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Gangrene

Last reviewed: 15 Apr 2025
Last updated: 14 May 2025

Summary

Definition

History and exam

Key diagnostic factors

  • pain
  • edema or swelling
  • skin discoloration
  • crepitus (gas gangrene)
Full details

Other diagnostic factors

  • diminished pedal pulses and ankle-brachial index (ischemic gangrene)
  • low-grade fever and chills (infectious gangrene)
Full details

Risk factors

  • diabetes mellitus
  • atherosclerosis (ischemic gangrene)
  • smoking (ischemic gangrene)
  • renal disease
  • drug and alcohol abuse
  • malignancy
  • trauma or abdominal surgery (infectious gangrene)
  • contaminated wounds (infectious gangrene)
  • immunosuppression (infectious gangrene)
  • malnutrition (infectious gangrene)
  • hypercoagulable states (ischemic gangrene)
  • prolonged application of tourniquets (ischemic gangrene)
  • community-acquired MRSA
Full details

Diagnostic tests

1st tests to order

  • CBC
  • comprehensive metabolic panel
  • serum LDH
  • coagulation panel
  • blood cultures
  • serum CRP
  • plain x-rays
  • CT of affected site
  • MRI of affected site
  • Doppler ultrasonography
Full details

Tests to consider

  • surgical exploration and skin biopsy
  • CT angiography
  • magnetic resonance angiography (MRA)
  • CT chest and abdomen
  • antinuclear antibodies (ANA), lupus anticoagulant, anticardiolipin, and anti beta2 glycoprotein-1 antibodies
  • serum cold agglutinins
  • serum cryofibrinogens
  • plasma cryoglobulin
Full details

Treatment algorithm

INITIAL

necrotizing fasciitis awaiting confirmation of microbial culture and sensitivity results

ACUTE

confirmed type I necrotizing fasciitis (polymicrobial)

confirmed type II necrotizing fasciitis (monomicrobial)

gas gangrene

ischemic gangrene

Contributors

Authors

Jason Jacob, MD

Attending Physician

Assistant Director

Department of Medicine

Hartford Hospital

Hartford

CT

Disclosures

JJ declares that he has no competing interests.

Robert J. Gionfriddo, DO

Assistant Director

Department of Medicine

Hartford Hospital

Hartford

CT

Disclosures

RJG declares that he has no competing interests.

Acknowledgements

Dr Jason Jacob and Dr Robert J. Gionfriddo would like to gratefully acknowledge Dr William Tennant, Dr Badr Aljabri, Dr Mohammed Al-Omran, Dr Jose Contreras-Ruiz, and Dr Iris Galvan-Martinez, the previous contributors to this topic.

Disclosures

WT, BA, MA, JC, and IG declare that they have no competing interests.

Peer reviewers

Meryl Davis, MD

Consultant Vascular Surgeon

Royal Free Hampstead

London

UK

Disclosures

MD declares that she has no competing interests.

Charles Fox, MD

Vascular Surgeon

Department of Surgery

Walter Reed Army Medical Center

Washington

DC

Disclosures

CF declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol. 2006 Apr;20(4):365-9.Full text  Abstract

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.Full text  Abstract

Nicolasora N, Kaul DR. Infectious disease emergencies. Med Clin North Am. 2008 Mar;92(2):427-41. Abstract

Bradbury AW, Adam DJ, Bell J, et al; BASIL trial Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010 May;51(5 Suppl):5-17S. Abstract

Norgren L, Hiatt WR, Dormandy JA, et al.; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007 Jan;45 Suppl S:S5-67.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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