What is subacute necrotizing fasciitis?: A proposed clinical diagnostic criteria
Introduction
Necrotizing fasciitis is perhaps the most severe and feared soft tissue infection, characterized by a fulminant course and a high mortality.1 Classic clinical presentation of necrotizing fasciitis is by a combination of severe local symptoms and systemic disturbances. In fact, several authors listed severe systemic sepsis as a diagnostic feature of this condition.2, 3 While this is undoubtedly true, the emergence of what appear to be subacute forms of necrotizing fasciitis in the literature have raised concerns over the possible changing clinical presentation of this disease. Indeed, while the existence of subacute necrotizing fasciitis is often questioned, its clinical implications are immense. While early surgical debridement has been proven in multiple studies to decrease mortality, delayed diagnosis is often seen due to the absence of specific clinical features early in the evolution of necrotizing fasciitis. This difficulty in clinical recognition is complicated by presence of atypical manifestations of this disease such as subacute forms of necrotizing fasciitis.6 We reviewed the literature with the purpose of clarifying and defining what subacute necrotizing fasciitis is.
Section snippets
Methods
A PUBMED search of the English language literature was performed using the following keywords: Necrotizing fasciitis, subacute, variant and indolent. We did a free text search or a MeSH search wherever appropriate and used the Boolean operators to combine the terms. The identified articles were review to identify patients that fulfil the diagnostic criteria for subacute necrotizing fasciitis. Cases in which insufficient information were available to conclusively classify as subacute necrotizing
Results
Majority of reported cases did not give sufficient information to satisfy the reviewer that these cases were indeed subacute forms of necrotizing fasciitis. We identified three cases of subacute necrotizing fasciitis that clearly are subacute cases and analysed their clinical presentation (Table 2). A diagnostic criterion for defining subacute necrotizing fasciitis was proposed based on these cases and the authors' clinical experiences (Table 1). Illustrated here are two patients that fulfilled
Discussion
While the term subacute necrotizing fasciitis has been variously mentioned in the literature for the past few decades, its definition remains vague and poorly defined. In fact, the existence of subacute forms of a fulminant condition such as necrotizing fasciitis is often questioned. The presence of subtypes of necrotizing fasciitis was first suggested by Leppard and Seal in 1983.8 They classified subacute necrotizing fasciitis as cases with symptoms developed over days to weeks, usually with
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