Review Early diagnosis of necrotizing fasciitis T. Goh 1 , L. G. Goh 2 , C. H. Ang 3 and C. H. Wong 4 1 Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, 2 Division of Medicine, University Medicine Cluster, National University Health System, 3 Yong Loo Lin School of Medicine, and 4 W Aesthetics, Singapore Correspondence to: Dr T. Goh, Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore 169608 (e-mail: terence.goh@sgh.com.sg) Background: Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis. Methods: A systematic literature search of PubMed was undertaken using the keywords ‘necrotising fasciitis’, ‘necrotising skin infection’, ‘diagnosis’ and ‘outcome’. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included. Results: Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co- morbidity in 44·5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80·8 per cent), pain (79·0 per cent) and erythema (70·7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24·8 per cent of patients). Conclusion: A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case. Paper accepted 7 October 2013 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9371 Introduction Necrotizing fasciitis (NF) is a rapidly progressing infection of the skin and soft tissues that has been known since the days of Hippocrates 1 . It causes extensive necrosis of the fascia and subcutaneous tissue leading to severe systemic toxicity. Early diagnosis and surgical intervention can reduce mortality and amputation rates. Its rarity and the paucity of early pathognomonic signs make NF a major diagnostic challenge. A systematic review was conducted with the objective of determining clinical features and investigations that could aid in early diagnosis. Methods This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology 2 . Search strategy A systematic literature search from January 1980 until May 2013 was undertaken in PubMed. Keywords used were ‘necrotising fasciitis’, ‘necrotising soft tissue infection’, ‘diagnosis’ and ‘outcome’ combined with the Boolean AND, OR operators. Both free-text and medical subject heading (MeSH) searches for keywords were employed. Results were limited to studies undertaken in humans and published in English. Inclusion criteria were: case series with information on initial presenting symptoms, and signs, investigations and outcome (amputation and mortality); and case series with at least 50 patients. Data extraction and assessment of methodological quality Data extraction and assessment of methodological qual- ity were undertaken by two reviewers independently.  2013 BJS Society Ltd BJS 2014; 101: e119–e125 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/101/1/e119/6138120 by guest on 14 April 2024