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• Pyomyositis
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• Myositis

Pyomyositis
AuthorsLarry M Baddour, MD, FIDSAAnuwat Section EditorDaniel J Deputy EditorElinor L
Keerasuntornpong, MD Sexton, MD Baron, MD, DTMH
As a subscriber you will have access to the full contents of this article
• INTRODUCTION
• EPIDEMIOLOGY
• Predisposing factors
• Immunodeficiency
• Trauma
• Injection drug use
• Concurrent infection
• MICROBIOLOGY
• CLINICAL MANIFESTATIONS
• DIFFERENTIAL DIAGNOSIS
• DIAGNOSIS
• Radiography
• Cultures
• Laboratory data
• TREATMENT
• Drainage
• Antibiotics
• SUMMARY AND RECOMMENDATIONS
• REFERENCES
GRAPHICS

• TABLES
• Dx muscle and fascia infection
• Risk factors for MRSA
• Abx therapy pyomyositis
• Immunocompromised pyo rx
INTRODUCTION

Pyomyositis is a purulent infection of skeletal muscle that arises from hematogenous

spread, usually with abscess formation [1]. The clinical approach to pyomyositis will be
reviewed here. Other soft tissue infections such as clostridial myonecrosis and
necrotizing fasciitis are discussed separately. (See "Clostridial myonecrosis" and
"Necrotizing infections of the skin and fascia".)

EPIDEMIOLOGY

Pyomyositis is classically an infection of the tropics, although it has been recognized in

temperate climates with increasing frequency [2-7]. Tropical pyomyositis primarily
occurs in two age groups: children (ages 2 to 5) and adults (ages 20 to 45), while the
majority of temperate pyomyositis cases occurs in adults. Males appear to be more
commonly affected than females. Most patients with tropical pyomyositis are otherwise
healthy without underlying comorbidities, while most patients in temperate regions are
immunocompromised or have other serious underlying conditions.

Predisposing factors — Predisposing factors for pyomyositis include immunodeficiency,

trauma, injection drug use, concurrent infection, and malnutrition [2,8-12].

Immunodeficiency — Immunodeficiency has been implicated in the development of

pyomyositis in both temperate and tropical climates. Forms of immunodeficiency
associated with pyomyositis include HIV infection, diabetes mellitus, malignancy,
cirrhosis, renal insufficiency, organ transplantation, and administration of
immunosuppressive agents [2,13].

HIV is a particularly important risk factor [2,4,7,11,14-18]. A case-control series in

Uganda demonstrated a significant association between pyomyositis and HIV infection
[7]. In a review of 98 cases in North America, about half of pyomyositis patients with
underlying medical conditions were seropositive for HIV [4]. The mechanism of HIV
infection in the predisposition to pyomyositis is unclear; factors may include immune
compromise, primary HIV myopathy, antiretroviral therapy, and increased rates of
staphylococcal carriage [2,7,17,18].
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Last literature review version 18.3: September 2010
This topic last updated: March 5, 2010
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References
Top
1. Stevens, DL, Bisno, AL, Chambers, HF, et al.
Practice guidelines for the diagnosis and
management of skin and soft-tissue infections.
Clin Infect Dis 2005; 41:1373.
2. Crum, NF. Bacterial pyomyositis in the United
States. Am J Med 2004; 117:420.
3. Gibson, RK, Rosenthal, SJ, Lukert, BP.
Pyomyositis. Increasing recognition in temperate
climates. Am J Med 1984; 77:768.
4. Christin, L, Sarosi, GA. Pyomyositis in North
America: case reports and review. Clin Infect Dis
1992; 15:668.
5. Bickels, J, Ben-Sira, L, Kessler, A, Wientroub, S.
Primary pyomyositis. J Bone Joint Surg Am 2002;
84-A:2277.
6. Chauhan, S, Jain, S, Varma, S, Chauhan, SS.
Tropical pyomyositis (myositis tropicans): current
perspective. Postgrad Med J 2004; 80:267.
7. Horn, CV, Master, S. Pyomyositis tropicans in
Uganda. East Afr Med J 1968; 45:463.
8. Small, LN, Ross, JJ. Tropical and temperate
pyomyositis. Infect Dis Clin North Am 2005;
19:981.
9. Widrow, CA, Kellie, SM, Saltzman, BR, Mathur-
Wagh, U. Pyomyositis in patients with the human
immunodeficiency virus: an unusual form of
disseminated bacterial infection. Am J Med 1991;
91:129.
10. Schwartzman, WA, Lambertus, MW, Kennedy,
CA, Goetz, MB. Staphylococcal pyomyositis in
patients infected by the human immunodeficiency
virus. Am J Med 1991; 90:595.
11. Rodgers, WB, Yodlowski, ML, Mintzer, CM.
Pyomyositis in patients who have the human
immunodeficiency virus. Case report and review
of the literature. J Bone Joint Surg Am 1993;
75:588.
12. Gomez-Reino, JJ, Aznar, JJ, Pablos, JL, et al.
Nontropical pyomyositis in adults. Semin Arthritis
Rheum 1994; 23:396.
13. Belsky, DS, Teates, CD, Hartman, ML. Case
report: diabetes mellitus as a predisposing factor
in the development of pyomyositis. Am J Med Sci
1994; 308:251.
14. Ansalonl, L, Acaye, GL, Re, MC. High HIV
seroprevalence among patients with pyomyositis
in northern Uganda. Trop Med Int Health 1996;
1:210.
15. Blumberg, HM, Stephens, DS. Pyomyositis and
human immunodeficiency virus infection. South
Med J 1990; 83:1092.
16. Jellis, JE. Viral infections: musculoskeletal
infection in the human immunodeficiency virus
(HIV) infected patient. Baillieres Clin Rheumatol
1995; 9:121.
17. Holbrook, KA, Klein, RS, Hartel, D, et al.
Staphylococcus aureus nasal colonization in HIV-
seropositive and HIV-seronegative drug users. J
Acquir Immune Defic Syndr Hum Retrovirol
1997; 16:301.
18. Miller, M, Cespedes, C, Vavagiakis, P, et al.
Staphylococcus aureus colonization in a
community sample of HIV-infected and HIV-
uninfected drug users. Eur J Clin Microbiol Infect
Dis 2003; 22:463.
19. Burkhart, BG, Hamson, KR. Pyomyositis in a 69-
year-old tennis player. Am J Orthop (Belle Mead
NJ) 2003; 32:562.
20. Chusid, MJ, Hill, WC, Bevan, JA, Sty, JR. Proteus
pyomyositis of the piriformis muscle in a
swimmer. Clin Infect Dis 1998; 26:194.
21. Jayoussi, R, Bialik, V, Eyal, A, et al. Pyomyositis
caused by vigorous exercise in a boy. Acta
Paediatr 1995; 84:226.
22. King, RJ, Laugharne, D, Kerslake, RW,
Holdsworth, BJ. Primary obturator pyomyositis: a
diagnostic challenge. J Bone Joint Surg Br 2003;
85:895.
23. Koutures, CG, Savoia, M, Pedowitz, RA.
Staphylococcus aureus thigh pyomyositis in a
collegiate swimmer. Clin J Sport Med 2000;
10:297.
24. Meehan, J, Grose, C, Soper, RT, Kimura, K.
Pyomyositis in an adolescent female athlete. J
Pediatr Surg 1995; 30:127.
25. Viani, RM, Bromberg, K, Bradley, JS. Obturator
internus muscle abscess in children: report of
 seven cases and review. Clin Infect Dis 1999;
28:117.
26. Hsueh, PR, Hsiue, TR, Hsieh, WC. Pyomyositis in
intravenous drug abusers: report of a unique
case and review of the literature. Clin Infect Dis
1996; 22:858.
27. Ebright, JR, Pieper, B. Skin and soft tissue
infections in injection drug users. Infect Dis Clin
North Am 2002; 16:697.
28. Lo, TS, Mooers, MG, Wright, LJ. Pyomyositis
complicating acute bacterial endocarditis in an
intravenous drug user. N Engl J Med 2000;
342:1614.
29. Crossley, M. Temperate pyomyositis in an
injecting drug misuser. A difficult diagnosis in a
difficult patient. Emerg Med J 2003; 20:299.
30. Rayes, AA, Nobre, V, Teixeira, DM, et al. Tropical
pyomyositis and human toxocariasis: a clinical
and experimental study. Am J Med 2000;
109:422.
31. Gubbay, AJ, Isaacs, D. Pyomyositis in children.
Pediatr Infect Dis J 2000; 19:1009.
32. Chiedozi, LC. Pyomyositis. Review of 205 cases in
112 patients. Am J Surg 1979; 137:255.
33. Martínez-Aguilar, G, Avalos-Mishaan, A, Hulten,
K, et al. Community-acquired, methicillin-
resistant and methicillin-susceptible
Staphylococcus aureus musculoskeletal infections
in children. Pediatr Infect Dis J 2004; 23:701.
34. Ruiz, ME, Yohannes, S, Wladyka, CG. Pyomyositis
caused by methicillin-resistant Staphylococcus
aureus. N Engl J Med 2005; 352:1488.
35. Zalavras, CG, Rigopoulos, N, Poultsides, L,
Patzakis, MJ. Increased oxacillin resistance in
thigh pyomyositis in diabetic patients. Clin
Orthop Relat Res 2008; 466:1405.
36. Fowler, A, Mackay, A. Community-acquired
methicillin-resistant Staphylococcus aureus
pyomyositis in an intravenous drug user. J Med
Microbiol 2006; 55:123.
37. Wang, TK, Wong, SS, Woo, PC. Two cases of
pyomyositis caused by Klebsiella pneumoniae
and review of the literature. Eur J Clin Microbiol
Infect Dis 2001; 20:576.
38. Falasca, GF, Reginato, AJ. The spectrum of
myositis and rhabdomyolysis associated with
bacterial infection. J Rheumatol 1994; 21:1932.
39. Lawn, SD, Bicanic, TA, Macallan, DC. Pyomyositis
and cutaneous abscesses due to Mycobacterium
avium: an immune reconstitution manifestation
 in a patient with AIDS. Clin Infect Dis 2004;
38:461.
40. Vigil, KJ, Johnson, JR, Johnston, BD, et al.
Escherichia coli Pyomyositis: an emerging
infectious disease among patients with
hematologic malignancies. Clin Infect Dis 2010;
50:374.
41. Chu, CK, Yang, TL, Tan, CT. Tuberculous
pyomyositis of the temporal muscle in a
nonimmunocompromised woman: diagnosis by
sonography. J Laryngol Otol 2004; 118:59.
42. Wang, JY, Lee, LN, Hsueh, PR, et al. Tuberculous
myositis: a rare but existing clinical entity.
Rheumatology (Oxford) 2003; 42:836.
43. Ahmed, J, Homans, J. Tuberculosis pyomyosits of
the soleus muscle in a fifteen-year-old boy.
Pediatr Infect Dis J 2002; 21:1169.
44. Johnson, DW, Herzig, KA. Isolated tuberculous
pyomyositis in a renal transplant patient. Nephrol
Dial Transplant 2000; 15:743.
45. Shih, JY, Hsueh, PR, Chang, YL, et al.
Pyomyositis due to Mycobacterium haemophilum
in a patient with polymyositis and long-term
steroid use. Clin Infect Dis 1998; 26:505.
46. Shepherd, JJ. Tropical myositis: is it an entity
and what is its cause? Lancet 1983; 2:1240.
47. Niamane, R, Jalal, O, El Ghazi, M, et al. Multifocal
pyomyositis in an immunocompetent patient.
Joint Bone Spine 2004; 71:595.
48. Peckett, WR, Butler-Manuel, A, Apthorp, LA.
Pyomyositis of the iliacus muscle in a child. J
Bone Joint Surg Br 2001; 83:103.
49. Nourse, C, Starr, M, Munckhof, W. Community-
acquired methicillin-resistant Staphylococcus
aureus causes severe disseminated infection and
deep venous thrombosis in children: literature
review and recommendations for management. J
Paediatr Child Health 2007; 43:656.
50. Lin, MY, Rezai, K, Schwartz, DN. Septic
pulmonary emboli and bacteremia associated
with deep tissue infections caused by community-
acquired methicillin-resistant Staphylococcus
aureus. J Clin Microbiol 2008; 46:1553.
51. Struk, DW, Munk, PL, Lee, MJ, et al. Imaging of
soft tissue infections. Radiol Clin North Am 2001;
39:277.
52. Quillin, SP, McAlister, WH. Rapidly progressive
pyomyositis. Diagnosis by repeat sonography. J
Ultrasound Med 1991; 10:181.
 53. Yuh, WT, Schreiber, AE, Montgomery, WJ, Ehara,
S. Magnetic resonance imaging of pyomyositis.
Skeletal Radiol 1988; 17:190.
54. Scharschmidt, TJ, Weiner, SD, Myers, JP.
Bacterial Pyomyositis. Curr Infect Dis Rep 2004;
6:393.
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Pyomyositis: Introduction

Pyomyositis: A bacterial infection of the muscles caused by Staphylococcus aureus. It occurs in

tropical areas and people with weak immune systems are the most vulnerable. More detailed
information about the symptoms, causes, and treatments of Pyomyositis is available below.

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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language
can be technical, however some people find that they add depth to the patient information
leaflets. You may find the abbreviations record helpful.
Necrotising Fasciitis
Necrotising fasciitis is an insidiously advancing soft tissue infection characterised by widespread
fascial necrosis. The condition was first described in the scrotum region by Fournier in 1883
(Fournier's gangrene) and as a more generalised condition by Meleney in 1924.

Although it is most often associated with S. pyogenes (group A beta-haemolytic streptococci)

infection, this accounts for a minority of cases and most infections are polymicrobial, with both
anaerobic and aerobic bacteria frequently present.1,2 Organisms spread from the subcutaneous
tissue along the superficial and deep fascial planes.

Epidemiology
• Necrotising fasciitis is uncommon but is a cause of severe morbidity and frequent mortality.
• The incidence in the United Kingdom is estimated at 500 new cases each year.3

Risk factors
• In many cases, there is no association with any underlying factor.
• May develop after skin biopsy, needle puncture sites in intravenous drug abusers and
associated with chronic venous leg ulcers, open bone fractures and surgical wounds.4
• Other predisposing factors include age over 60, malnutrition, penetrating wounds,
diabetes mellitus, alcohol abuse, peripheral vascular disease, renal failure, underlying
malignancy, obesity, intravenous drug misuse and immunosuppression.
• However, approximately 50% of cases of streptococcal necrotising fasciitis occur in
young, previously healthy individuals.
Presentation
• The diagnosis is clinical. Necrotising fasciitis can affect any part of the body but the
extremities, the perineum, and the truncal areas are the most commonly involved.3
• Patients are very ill with disproportionate pain and only minor skin changes in the early
phases.5
• The diagnosis of necrotising fasciitis should be considered in any patient with unexplained
limb pain, especially if that person has diabetes mellitus, chronic liver disease or any other
risk factor.6
• Tends to begin with constitutional symptoms of fever and chills.
• Patients may present with skin vesicles, bullae, oedema, crepitus, erythema, and fever.7
• The degree of pain may be out of proportion to the physical findings. As the infection
progresses, their pain may decrease due to nerve damage.
• After 2-3 days, erythema and vesiculation or bullae develop.

Signs
• From a rapidly advancing erythema, painless ulcers may appear as the infection spreads
along the fascial planes.
• A black necrotic eschar may be evident at the borders of the affected areas.
• Metastatic cutaneous plaques.
• In patients with diabetes, crepitus is often evident, as are non-clostridial anaerobic
infections.
• The following features may suggest necrotising fasciitis:
○ Rapid progression and poor therapeutic response.
 ○ Extreme local tenderness; blistering necrosis; cyanosis.
○ High temperature, tachycardia, hypotension, altered level of consciousness.
Differential diagnosis
• Cellulitis
• Erysipelas
• Erythema induratum
• Pyoderma gangrenosum
Investigations
• Blood tests: leucocytosis, acidosis, altered coagulation profile, hypoalbuminaemia,
abnormal renal function.3
• X-ray: soft tissue gas.
• One study has shown that a white cell count greater than 15.4 x 10(9)/L and serum sodium
less than 135 mmol/L are useful parameters that may help to distinguish necrotising from
non-necrotising infection.8
• New diagnostic techniques include rapid streptococcal diagnostic kits and a polymerase
chain reaction involving SPE genes (eg, SPE-B).
• MRI or CT delineation of the extent of infection may be useful in directing rapid surgical
debridement.
• Excisional deep skin biopsy may be helpful in diagnosing and identifying the causative
organisms. Cultures of the affected tissue obtained at initial debridement may be helpful.
Management
• Resuscitation as required.
• The primary treatment is early and aggressive debridement of involved skin, subcutaneous
fat and fascia.3,6
• The role of hyperbaric oxygen is controversial but has been shown to improve survival and
limb salvage.3,9

Drugs 1

• Antimicrobial therapy is important but remains secondary to the removal of diseased and
necrotic tissues.
• Intravenous immunoglobulin may be a useful adjunct in severe streptococcal infections
associated with necrotising fasciitis.
• The choice of antibiotic(s) will depend on local guidelines and the individual situation of
each patient. The choice of antibiotic(s) should be discussed with the local consultant
microbiologist.
• The maximum doses of the antibiotics should be used. Once culture and sensitivity results
are available, the antibiotic coverage should be reviewed.
• Empirical broad-spectrum antibiotics should be administered immediately. A foul smell in
the lesion strongly suggests the presence of anaerobic organisms.
• Combination therapy with 2 or 3 antibiotics. Ampicillin and gentamicin are useful for
aerobic infection (usually gram-negative organisms). Clindamycin or metronidazole have
been used against anaerobes. Clindamycin with a beta-lactam antibiotic has been used
against group A streptococcal infections.
• Single antibiotic: broad-spectrum beta-lactam drugs such as imipenem cover aerobes,
including Pseudomonas spp. Ampicillin also has broad-spectrum coverage, but it does not
cover Pseudomonas spp.
Complications
 • Deep infection causes vascular occlusion, ischaemia and tissue necrosis. Superficial nerves
are damaged, causing local anaesthesia. Infection then spreads to septicaemia, which leads
to severe systemic toxicity and rapid death unless appropriately treated.
• Streptococcal exotoxin production may lead to toxic shock with fever, rash, hypotension,
multiorgan involvement (e.g. cardiomyopathy, renal failure, encephalopathy, hepatic
necrosis) and desquamation of the skin of the palms and soles.
• Metastatic cutaneous plaques may occur.
Prognosis
• These infections must be detected and treated rapidly to prevent loss of limb or a fatal
outcome.
• One study of necrotising fasciitis affecting upper or lower limbs found 22.3% underwent
amputation or disarticulation of a limb following failure of multiple debridements to
control infection, and the mortality rate was estimated as high as 21.9%.10
• Estimates of mortality rate vary from 6-76% but recent studies suggest a mortality rate in
the region of 25%.3,11
• Increased mortality is associated with delays in diagnosis, poor surgical technique and
diabetes.12

Document references
1. Schwartz RA, Kapila R; Necrotizing Fasciitis. eMedicine, March 2008.
2. Elliott D, Kufera JA, Myers RA; The microbiology of necrotizing soft tissue infections. Am J
Surg. 2000 May;179(5):361-6. [abstract]
3. Hasham S, Matteucci P, Stanley PR, et al; Necrotising fasciitis. BMJ. 2005 Apr
9;330(7495):830-3.
4. Bosshardt TL, Henderson VJ, Organ CH Jr; Necrotizing soft-tissue infections. Arch Surg. 1996
Aug;131(8):846-52; discussion 852-4. [abstract]
5. Burge TS, Watson JD; Necrotising fasciitis. BMJ 1994;308:1453-1454 (4 June).
6. Ozalay M, Ozkoc G, Akpinar S, et al; Necrotizing soft-tissue infection of a limb: clinical
presentation and factors related to mortality. Foot Ankle Int. 2006 Aug;27(8):598-605.
[abstract]
7. Headley AJ; Necrotizing soft tissue infections: a primary care review. Am Fam Physician.
2003 Jul 15;68(2):323-8. [abstract]
8. Wall DB, Klein SR, Black S, et al; A simple model to help distinguish necrotizing fasciitis
from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000 Sep;191(3):227-31. [abstract]
9. Wilkinson D, Doolette D; Hyperbaric oxygen treatment and survival from necrotizing soft
tissue infection. Arch Surg. 2004 Dec;139(12):1339-45. [abstract]
10. Angoules AG, Kontakis G, Drakoulakis E, et al; Necrotising fasciitis of upper and lower limb:
a systematic review. Injury. 2007 Dec;38 Suppl 5:S19-26. Epub 2007 Nov 28. [abstract]
11. Urschel JD; Necrotizing soft tissue infections. Postgrad Med J. 1999 Nov;75(889):645-9.
[abstract]
12. Ward RG, Walsh MS; Necrotizing fasciitis: 10 years' experience in a district general hospital.
Br J Surg. 1991 Apr;78(4):488-9. [abstract]

Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article. The final copy
has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
DocID: 2495
Document Version: 21
 DocRef: bgp231
Last Updated: 29 Dec 2008
Review Date: 29 Dec 2010

The authors and editors of this article are employed to create accurate and up to date content
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Necrotizing Fasciitis
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Medical Author: Charles Davis, MD, PhD

Medical Editor: Melissa Conrad Stöppler, MD
• What is necrotizing fasciitis?
• Do different types of necrotizing fasciitis exist?
• What causes necrotizing fasciitis?
• What are the symptoms of necrotizing fasciitis?
• How is necrotizing fasciitis diagnosed?
• How is necrotizing fasciitis treated?
• How is necrotizing fasciitis prevented? Is it contagious?
 • Who is at risk to get necrotizing fasciitis?
• What is the prognosis (outcome) for patients with
necrotizing fasciitis?
• What are some additional sources of information on
necrotizing fasciitis?
• Necrotizing Fasciitis At A Glance

What Is a "Flesh-Eating" Bacterial Infection?

Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: Jay W. Marks, MD, William C. Shiel Jr., MD, FACP,
FACR
Media reports have popularized the term "flesh-eating bacteria" to refer to a
very rare but serious bacterial infection known as necrotizing fasciitis.
Necrotizing fasciitis is an infection that starts in the tissues just below the
skin and spreads along the flat layers of tissue (known as fascia) that
separate different layers of soft tissue, such as muscle and fat. This
dangerous infection is most common in the arms, legs, and abdominal wall
and is fatal in 30%-40% of cases.
Although necrotizing fasciitis may be caused by an infection with one or
more than one bacterium, in most cases the term flesh-eating bacteria has
been applied to describe infections caused by the bacterium known as
Streptococcus pyogenes. The term flesh-eating has been used because the
bacterial infection produces toxins that destroy tissues such as muscles,
skin, and fat. Streptococcus pyogenes is a member of the group A
streptococci, a group of bacteria that are responsible for mild cases of sore
throat (pharyngitis) and skin infections, as well as rare, severe illnesses such
as toxic shock syndrome and necrotizing fasciitis. Most infections with
group A streptococci result in mild illness and may not even produce
symptoms.
Learn the symptoms of necrotizing fasciitis »

Top Searched Necrotizing Fasciitis Terms:

causes, contagious, group A Streptococcus, cellulitis, treatment,
information, gangrene, symptoms, diagnosis, prevention, who's at
risk, morbidity and mortality rates

What is necrotizing fasciitis?

Necrotizing fasciitis is a term that describes a disease condition of rapidly
spreading infection, usually located in fascial planes of connective tissue
that results in tissue necrosis (dead and damaged tissue). The disease occurs
infrequently, but it can occur in almost any area of the body. Although
many cases have been caused by group A beta-hemolytic streptococci
(Streptococcus pyogenes), most investigators now agree that many different
bacterial genera and species, either alone or together (polymicrobial) can
cause this disease. Occasionally, mycotic (fungal) species cause necrotizing
fasciitis.
This condition was described by several people in the 1840s to 1870s, and
Dr. B. Wilson in 1952 first termed the condition necrotizing fasciitis. It is
likely that the disease has been occurring for many centuries before it was
first described in the 1800s. Currently, there are many names that have been
used loosely to mean the same disease as necrotizing fasciitis: flesh-eating
bacterial infection or disease; suppurative fasciitis; dermal, Meleney,
hospital, or Fournier's gangrene; and necrotizing cellulitis. Body regions
frequently have the term "necrotizing" placed before them to describe the
initial localization of necrotizing fasciitis (for example, necrotizing colitis,
necrotizing arteriolitis), but they all refer to the same disease process in the
tissue. Important in understanding necrotizing fasciitis is the fact that
whatever the infecting organism(s), once it reaches and grows in connective
tissue, the spread of the infection can be so fast (investigators suggest some
organisms can progress about 3 centimeters per hour) that the infection
becomes difficult to stop with both antimicrobial drugs and surgery.
Mortality (death) rates have been reported as high as 75% for necrotizing
fasciitis associated with Fournier's (testicular) gangrene. Patients with
necrotizing fasciitis have an ongoing medical emergency that often leads to
death or disability if it is not promptly and effectively treated.
 Picture of necrotizing fasciitis (flesh-eating disease)

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