J Ayub Med Coll Abbottabad 2009;21(1) http://www.ayubmed.edu.pk/JAMC/PAST/21-1/Surahio.pdf 125 PREVALENCE OF NECROTIZING FASCIITIS DURING RAMADAN AND HAJJ 1427-H Abdul Rashid Surahio, Ashar Ahmad Khan, Main Usman Farooq, Iffat Fatima*, Muhammad Zeeshan Azhar Department of General Surgery, *Department of Obstetrics and Gynaecology, Al-Noor Specialist Hospital, Makkah, Kingdom of Saudi Arabia Background: Necrotizing Fasciitis is a rare progressive disease which results in significant rate of mortality and morbidity if there is any delay in diagnosis and treatment. Objectives of this Prospective observational study were to share our experience of dealing necrotizing fasciitis in terms of different presentations, diagnosis, treatment and outcome during Ramadan and Hajj. It was conducted in the Department of General Surgery, Al-Noor Specialist Hospital, Holly Makkah, KSA during Ramadan and Hajj period from 1-8-1427 to 30-1-1428. Methods: Total 35 patients >12 years of age, irrespective of the gender belonging to different nationalities admitted to Al-Noor specialist hospital, Makkah, KSA were included in this study to evaluate the different causative factors, presentations, response to medical/ surgical treatment and outcome. Results: Total 35 patients with male to female ratio of 6:1 were admitted during Ramadan and hajj period from 1-8-1427 to 30-1-1428 (six months) with the features of necrotizing Fasciitis. Out of these 35 patients, 23 (65.7%) were hajji and 12 (34.28%) were residents (Both Saudi and non Saudi) with a ratio of 2:1. Major co-morbid factors were old age, diabetes mellitus, hypertension and renal failure. Among systemic manifestations, 4 (11.42%) developed septic shock and admitted to ICU, 4 (11.42%) needed ventilator support for respiratory failure, and 5 (14.28%) patients developed Myocardial infarction. After resuscitation, 33 patients under went aggressive surgical debridement and two patients died before surgery. Microbiology revealed, 15 (42.85%) Streptococcus Group-A infection, l3 (8.51%) Polymicrobial and 4 (11.42%) MRSA. Diagnosis was conformed by histopathology. Mortality rate was 11.5%. Conclusion: Better outcome in necrotizing fasciitis depends upon early presentation, prompt diagnosis and aggressive surgical debridement. There was strong correlation between severity of necrotizing fasciitis and co morbid factors, general condition at presentation, systemic toxicity and raised WBC count. Keywords: Necrotizing fasciitis, Septic shock, Bullae, Blister INTRODUCTION Necrotizing Fasciitis is a rare, rapidly progressing infection affecting the superficial fascia and subcutaneous tissue, accompanied by severe systemic toxicity and multiorgan failure. 1,2 In the management of necrotizing fasciitis, early diagnosis is always a challenge for surgeons because of vague presentation, lack of clear boundaries and palpable limits between viable, nonviable and infected tissue. There is layer of necrotic tissue which is not walled off by an inflammatory reaction. Overlying skin has a relatively normal appearance in early stages of infection and visible degree of involvement is substantially less than actual pathology. 3 Despite the much clinical experience, management of this disease remains suboptimal with mortality rates of approximately 30%. 4,5 Most common organism involved is Group-A beta haemolytic streptococcus. 1 Polymicrobial infection tends to be more common findings in necrotizing infection than single organism. Other organisms include Enterococci, Staphylococci, Staphaureus, Clostridium species, Escherichia coli, Enterobacteria and Pseudomonas. Recently bacteriology reports indicate an increasing incidence of infection caused by Methicillin resistant Staphaureus (MRSA). 6 The predisposing factors for necrotizing fasciitis include Diabetes mellitus, malnutrition, obesity, chronic alcoholism, peripheral vascular disease, chronic lymphocytic leukaemia, steroid use, chronic renal failure, cirrhosis and autoimmune deficiency syndrome. Different classifications for necrotizing soft tissue infection have been reported. These are based on anatomical sites, causative pathogens and tissue planes affected and extent of invasions. According to the site, different names given such as a Fournier’s gangrene 7 when involving the perineum and genitalia, described by Fournier in 1883 and Meleney’s gangrene when involving the abdominal wall described by Meleney 8 in 1924. Classification according to the causative pathogens, necrotizing fasciitis can be due to single organism or multiple organisms (Synergistic gangrene). According to the tissue planes, if only skin and subcutaneous tissue involved, called necrotizing fasciitis but if muscles also involved then called necrotizing myositis. Common presentations of necrotizing fasciitis include cellulitis with ecchymosis, bullae, palpable Crepitation, failure to response to conservative non- operative treatment and septic shock. There is no definite diagnostic test but it can be dealt with high