, Demers DM, Bass JW: Infectious exanthems and unusual infections. .Adolesc Med 11::327. ,2000. .

  • 25

    Danino AM, Malka G: A lethal necrotizing fasciitis after human bite. .Plast Reconstr Surg 113::2234. ,2004. .

  • 26

    Gilad J, Borer A, Weksler N, et al: Fatal necrotizing fasciitis caused by a toothpick injury. .Scand J Infect Dis 30::189. ,1998. .

  • 27

    Verma SB: Necrotizing fascitis induced by mosquito bite. .J Eur Acad Dermatol Venereol 17::591. ,2003. .

  • 28

    Chen JL, Fullerton KE, Flynn NM: Necrotizing fasciitis associated with injection drug use. .Clin Infect Dis 33::6. ,2001. .

  • 29

    Lombardi CM, Silver LM, Lau KK, et al: Necrotizing fasciitis in the lower extremity: a review and case presentation. .J Foot Ankle Surg 39::244. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Tsai YH, Hsu RW, Huang KC, et al: Systemic Vibrio infection presenting as necrotizing fasciitis and sepsis: a series of thirteen cases. .J Bone Joint Surg Am 86::2497. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Wong CH, Tan SH, Kurup A, et al: Recurrent necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus.. Eur J Clin Microbiol Infect Dis 23::909. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Francis KR, Lamaute HR, Davis JM, et al: Implications of risk factors in necrotizing fasciitis. .Am Surg 59::304. ,1993. .

  • 33

    Wong CH, Chang HC, Pasupathy S, et al: Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. .J Bone Joint Surg Am 85::1454. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Mawhorter SD: Nonhealing cellulitis in a 54-year-old man with diabetes mellitus. .Cleve Clin J Med 67::21. ,2000. .

  • 35

    Wall DB, de Virgilio C, Black S, et al: Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. .Am J Surg 179::17. ,2000. .

    • Search Google Scholar
    • Export Citation
  • 36

    Wall DB, Klein SR, Black S, et al: A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. .J Am Coll Surg 191::227. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Yen ZS, Wang HP, Ma HM, et al: Ultrasonographic screening of clinically-suspected necrotizing fasciitis. .Acad Emerg Med 9::1448. ,2002. .

  • 38

    Chao HC, Kong MS, Lin TY: Diagnosis of necrotizing fasciitis in children. .J Ultrasound Med 18::277. ,1999. .

  • 39

    Schmid MR, Kossmann T, Duewell S: Differentiation of necrotizing fasciitis and cellulitis using MR imaging. .AJR Am J Roentgenol 170::615. ,1998. .

  • 40

    Becker M, Zbaren P, Hermans R, et al: Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. .Radiology 202::471. ,1997. .

  • 41

    Wysoki MG, Santora TA, Shah RM, et al: Necrotizing fasciitis: CT characteristics. .Radiology 203::859. ,1997. .

  • 42

    Stamenkovic I, Lew PD: Early recognition of potentially fatal necrotizing fasciitis: the use of frozen-section biopsy. .N Engl J Med 310::1689. ,1984. .

  • 43

    Majeski J, Majeski E: Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. .South Med J 90::1065. ,1997. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Argenta LC, Morykwas MJ: Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. .Ann Plast Surg 38::563. ,1997. .

  • 45

    Morykwas MJ, Argenta LC, Shelton-Brown EI, et al: Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. .Ann Plast Surg 38::553. ,1997. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    DeFranzo AJ, Argenta LC, Marks MW, et al: The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. .Plast Reconstr Surg 108::1184. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Moues CM, Vos MC, van den Bemd GJ, et al: Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. .Wound Repair Regen 12::11. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Riseman JA, Zamboni WA, Curtis A, et al: Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. .Surgery 108::847. ,1990. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Korhonen K: Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. .Ann Chir Gynaecol Suppl 214::7. ,2000. .

    • Search Google Scholar
    • Export Citation
  • 50

    Gibson A, Davis FM: Hyperbaric oxygen therapy in the management of Clostridium perfringens infections. .N Z Med J 99::617. ,1986. .

  • 51

    Armstrong DG, Lavery LA, Sariaya M, et al: Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. .J Foot Ankle Surg 35::280. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Armstrong DG, Perales TA, Murff RT, et al: Value of white blood cell count with differential in the acute diabetic foot infection. .JAPMA 86::224. ,1996. .

    • Search Google Scholar
    • Export Citation
  • 53

    Zgonis T, Jolly GP: Beyond off-loading. .Ortho Kinetic Rev 4::20. ,2004. .

Necrotizing Fasciitis in a Patient with Type 2 Diabetes Mellitus

David M. Kanuck Center for Reconstructive Foot Surgery, PC, Plainville, CT.

Search for other papers by David M. Kanuck in
Current site
Google Scholar
PubMed
Close
 DPM
,
Thomas Zgonis Department of Orthopaedics, The University of Texas Health Science Center at San Antonio, San Antonio.

Search for other papers by Thomas Zgonis in
Current site
Google Scholar
PubMed
Close
 DPM
, and
Gary Peter Jolly Center for Reconstructive Foot Surgery, PC, Plainville, CT.

Search for other papers by Gary Peter Jolly in
Current site
Google Scholar
PubMed
Close
 DPM
Restricted access

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome. (J Am Podiatr Med Assoc 96(1): 67–72, 2006)

Corresponding author: Thomas Zgonis, DPM, Department of Orthopaedics, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MCS 7776, San Antonio, TX 78229.