Necrotizing fasciitis or NF, commonly known
as flesh-eating disease, flesh-eating bacteria or flesh-eating bacteria syndrome, is a rare
infection of the deeper layers of skin and subcutaneous tissues, easily spreading across
the fascial plane within the subcutaneous tissue. The most consistent feature of Necrotizing
Fasciitis was first described in 1952 as necrosis of the subcutaneous tissue and fascia with
relative sparing of the underlying muscle. Necrotizing fasciitis progresses rapidly,
having greater risk of developing in the immunocompromised due to conditions such as diabetes or cancer.
It is a severe disease of sudden onset and is usually treated immediately with surgical
debridement and high doses of intravenous antibiotics, with delay in surgical treatment
being associated with higher mortality. Many types of bacteria can cause necrotizing
fasciitis, Staphylococcus aureus, Clostridium perfringens, Bacteroides fragilis, Aeromonas
hydrophila). The disease is classified as Type I or Type II. The majority of cases of
necrotizing fasciitis are polymicrobial, with 25-45% of cases being Type II. Such infections
are more likely to occur in people with compromised immune systems secondary to chronic disease.
Historically, most cases of Type II infections have been due to group A streptococcus and
staphylococcal species. Since as early as 2001, a particularly difficult to treat form
of monomicrobial necrotizing fasciitis has been observed with increasing frequency caused
by methicillin-resistant Staphylococcus aureus. Possible sources
The majority of infections are caused by organisms that normally reside on the individual’s skin.
These skin flora exist as commensals and infections reflect their anatomical distribution.
Sources of MRSA may include eating undercooked contaminated meats, working at municipal waste
water treatment plants, exposure to secondary waste water spray irrigation, consuming raw
products produced from farm fields fertilized by human sewage sludge or septage, in hospital
settings from people with weakened immune systems, or sharing/using dirty needles. The
risk of infection during regional anaesthesia is considered to be very low, though reported.
Signs and symptoms Over 70% of cases are recorded in people with
at least one of the following clinical situations: immunosuppression, diabetes, alcoholism/drug
abuse/smoking, malignancies, and chronic systemic diseases. For reasons that are unclear, it
occasionally occurs in people with an apparently normal general condition.
The infection begins locally at a site of trauma, which may be severe, minor, or even
non-apparent. People usually complain of intense pain that may seem excessive given the external
appearance of the skin. People initially have signs of inflammation, fever and tachycardia.
With progression of the disease, often within hours, tissue becomes progressively swollen,
the skin becomes discolored and develops blisters. Crepitus may be present and there may be discharge
of fluid, said to resemble “dish-water”. Diarrhea and vomiting are also common symptoms.
In the early stages, signs of inflammation may not be apparent if the bacteria are deep
within the tissue. If they are not deep, signs of inflammation, such as redness and swollen
or hot skin, develop very quickly. Skin color may progress to violet, and blisters may form,
with subsequent necrosis of the subcutaneous tissues.
Furthermore, people with necrotizing fasciitis typically have a fever and appear very ill.
Mortality rates have been noted as high as 73 percent if left untreated. Without surgery
and medical assistance, such as antibiotics, the infection will rapidly progress and will
eventually lead to death. Pathophysiology “Flesh-eating bacteria” is a misnomer, as
in truth, the bacteria do not “eat” the tissue. They destroy the tissue that makes up the
skin and muscle by releasing toxins, which include streptococcal pyrogenic exotoxins.
Diagnosis The Laboratory Risk Indicator for Necrotizing
Fasciitis score can be utilized to risk stratify people having signs of cellulitis to determine
the likelihood of necrotizing fasciitis being present. It uses six serologic measures: C-reactive
protein, total white blood cell count, hemoglobin, sodium, creatinine and glucose. A score greater
than or equal to 6 indicates that necrotizing fasciitis should be seriously considered.
The scoring criteria are as follows: CRP ≥150: 4 points
WBC count25: 2 points Hemoglobin
>13.5: 0 points 11–13.5: 1 point
141: 2 points Glucose>10: 1 point
Treatment Early medical treatment is often presumptive;
thus, antibiotics should be started as soon as this condition is suspected. Initial treatment
often includes a combination of intravenous antibiotics including piperacillin/tazobactam,
vancomycin, and clindamycin. Cultures are taken to determine appropriate antibiotic
coverage, and antibiotics may be changed when culture results are obtained.
People are typically taken to surgery based on a high index of suspicion, determined by
the person’s signs and symptoms. In necrotizing fasciitis, aggressive surgical debridement
is always necessary to keep it from spreading and is the only treatment available. Diagnosis
is confirmed by visual examination of the tissues and by tissue samples sent for microscopic
evaluation. As in other maladies characterized by massive
wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy
but is not widely available. Amputation of the affected limb(s) may be necessary. Repeat
explorations usually need to be done to remove additional necrotic tissue. Typically, this
leaves a large open wound, which often requires skin grafting, though necrosis of internal
viscera – such as intestinal tissue – is also possible. The associated systemic
inflammatory response is usually profound, and most people will require monitoring in
an intensive care unit. Because of the extreme nature of many of these wounds and the grafting
and debridement that accompanies such a treatment, a burn center’s wound clinic, which has staff
trained in such wounds, may be utilized. Treatment for necrotizing fasciitis may involve
an interdisciplinary care team. For example, in the case of a necrotizing fasciitis involving
the head and neck, the team could include otolaryngologists, speech pathologists, intensivists,
microbiologists and plastic surgeons or oral and maxillofacial surgeons. Maintaining strict
asepsis during any surgical procedure and regional anaesthesia techniques is vital in
preventing the occurrence of the disease. Notable cases
1994 Lucien Bouchard, former premier of Québec, Canada, who became infected in 1994 while
leader of the federal official opposition Bloc Québécois party, lost a leg to the
illness. 1994 A cluster of cases occurred in Gloucestershire,
in the west of England. Of five confirmed and one probable infection, two died. The
cases were believed to be connected. The first two had acquired the Streptococcus pyogenes
bacteria during surgery, the remaining four were community-acquired. The cases generated
much newspaper coverage, with lurid headlines such as “Flesh Eating Bug Ate My Face”.
1997 Ken Kendrick, former agent and partial owner of the San Diego Padres and Arizona
Diamondbacks, contracted the disease in 1997. He had seven surgeries in a little more than
a week and later recovered fully. 2004 Eric Allin Cornell, winner of the 2001
Nobel Prize in Physics, lost his left arm and shoulder to the disease in 2004.
2005 Alexandru Marin, an experimental particle physicist, professor at MIT, Boston University
and Harvard University, and researcher at CERN and JINR, died from the disease.
2006 David Walton, a leading economist in the UK and a member of the Bank of England’s
Monetary Policy Committee, died in June 2006 of the disease within 24 hours of diagnosis.
2006 Alan Coren, British writer and satirist, announced in his Christmas 2006 column for
The Times that his long absence as a columnist had been caused by his contracting the disease
while on holiday in France. 2009 R. W. Johnson, South African journalist
and historian, contracted the disease in March 2009 after injuring his foot while swimming.
His leg was amputated above the knee. 2011 Jeff Hanneman, guitarist for the thrash
metal band Slayer, contracted the disease in 2011. He died of liver failure two years
later, on May 2, 2013, and it was speculated his infection might be the cause of death.
However, on May 9, 2013, the official cause of death was announced as alcohol-related
cirrhosis. Hanneman and his family had apparently been unaware of the extent of the condition
until shortly before his death. 2011 Peter Watts, Canadian science fiction
author, contracted the disease in early 2011. On his blog, Watts reported, “I’m told I
was a few hours away from being dead…If there was ever a disease fit for a science
fiction writer, flesh-eating disease has got to be it. This…spread across my leg as fast
as a Star Trek space disease in time-lapse.” 2012 Aimee Copeland, a 24-year old graduate
student, contracted necrotizing fasciitis after she fell from a zip-line into the Little
Tallapoosa River which caused a deep cut in her leg. Copeland’s entire leg was amputated
along with her other limbs as a side effect of the disease and treatment. Five of her
organs also failed as a result of the ordeal. 2012 Mary Ryan from Florida – originally
from Cork, Ireland – underwent liposuction on her abdomen, neck and jowls on December
19. After the procedure she complained about extreme nausea and pain in her abdomen, and
because of this she failed to attend a scheduled post-op checkup. As she reported feeling better,
she traveled to Ireland on December 24 to visit her family. However, she did not travel
with the prescribed antibiotics due to a communication breakdown. On arrival at her son’s home on
December 26 she reported feeling very ill. After consulting a local GP, Mrs. Ryan was
admitted to the Intensive Care department of Cork University Hospital the same evening.
Despite surgical intervention and high doses of antibiotics she died on December 29, only
ten days after the liposuction treatment. The coroner’s verdict was ‘death by medical
misadventure’. 2013 Rick Teal, New Zealand father of three,
was at work when he noticed a nagging pain in his right leg. Within half an hour he had
developed a limp. He was subsequently admitted to Wellington Hospital and, two days after
the onset of symptoms, he gave doctors permission to amputate his leg. Teal eventually recovered
without amputation but large areas of infected flesh between his knee and ankle had to be
debrided. Necrotizing fasciitis is on the rise in New Zealand.
2014 Don Rickles, a celebrated American stand-up comedian, revealed on The Late Show With David
Letterman on 2 May 2014 that he had contracted necrotizing fasciitis on his right leg. His
doctor came over to his house for a visit and noticed a sore on Don’s leg. After examining
it he sent him straight to the hospital. Treatment was successful, though he now requires a cane.
If it had progressed further, Don quipped, he would have wound up with Johnny Depp as
a one legged pirate. NOTE: It is often incorrectly reported that
Jim Henson, creator of the Muppets, died of necrotizing fasciitis. In fact he died of
toxic shock syndrome caused by Streptococcus pyogenes.
See also Mucormycosis, a rare fungal infection that
can present like necrotizing fasciitis Toxic shock syndrome
Fournier gangrene Vibrio vulnificus
References External links
National Necrotizing Fasciitis Foundation Necrotizing fasciitis at DMOZ