Clinical presentation and diagnosis

Patient outcomes rely on the clinician's ability to recognize NF early in the course of disease. This is often difficult because early disease tends to be indistinguishable from cellulitis. The clinical presentation of NF is presented in Table 73-4.

NF is perhaps the most devastating SSTI. Left untreated, it can invade the muscles and circulation, resulting in myonecrosis and septic shock, respectively. Half of the cases caused by GAS are accompanied by GAS toxic shock-like syndrome. The syndrome is endotoxin-mediated, manifested by hypotension and multiorgan dysfunc-

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tion, and highly lethal. ' Amputation is required in up to 50% of patients with ex-28

tremity infections. Once the patient recovers from acute NF, he or she often requires skin and/or muscle grafting and consequent physical rehabilitation depending on the amount and types of tissues removed during surgical intervention and the duration of hospital stay.

Table 73-4 Presentation of NF Symptoms

• Early: Severe pain that is disproportionate to clinical signs and extends beyond the margins of the infected area

• Late: Area may become numb secondary to muscle and nerve involvement Signs

• Early: Skin is erythematous, edematous, and warm; the clinical presentation is similar to that of cellulitis

• Intermediate (within 24-48 hours): Blisters and bullae indicate severe skin and tissue ischemia

• Late: The skin becomes violaceous and progressively gangrenous; hemorrhagic bullae may be present. Systemic signs may include fever, tachycardia, hypotension, and shock

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