Necrotising fasciitis of the lower extremity following streptococcal pharyngitis

  • Ch Ioannidis
  • B Cohen
  • S Giannacopoulou
  • P Alevras
Keywords: necrotising infections - fasciitis - myositis - streptococcal infections -, pharyngitis -


Necrotising fasciitis is a grave infectious process affecting the fascia, the overlying soft tissues, and, occasionally, the underlying muscle. Various bacteria can be the cause of this aggressive and fast progressing disease. Skin lacerations or surgical wounds are the portal of entry in most patients; however, hematogenous spread of the microorganism can occasionally initiate the process.  Streptococcal pharyngitis (group A β hemolytic streptococcus – GAS) followed by necrotizing fasciitis of the lower limb is a very rare finding with only a few case reports found in the literature. Two such cases of necrotising fasciitis of the left lower limb with similar features treated by the same surgeon at two different hospitals in two different countries are presented. The outcome was favorable in both patients. The diagnostics and appropriate mode of treatment are reviewed. The importance of early surgical intervention is stressed, as it can save lives.


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Author Biographies

Ch Ioannidis

University College London Hospitals NHS Trust, London, UK

IASO General Hospital, Athens, Greece

B Cohen

University College London Hospitals NHS Trust, London, UK

S Giannacopoulou

IASO General Hospital, Athens, Greece

P Alevras

IASO General Hospital, Athens, Greece


Ozalay M, Ozcoc G, Akpinar S et al. Necrotizing soft-tissue infection of a limb: Clinical presentation and factors related to mortality. Foot & Ankle Internat 2006; 27: 598-605

Bilton BD, Zibari GB, McMillan RW et al. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 1998; 64: 397-400; Discussion 400-1

Wilson BL. Necrotizing fasciitis. Am Surg 1952; 18; 416-31

Wallace HA, Perera TB. Necrotizing fasciitis. In: Stat Pearls [Internet]. Treasure Island (FL): Stat Pearls Publishing, 2020

May AK, Talisa VB, Wilfret DA et al. Estimating the impact of necrotizing soft tissue infections in the United States: Incidence and re-admissions. Surg Infect (Larchmet) 2020; doi:10.1089/sur.2020.099

Cheung JP, Fung B, Tang WM et al. A review of necrotizing fasciitis in the extremities. Hong Kong Med J 2009; 15: 44-52

Widjaja AB, Tran A, Cleland H et al. The hospital costs of treating necrotizing fasciitis. ANZ J Surg 2005; 75: 1059-64

Elliott DC, Kufera JA, Myers RAM. Necrotizing soft tissue infections: Risk factors for mortality and strategies for management. Ann Surg 1996; 224: 672-83

Rantala S, Vuopio- Varkila J, Vuento R et al. Predictors of mortality in beta – hemolytic streptococcal bacteremia: A population – based study. J Infect 2009; 58: 266-72

Ioannidis Ch. Necrotising fasciitis after cesarean section. HJOG 2013; 12: 63-7

Hasham S, Matteucci P, Stanley PRW et al. Necrotising fasciitis. BMJ 2005; 330: 830-3

Whallett EJ, Stevenson JH, Wilmhurst AD. Necrotising fasciitis of the extremity. J Plast Reconstr Aesthet Surg 2010; 63: e469-73

Wong CH, Wang YS. The diagnosis of necrotising fasciitis. Curr Opin Infect Dis 2005; 18: 101-6

v Sambeek CHL, v Stigt SF, Browers L et al. Necrotising fasciitis: a ticking time bomb? BMJ Case Rep 2017; bcr 2017 221770

Brown CN, Pollard TCB, Iyer S et al. Invasive group A streptococcal infection. J Bone Joint Surg (Br) 2010; 92: 763-9

Bodansky DMS, Begaj I, Evison F et al. A 16-year longitudinal cohort study of incidence and bacteriology of necrotising fasciitis in England. World J Surg 2020; 44: 2580-91

Das DK, Baker MG, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over the period 1990 to 2006. J Infect 2011; 63: 429-33

Faraklas I, Yang D, Eggerstedt M et al. A multi – center review of care patterns and outcomes in necrotizing soft tissue infections. Surg Infect (Larchmt) 2016; 17: 773-8

Edlich RF, Cross CL, Dahlstrom JJ et al. Modern concepts on the diagnosis and treatment of necrotizing fasciitis. J Emerg Med 2010; 39: 261-5

Dobbs F. A scoring system for predicting group A streptococcal throat infection. Br J Gen Pract 1996; 46: 461-4

Martin PR, Høiby EA. Streptococcal serogroup A epidemic in Norway 1987-1988. Scand J Infect Dis 1990; 22: 421-9

Kotb M, Norby – Jeglund A, McGeer A et al. An immunogenetic and molecular basis for differences in outcomes of invasive group A streptococcal infections. Nat Med 2002; 8: 366-71

Singh G, Sinha SK, Adhikary S et al. Necrotizing infections of soft tissues – a clinical profile. Eur J Surg 2002; 168: 366-71

Wong CH, Khin LW, Heng KS et al. The LRINEC (Laboratory Risk Indicator for Necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004; 32: 1535-41

Su YC, Chen HW, Hong YC et al. Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg 2008; 78: 968-72

Bechar J, Sepehripour S, Hardwicke J et al. Laboratory Risk Indicator for necrotizing fasciitis (LRINEC) score for the assessment of early necrotizing fasciitis: a systematic review of the literature. Ann R Coll Surg Engl 2017; 99: 341-46

Henry R, Matsushima K, Etzel M et al. Utility of the Laboratory Risk Indicator for Necrotizing Fasciitis Score: Comorbid conditions do matter. Surg Infect (Larchmt) 2021. doi: 10. 1089/sur 2020.398

Tsai YH, Hsu RW, Huang KC et al. Laboratory indicators for early detection and surgical treatment of vibrio necrotizing fasciitis. Clin Orthop Relat Res 2010; 468: 2230-7

Kishino T, Asai N, Okashi W et al. Usefulness of serum procalcitonin for necrotizing fasciitis as an early diagnostic tool. J Infect Chemother 2021; S1341-321X (21)00003-9

Malghem J, Lecouvet FE, Omoumi P et al. Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Joint Bone Spine 2013; 80: 146-54

Kim MC, Kim S, Cho EB et al. Utility of magnetic resonance imaging for differentiating necrotizing fasciitis from severe cellulitis: A magnetic resonance indicator for necrotizing fasciitis (MRINEC) algorithm. J Clin Med 2020; 9: 3040. doi: 10.3390/jcm9093040

Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 1984; 310: 1689-93

Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg 2001; 107: 1025-34

Childers BJ, Potyondy LD, Nachreiner R et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg 2002; 68: 109-16

Carter PS, Banwell PE. Necrotizing fasciitis: a new management algorithm based on clinical classification. Int Wound J 2004; 1: 189-97

Horn DL, Shen J, Roberts E et al. Predictors of mortality, limb loss, and discharge disposition at admission among patients with necrotizing skin and soft tissue infections. J Trauma Acute Care Surg 2020; 89: 186-91

Gawaziuk JP, Liu T, Sigurdson L et al. Free tissue transfer for necrotizing fasciitis reconstruction: a case series. Burns 2017; 43: 1561-66

Frame JD, Still J, Lakhel – LeCoadou A et al. Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg 2004; 113: 1330-8

Climov M, Panayi A, Borah G et al. The life – cycles of skin replacement technologies. PLoS One 2020; 15: e0229455

Bodansky DMS, Begaj I, Evison F et al. A 16-year longitudinal cohort study of incidence and bacteriology of necrotizing fasciitis in England. World J Surg 2020; 44: 2580-91

Hedetoft M, Madsen MB, Madsen LB et al. Incidence, comorbidity and mortality in patients with necrotizing soft- tissue infections, 2005-2018: a Danish nationwide register-based cohort study. BMJ Open 2020; 10; e041302

Khamnuan P, Chongruksut W, Jearwattanakanok K et al. Necrotizing fasciitis: epidemiology and clinical predictors of amputation. Int J Gen Med 2015; 8: 195-202

Madsen MB, Skrede S, Perner A et al. Patients’ characteristics and outcomes in necrotizing soft-tissue infections: results from a Scandinavian, multicenter, prospective cohort study. Intensive care med 2019; 45: 1241-51

Hua C, Bose R, Sbidian E et al. Interventions for necrotizing soft tissue infections in adults. Cochrane Database Syst Rev 2018; 5: CD011680

May AK, Stafford RE, Bulger EM et al. Surgical Infection Society. Surg Infect (Larchmt) 2009; 10: 467-99

Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections. 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59: 147-59

Bonne S, Kadri SS. Evaluation and management of necrotizing soft tissue infections. Infect Dis Clin North Am 2017; 31: 497-511

Kadri SS, Swihart BJ, Bonne SL et al. Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor – dependent shock: A propensity – score matched analysis from 130 US hospitals. Clin Infect Dis 2017; 64: 877-85

Madsen MB, Hjortrup PB, Hansen MB et al. Immunoglobulin G for patients with necrotizing soft tissue infection (INSTINCT): a randomized, blinded, placebo – controlled trial. Intensive Care Med 2017; 43: 1585-93

Jallali N, Withey S, Butler PE: Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg 2005; 189: 462-6

Levett D, Bennett MH, Millar I: Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev 2015; 1: CD007937

Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003-2013. Epidemiol Infect 2016; 144: 1338-44

Ahn J, Raspovic KM, Liu GT et al. Lower extremity necrotizing fasciitis in diabetic and non-diabetic patients: Mortality and amputation. Int J Low Extrem Wounds 2019; 18: 114-21

Gawaziuk JP, Strazar R, Cristall N et al. Factors predicting health-related quality of life following necrotizing fasciitis. J Plast Reconstr Aesthet Surg 2018; 71: 857-62

Kruppa C, Hutter DJ, Königshausen M et al. necrotizing fasciitis and the midterm outcomes after survival. SAGE Open Med 2019; 7: 2050312119842433

Hakkarainen TW, Ikebata NB, Bulger E et al: Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft – tissue infections. J Surg Res 2014; 192: 143-9