Summary
Definition
History and exam
Key diagnostic factors
- pain
- edema or swelling
- skin discoloration
- crepitus (gas gangrene)
Other diagnostic factors
- diminished pedal pulses and ankle-brachial index (ischemic gangrene)
- low-grade fever and chills (infectious gangrene)
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
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
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
Treatment algorithm
necrotizing fasciitis awaiting confirmation of microbial culture and sensitivity results
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
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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