Necrotising Fasciitis – A topic so much fun it’ll melt your face off!

Ahhhhh, necrotising fasciitis, the holy grail for any kid who has poked something disgusting with a stick. Commonly called ‘flesh-eating disease’ even though it’s not really affecting your ‘flesh’, nor are you be eaten, it remains one of the more truly horrifying diseases you can pick up on this planet.

Warning: Graphic picture of wound at the end of the article

I’m melting! Melting! (Wicked Witch of the West)

Okay so in that movie the witch doesn’t have necrotising fasciitis but what else would you say if your skin and tissues were tuning black before your eyes! Well I can actually think of a lot of things now that I mention it. Swearing would probably take centre stage but I digress…

Necrotising fasciitis (or NF to the cool kids) is a bacterial disease which can be caused by either one (Type I) or many causative agents concurrently (Type II) including many species of Streptococcus and Staphylococcus as well as select Vibrio and Clostridia species. “Where on Earth would you pick those up?” I hear you say, in fact you find them everywhere as some live inside you already (Streptococci), some on the surface of your skin (Staphylococci) some in the soil (Clostridia) and others in water supplies (Vibrio). These bacterial species are in fact very common but the disease is not.

This is primarily due to the fact that it requires these specific bacteria, which are mostly anaerobic (hate oxygen like the plague) to descend beyond the outer layers of the skin to a layer called the ‘fascia’. The fascia is found between the skin and muscle and is home to the nerves and blood vessels (remember these, it becomes important later) among other things.

Anatomy of skin tissue nd underlying tissues (Green etal., 1996)

Ye Olde Necrotising fasciitis

NF was first observed by the granddaddy of medicine Hippocrates in the 5th century BC. He noted that it appeared similar to Erysipelas (infection of the skin layer) and gangrene (which is localised to the muscles) but was not localised to the skin or muscle but to the space between them. By the early 19th century it had gone by many names but was most commonly referred to as phagedena which means to eat away! It was most commonly diagnosed in the military forces due to close quarter living conditions and lots of pointy metal sticks to break the skin layer (presumably). In those days, nobody really had a good grasp on what they needed to do so sufferers dealt with pain, pain, more pain, skin falling off in clumps, perpetual fever and death.

So what’s happening under the skin?

After making it past the skin barrier, the bacteria multiply in the fascia and disturb the tissue, prompting an inflammatory response by the body causing swelling and pain, lots of pain. So much pain in fact, that clinical symptoms include people complaining about pain in an area that doesn’t appear to have anything wrong with it. Over time the immune system responds to the bacteria directly, but the response is often overdone The result is that the immune system starts to kill off the fascia whilst trying to kill the bacteria. Oh, the bacteria also make toxins (depending on the species of bacteria) which kill off the fascia as well. Everything combines to say ‘shutupa your fascia!’ (it actually hurt to write that…)

So this continues for a bit until you have an increasing area of dead fascia under the skin. Now the pain really kicks in. Remember where the blood vessels were, in the fascia, yeah there not there anymore so the skin becomes necrotic (dies) and falls off as the nutrients form the blood cannot reach the skin. The muscles underlying the area also tend to waste a bit at the same time. All those toxins in your system overload your body causing you to go into toxic shock syndrome and multiple organ failure. If not treated straight away, the patient faces a mortality rate of 75%.

Male forearm with necrotising faciitis

OMG I THINK I HAVE IT!! Will I die?

Do you look like the picture? Yes? You have it, don’t finish this, go now to the hospital, I’m not even kidding…

You don’t look like the picture? Feel free to carry on reading.

Are you are a diabetic, alcoholic, intravenous drug user, immuno-suppresed? Do you suffer from hypertension or do you work with the bacteria responsible for this disease? These are the main risk factors that put you at a greater risk of contracting the disease and dying. I guess what I’m trying to say is, if you have just had surgery and that weird bulge on you leg is hurting, maybe see a doctor.

It’s unfortunate that those with the disease have had to run off, they’re going to miss out on finding out what they can look forward too.

Luckily for them the treatments for NF are simple, non-invasive and very effective. Actually the exact opposite of that sentence is the case… The most effective treatment is initial exploratory surgery. Starting at the wound, the skin is peeled away from the necrotic fascia allowing the dead tissue to be scraped away until healthy tissue is found, them some of that is removed for good measure. This requires a very good surgeon, and even then most people have to be re-opened 2-3 times to get all the infected tissue out. In extreme cases up to 50% of the fascia has been removed and the patient survived.

Surgical intervention is currently the most effective treatment option for NF. Antibiotics don’t work particularly well as they are delivered by the bloodstream and, well, that was destroyed with the fascia so good luck there. Spending some time in a hyperbaric oxygen chamber will also help as it increases the amount of oxygen at your tissues and most of the bacteria that cause NF hate oxygen. But surgery first, oxygen and antibiotics later.

Fun facts about Necrotising fasciitis!

If funniest home videos has taught me anything it’s that men get punched, kicked, whacked or otherwise suffer blunt trauma to the…ugh…equipment all the time. Apparently a good proportion of those traumas cause enough tissue damage that in some cases bacteria from the bowel get access to the genital region causing NF that it gets its own name, Fournier’s gangrene! It’s named after Jean Fournier who described a case of it back in 1843. No name is used specifically for the female equivalent but this crops up a lot in medicine. If it was found by a man, in a man, sometime before the 20th century then this is a disease for men only!

Despite the gory details, NF is not something you are likely to encounter often. Data from the US shows that only 10,000-15,000 people suffer from the disease annually. In a population of over 300 million that’s 0.00005% of people contracting NF. Mind you 2,000-3,000 of those people die as a result of those infections so while unlikely it still is very deadly.

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2 Comments

Filed under James' Corner

2 responses to “Necrotising Fasciitis – A topic so much fun it’ll melt your face off!

  1. maxine woodward

    I found the subject matter to be a little flipant but to the point. My husband had fourniers about three years ago, scary as , but do not decieve yourself that people even take the time to think it won’t happen to them.I was appalled and until this day i am still reeling from the fact that his sister ignored all the warning signs and died a very painful death. She was a very stubborn woman and did not let anybody know how bad things were, not even her own daughter.We as her family were somewhat scutinised by the medical fraternity for letting it get that far…We did not realise what was happening to her . She died on the operating table as they were trying to amputate her leg. She was a classic case for getting this disease, Diabetes, overweight, smoker…Why am i writing to you about this…Because i am so mad at her on so many levels, and it is almost twelve months since she passed…All because she was too embarassed and too stubborn to get help….

    • thomastu

      I’m sorry about your loss, Maxine. We aren’t health care workers at all, so I can’t comment about the way they handled your case. Sometimes it does get lost that these diseases we are so excited about do make people sick and sometimes kill them.

      Having said that, as I am of South-East Asian descent, it is no surprise that some members of my family have hepatitis B (prevalence is 30 to 40% of the population). It helps drive me in my research as well as keep a grounding in what effects it has on the everyday person. I know what I’m doing is worthwhile because of this connection and that makes me satisfied.

      And indeed, as scientists, we may seem flippant at times and not treating the diseases we talk about with enough gravitas. We can casually toss out statistics of 1 million people die each year of blah blah and not bat an eyelid at it. In some ways, it is built into the culture; evidence is treated as impersonally and objectively as possible. To make logical connections between data, emotions can lead you astray.

      TT

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