Necrotizing fasciitis: a plea for early diagnosis and treatment.

INTRODUCTION: Necrotizing fasciitis is an uncommon infectious entity that poses difficult diagnostic and therapeutic management decisions.
PURPOSE: This paper addresses the presentation, evaluation and management of the patient with a necrotizing soft tissue infection. CASE REPORT: A 54-year-old man presented to his physician with pain and swelling of the left anterior chest wall following a presumed insect bite several days prior. He was treated with oral antibiotics but returned to the office three days later with increased swelling, pain, and erythema in the axilla. Necrotizing fasciitis was diagnosed. He was hospitalized and taken to the operating room for debridement of the chest wall. Extensive necrosis of the skin, subcutaneous tissue and muscle was encountered. Muscle debridement extended from the pectoralis major and both obliques anteriorly to the latissimus dorsi and para-spinalis muscles posteriorly. Multiple operative debridements were performed over several days. The patient developed septic shock requiring blood pressure support, and multiple organ system failure requiring hemodialysis, prolonged ventilatory support and eventual tracheostomy. Split-thickness skin grafts were placed during the third operative debridement and concluded on the 15th day of hospitalization. The patient eventually recovered and on the 53rd hospital day was transferred to the rehabilitation service, where he spent the next four weeks recovering movement in the left arm.
CONCLUSION: Necrotizing fasciitis is an infectious entity that requires rapid diagnosis, surgical debridement, and tissue coverage if the patient is to survive.