Dataset Information

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report.

ABSTRACT:

Background

Necrotizing skin and soft tissue infections are life-threatening conditions. Reliance on gas in tissue planes leads to worsened outcomes in patients with non-gas forming types of necrotizing fasciitis (NF).

Case presentation

We present a case of Group A Strep (GAS) necrotizing fasciitis, which was identified at bedside with point-of-care ultrasound (US) including an area of subfascial fluid. Computerized tomography only revealed diffuse cellulitic changes. Patient was taken to the operating room where fascial exploration was not performed at the concerning area seen on ultrasound and thus falsely negative. The patient subsequently developed multi-system organ failure and required amputation of the limb due to rapid spread of GAS NF.

Conclusion

We suggest an US protocol to help identify optimal areas for fascial exploration-sonographic exploration for fascial exploration (SEFE).

SUBMITTER: Fozard J

PROVIDER: S-EPMC7176767 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Publications

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report.

Fozard Jessica J Shafer Krystle K Kehrl Thompson T

The ultrasound journal 20200422 1

<h4>Background</h4>Necrotizing skin and soft tissue infections are life-threatening conditions. Reliance on gas in tissue planes leads to worsened outcomes in patients with non-gas forming types of necrotizing fasciitis (NF).<h4>Case presentation</h4>We present a case of Group A Strep (GAS) necrotizing fasciitis, which was identified at bedside with point-of-care ultrasound (US) including an area of subfascial fluid. Computerized tomography only revealed diffuse cellulitic changes. Patient was t ...[more]

PMID: 32323044

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Project description:ObjectivesThe Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities.MethodsWe conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve.ResultsA total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751).ConclusionThe Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.

Project description:ImportancePyoderma gangrenosum and necrotizing Sweet syndrome are diagnostically challenging variants of neutrophilic dermatosis that can clinically mimic the cutaneous and systemic features of necrotizing fasciitis. Improved characterization of these rare variants is needed, as improper diagnosis may lead to inappropriate or delayed treatment and the potential for morbidity.ObjectiveTo determine the characteristics of necrotizing neutrophilic dermatosis to improve diagnostic accuracy and distinguish from infection.Design, setting, and participantsA case series of patients with necrotizing neutrophilic dermatosis treated at 3 academic hospitals (University of California San Francisco, Oregon Health and Science University, and University of Minnesota) from January 1, 2015, to December 31, 2017, was performed along with a literature review of related articles published between January 1, 1980, and December 31, 2017. Data were obtained from medical records as well as Medline and Embase databases. All patients had signs resembling necrotizing infection and had a final diagnosis of pyoderma gangrenosum with systemic features or necrotizing Sweet syndrome. Patients were excluded if a diagnosis other than neutrophilic dermatosis was made, if key clinical information was missing, and if reported in a non-English language.Main outcomes and measuresDescription of key characteristics of necrotizing neutrophilic dermatosis.ResultsOverall, 54 patients with necrotizing neutrophilic dermatosis were included, of which 40 had pyoderma gangrenosum with systemic features and 14 had necrotizing Sweet syndrome. Of the 54 patients, 29 (54%) were male and 25 (46%) were female, with a mean (SD) age of 51 (19) years. Skin lesions commonly occurred on the lower (19 [35%]) and upper (13 [24%]) extremities and developed after a surgical procedure (22 [41%]) or skin trauma (10 [19%]). Shock was reported in 14 patients (26%), and leukemoid reaction was seen in 15 patients (28%). Of the patients with necrotizing neutrophilic dermatosis, 51 (94%) were initially misdiagnosed as necrotizing fasciitis and subsequently received inappropriate treatment. Debridement was performed in 42 patients (78%), with a mean (SD) of 2 (2 [range, 1-12]) debridements per patient. Four amputations (7%) were performed. Forty-nine patients (91%) received antibiotics when necrotizing neutrophilic dermatosis was misdiagnosed as an infection, and 50 patients (93%) received systemic corticosteroids; all patients responded to immunosuppressants.Conclusions and relevanceA complex spectrum of clinical findings of pyoderma gangrenosum and Sweet syndrome with prominent systemic inflammation exists that defines a new subset of neutrophilic dermatoses, termed necrotizing neutrophilic dermatoses; recognizing the difference between this variant and severe infection may prevent unnecessary surgical procedures and prolonged disease morbidity associated with a misdiagnosis and may expedite appropriate medical management.

Dataset Information

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report.

Background

Case presentation

Conclusion

Publications

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report.

Similar Datasets

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