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Necrotizing Fasciitis

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Necrotizing Fasciitis

Necrotizing fasciitis is a rare disease which is characterized by the bodies inflammatory response initiated by the immune system. Necrotizing fasciitis quickly spreads throughout the body (WebMD 2014). The inflammatory response is followed by necrosis of fascial planes and surrounding tissue. Trauma usually ensues after the infection. The infection is usually triggered when an injury occurs. Minor abrasions or lesions are enough to allow susceptibility of this bacterial infection (Bellapianta et al., 2009).

What is the causative agent?

There are two factors that are crucial in developing necrotizing fasciitis. These include exposure to bacteria of the group A Streptococcus and the susceptibility of an individual to the bacteria. The genus Streptococcus belongs to a group of Gram-positive bacteria. Group a streptococci are mostly facultative anaerobes and some are strictly anaerobes. This genus has also been associated with the following medical conditions; scarlet fever, rheumatic heart disease, glomerulonephritis, and pneumococcal pneumonia. The microbe, Streptococcus pyogenes, is the causative agent of necrotizing fasciitis, it is also referred to as the flesh eating bacteria. The S. pyogenes capsule is composed of hyaluronic acid. Hyaluronic acid is also found in the connective tissue of human. Thus, the bacterium is regarded as antigenic. The cytoplasmic membrane of S. pyogenes has a semblance to the antigen of the human heart, skeletal and smooth muscle cells. The antigen of the microbes is also similar to that of the heart valve fibroblast and neuronal tissues. As a result, molecular imitation occurs inside the host infected with S. pyogenes. Some of the toxins produced by S. pyogenes include: the spreading factor of hyaluronidase, streptolysin (causes cell breakdown), streptokinase (responsible in fibrin lysis), and proteases that cause tissue necrosis or toxic shock syndrome (Patterson 1991).


How is the disease transmitted?

About 5-15% of humans are carriers of S. pyogenes in the nasopharynx. Skin infections related to S. pyogenes are usually observed in pre-school aged children. The bacteria is spread via nasal droplets or contact with contaminated objects used by the index individual (i.e. patient or carrier). Late sequelae infections of S. pyogenes had moved from temperate locations to tropical regions. However, the cause of the shift of the infection has remained unknown. S. pyogenes can also be transmitted through feces, ingestion of contaminated food and vector parasites (Patterson 1991), The primary method of transmission for bacteria such as S. pyogenes is through the first line of our bodies defense, the skin, particularly open wounds. Further, the bacteria could also be transferred through bedsores and post-surgical incisions (Johnson and Finley 2013)..

Who does this disease affect and how dangerous is it?

Mortality rate of patients afflicted with necrotizing fasciitis was estimated from 25% to 73% overall in literatures. The Center for Disease and Control Prevention estimated that nearly 500 to 1500 patients (about 30% mortality rate) die every year because of group a Streptococcus in the United States in 1996. Recently, about 650 to 800 cases were reported by CDC but the statistics were underestimated because some cases were not reported. But the numbers were not expected to rise because the chances of having one is 1 out of 4. Those who are immunocompromised are at high risk of getting the disease. By immunocompromised, these are patient suffering from diabetes, cancer and kidney diseases to include those who also take steroids to alleviate their medical conditions (Johnson and Finley 2013).

Signs and symptoms and how soon do they appear?

Necrotizing fasciitis usually starts with a simple cut or an insect bite where bacteria can infiltrate the body and eventually proliferate. The earliest stage of necrotizing fasciitis show signs of a minor trauma. Pain is present in the general area of the injury extending to the same region at the site of the injury or the limb of the body. The pain is not in proportion to the injury such that the level of pain for a small cut is akin to a muscle pull that becomes more and more painful. Flu like symptoms are also present (i.e. diarrhea, nausea, fever, confusion, dizziness, weakness, and general malaise). The patient may also experience dehydration. Advanced symptoms are usually underway within three to four days. From here, the patient may feel excruciating pain in the limb or other areas of the body. Purplish discoloration and swelling becomes evident. Large, dark marks that were observed in the limb will blister with blackish fluid. The wound appears to be a bluish white, or dark mottled, and flaky during necrosis. Within four-five days, a patient may experience critical symptoms such as: severe drop in blood pressure (hypotension), septic shock from the toxins elicited by bacteria (systemic sepsis) and or unconsciousness (Taviloglu and Yanar 2007).


How is the disease treated?

There are five types of therapy for necrotizing fasciitis that are commonly applied to patients. These include: early diagnosis and debridement, broad-range antibiotics, aggressive resuscitation, frequent reevaluation and comprehensive nutritional support (Bellapianta et al. 2009). Surgical debridement is the fastest and most effective way to reduce bacterial proliferation and stop tissue death. The objective of the surgery is to remove all of the necrotic tissue in the body (debridement). Antibiotic therapy is used to complement surgical therapy. However, it is not mainly used for therapy due to the fact that the fascia is poorly vascularized. And the blood facilitates the antibiotic to the target antigen. Clindamycin is prescribed at the earliest signs of group A Streptococcus infection. Support through fluid resuscitation and blood pressure monitoring are essential for patients suffering from necrotizing fasciitis. This is to avoid loss of fluid, protein and electrolytes. Further, adequate pain management should also be provided for post-surgical debridement patients. Adjuctive therapies such as immunoglobulin G (IVIG) and hyperbaric oxygen (HBO) are seemingly promising options for patients. IVIG halts the activation of the T-cell and the cytokine production of Streptococcus. HBO treatment on the other hand is used to establish normal or elevated partial oxygen pressure so as to terminate the cycle of infection and improve the host defense mechanism (Bellapianta et al. 2009).

How can this disease be prevented?

Several recommendations have been listed to prevent the spread of necrotizing fasciitis and other related diseases caused by group A Streptococcus. These preventive measures include: good hand washing, keeping the skin intact, staying at home until the last dosage of antibiotics has been administered when the throat is infected with Streptococcus, seeing a doctor immediately upon having a sore throat, cleaning wounds immediately and consulting a doctor when a fever occurs during a wound infection (Taviloglu and Yanar 2007).

Work Cited
Abass K, Saad H, Abd-Elsayed A A. 2008. Necrotizing Fasciitis with Toxic Shock Syndrome in a Child: A Case Report and Review of Literature. Cases Journal [online]. [cited 2014 February 6]; 1: 228. Available from: http://www.casesjournal.com/content/1/1/228

Bellapianta JM, Ljungquist K, Tobin E, Uhl R. 2009. Necrotizing Fasciitis. Journal of the American Academy of Orthopaedic Surgeons. 17: 174-182.

Johansson L, Thulin P, Low DE and Norrby-Teglund A. 2010. Getting under the Skin: The Immunopathogenesis of Streptococcus pyogenes Deep Tissue Infections. Clinical Infectious Diseases. 51(1): 58-65.

Johnson PA, and Finley K. 2013. Necrotizing Fasciitis [Internet]. 3rd ed. Detroit (MI): Gale; [cited 2014 February 6]. Vol. 4, p. 2298-2300.Available from: Gale Virtual Reference Library; http://ezproxy.pc.maricopa.edu:2071/ps/i.do?id=GALE%7CCX2760400724&v=2.1&u=mcc_phoe&it=r&pGVRL&sw=w&asid=fcdb897281d82aab67c5478d5c6dbf4.

Patterson MJ. 1991. Streptococcus. In: Baron S, editor. Medical Microbiology. 3rd ed. New York: Churchill Livingstone. p. 215-230.

Taviloglu K, Yanar H. 2007. Necrotizing Fasciitis: Strategies for Diagnosis and Management. World Journal of Emergency Surgery [online]. [cited 2014 February 6]; 2(19): 1-3. Available from: http://www.wjes.org

WebMD[Internet]. 2014. Necrotizing Fasciitis (Flesh-eating Bacteria) [cited 2014 February 6]. Available from: http://www.webmd.com/a-to-z-guides/necrotizing-fasciitis-flesh-eating-bacteria-topic-overview.…...

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