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Journal of Long-Term Effects of Medical Implants

ISSN for PRINT: 1050-6934

Institutional price:	$1021.00
Issues per year:	6

Best Paper Award Selection - Editorial Board Site

2005, Volume15

124 pages

DOI: 10.1615/JLongTermEffMedImplants.v15.i1

Issue price - $175.00

Massive Soft Tissue Infections: Necrotizing Fasciitis and Purpura Fulminans

Richard F. Edlich
Distinguished Professor of Plastic Surgery, Director of Trauma Prevention, Education, and Research, Trauma Specialists, LLP, Legacy Emanuel Hospital; 22500 NE 128th Circle, Brush Prairie WA 98606, USA; Phone: 360-944-7641, Fax: 360-944-7612

Kathryne L. Winters
Website Manager and Information Specialist, Trauma Specialists, LLP, Legacy Emanuel Hospital, Portland, Oregon, 1917 NE 97th St. Vancouver WA 98665, USA

Charles R. Woodard, BS
Eastern Virginia Medical School, Norfolk; Department of Plastic Surgery, Box 800376, University of Virginia Health Systems, Charlottesville, Virginia, USA

L. D. Britt, MD, MPH, FACS
Chairman, Brickhouse Professor of Surgery. Department of General Surgery, Eastern Virginia Medical School, Hofheimer Hall, 825 Fairfax Avenue, Norfolk VA 235001, USA

William B. Long III
Medical Director of Trauma Center, Trauma Specialists, LLP, Legacy Emanuel Hospital, Portland, Oregon, USA

ABSTRACT

Necrotizing fasciitis and purpura fulminans are two destructive infections that involve both skin and soft tissue. Necrotizing fasciitis is characterized by widespread necrosis of subcutaneous tissue and the fascia. Historically, group A β-hemolytic streptococcus has been identified as a major cause of this infection. However, this monomicrobial infection is usually associated with some underlying cause, such as diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is polymicrobial. The diagnosis of necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous antibiotic therapy is one of the cornerstones of managing this life-threatening skin infection. Surgery is the primary treatment for necrotizing fasciitis, with early surgical fasciotomy and debridement. Following debridement, skin coverage by either Integra^® Dermal Regeneration Template or AlloDerm^® should be undertaken. Hyperbaric oxygen therapy complemented by intravenous polyspecific immunoglobulin are useful adjunctive therapies.
Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of purpura fulminans: neonatal purpura fulminans, idiopathic or chronic purpura fulminans, and acute infectious purpura fulminans. Clinical presentation of purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with fever, shock, and disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of multiple organ failure can be conducted with aggressive debridement and fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal purpura fulminans is the use of activated protein C.