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The Clinical Challenges of Necrotizing Fasciitis.

Necrotizing fasciitis (NF) is a rare, rapidly spreading infection of the subcutaneous tissue that can lead to life- and/or limb-threatening systemic toxicity. The etiology is usually polymicrobial, but single-species organisms (usually streptococcal or staphylococcal) are isolated in about one-third of cases.

Despite its relative rarity, many medical specialists, including orthopaedists, can expect to see at least 1 case of NF in their career. Early cutaneous signs (erythema, edema, and occasionally crepitus) are nonspecific, but because the infection spreads so rapidly, prompt diagnosis and early treatment are of paramount importance.

This month’s “Case Connections” springboards from a case report about necrotizing fasciitis in which the infectious source was highly unusual.

In the June 8, 2016, edition of JBJS Case Connector, Connor et al. reported on the case of a 70-year-old man who developed necrotizing fasciitis of the thigh and calf following sigmoid diverticulitis perforation. The patient presented with fever and acute-onset left calf and knee pain of 3 days’ duration. He had no history of diverticular disease, surgery, blunt trauma, or penetrating injury to the affected limb.

Lab results indicated the presence of systemic infection and inflammation, and radiography and ultrasound revealed subcutaneous and intramuscular gas in the lower leg (Fig. 1) and thigh. Doctors presumptively diagnosed necrotizing fasciitis and began intravenous antibiotics. On the day of admission, surgeons performed extensive skin and subcutaneous tissue debridement and irrigation in all of the affected compartments.



Fig. 1 
Radiograph of the tibia and fibula showing subcutaneous and intramuscular gas. These findings led surgeons to presumptively diagnose necrotizing fasciitis.



Shortly thereafter, a CT scan of the abdomen revealed sigmoid diverticulitis with a perforation that communicated with the left hip via the iliopsoas fascia. Surgeons performed a sigmoid colectomy and transverse loop colostomy, and the antibiotic regimen was adjusted to cover the pseudomonal organisms that were …