Title : Necrotising fasciitis in all four extremities and abdominal wall
Abstract:
Necrotising fasciitis, commonly known as flesh eating bacteria, is a fulminant, lethal soft tissue infection that poses a challenge to surgeons all over the world and making it a medical and surgical emergency. Early diagnosis, radical debridement, intravenous antibiotics, multidisciplinary approach and rehabilitation are mainstay of treatment. Since it presents with non-specific signs and symptoms that change over time and spreads along fascial planes, it is often missed. The diagnosis is clinical and requires a high index of suspicion and a low threshold for referral to surgical care. There is extensive necrosis of the dermis and fat with little muscle sparing, rapidly causing sepsis. Characteristics of this highly lethal infection include clinical symptoms of pain out of proportion, edema ,erythema, ulceration, discharge,fever, hypotension, disorientation, local anaesthesia(as nerves get involved), crepitus and blistering and with histopathologic features of fascial necrosis, vasculitis, and thrombosis of perforating veins. The disease can progress swiftly without specific signs to reflect the underlying pathophysiological process, requiring ICU admission, mechanical ventilation, and inotropic support. Recognised predisposing factors include any trauma causing breach in skin, immunosuppression, NSAIDS and chronic diseases. Necrotising fasciitis can be sub-classified by pathogens as: type 1 (polymicrobial- Klebsiella pneumonia, Aeromonas hydrophila, Pseudomonas aeruginosa, and Streptococcus), type 2 (beta haemolytic Streptococcus pyogenes, monomicrobial), type 3 (Clostridium species and Gram negative bacteria), and type 4 (fungal). Type 1 necrotizing fasciitis is a polymicrobial infection( most common) mainly involving the trunk whereas, Type 2 necrotizing fasciitis contains group A Streptococcus with or without a coexisting staphylococcal infection mainly affecting limbs. The responsible organisms produce pyogenic exotoxins and cytolysin that are responsible for hypotension, multi-organ failure, and disseminated intravascular coagulation. The treatment of choice for NF is aggressive debridement of all necrotic tissues even beyond normal tissue within 24 hrs of onset of symptoms after rescucitation. However, despite radical initial surgical debridement and a limb amputation, surgical control of the infectious source is often not achieved resulting into high mortality. It is very rare and unfortunate to get simultaneous infections in all four limb as well as infections in groin and abdomen which poses a great challenge in total care of the patient especially in deciding the depth and breadth of the sequential debridement and decision of limb reconstruction with tissue coverage v/s amputation. I present a case of NEC of a young patient who presented with involvement of all four limbs, groin and abdomen, eventually ends up in having an above knee amputation after multiple debridements requiring soft tissue reconstruction along with using newer modalities of treatment which helped us to save her life after a long battle of 30 days stay in ICU where she was on vasopressor support and tracheostomized. At the end, she was able to move her limbs and amputation stump and she was discharged to rehab. Here, I would like to discuss the newer modalities of treating NF like IVIg, HBO, versajet, BTM, INTEGRA, VAC and honey, out of which, which we have used a couple for our patient.
