Skip to main content
SpringerLink
Log in

Pathogenese, Klassifikation und Diagnose der nekrotisierenden Weichteilinfektionen

Pathogenesis, classification and diagnosis of necrotizing soft tissue infections

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Nekrotisierende Hautweichteilinfektionen werden durch ein breites Spektrum an Krankheitserregern ausgelöst und können verschiedene Gewebearten betreffen. Auch heute noch zeichnen sich diese durch eine hohe Morbidität und Letalität aus. Die Kardinalsymptome der nekrotisierenden Hautweichteilinfektionen sind stärkster Druckschmerz („pain out of proportion“), Schwellung und Rötung sowie Krepitationen bei subkutaner Gasbildung. Sehr häufig besteht ein begleitendes systemisches inflammatorisches Response-Syndrom (SIRS). Durch rechtzeitiges Erkennen und Einleitung einer adäquaten Therapie konnte die Letalität in den letzten Jahrzehnten auf durchschnittlich 20% gesenkt werden. Diagnostisch ist die klinische Untersuchung wegweisend und wird durch typische Befunde in bildgebenden Verfahren, wie z. B. subkutane Gasansammlung im Röntgen, und entsprechende Laboruntersuchungen unterstützt. Nach Diagnosestellung sollte sofort eine geeignete antibiotische und chirurgische Therapie erfolgen.

Abstract

Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6

Literatur

  1. Ahrenholz DH (1988) Necrotizing soft-tissue infections. Surg Clin North Am 68:199–214

    PubMed  CAS  Google Scholar 

  2. Al Ghazal P, Dissemond J (2012) Multilocular pyoderma gangrenosum after uterus resection. Chirurg (in press)

  3. Anonymous (1993) Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA 269:390–391

    Article  Google Scholar 

  4. Bleiziffer O, Hammon M, Naschberger E et al (2011) Endothelial progenitor cells are integrated in newly formed capillaries and alter adjacent fibrovascular tissue after subcutaneous implantation in a fibrin matrix. J Cell Mol Med 15:2452–2461

    Article  PubMed  CAS  Google Scholar 

  5. Boos AM, Loew JS, Deschler G et al (2011) Directly auto-transplanted mesenchymal stem cells induce bone formation in a ceramic bone substitute in an ectopic sheep model. J Cell Mol Med 15:1364–1378

    Article  PubMed  CAS  Google Scholar 

  6. Brook I (2004) Microbiology and management of myositis. Int Orthop 28:257–260

    Article  PubMed  Google Scholar 

  7. Chan T, Yaghoubian A, Rosing D et al (2008) Low sensitivity of physical examination findings in necrotizing soft tissue infection is improved with laboratory values: a prospective study. Am J Surg 196:926–930 (discussion 930)

    Article  PubMed  Google Scholar 

  8. Chen SY, Fu JP, Wang CH et al (2010) Fournier gangrene: a review of 41 patients and strategies for reconstruction. Ann Plast Surg 64:765–769

    Article  PubMed  CAS  Google Scholar 

  9. Dalal M, Sterne G, Murray DS (2002) Streptococcal myositis: a lesson. Br J Plast Surg 55:682–684

    Article  PubMed  CAS  Google Scholar 

  10. Dragu A, Schnurer S, Surmann-Schmitt C et al (2011) Gene expression analysis of ischaemia and reperfusion in human microsurgical free muscle tissue transfer. J Cell Mol Med 15:983–993

    Article  PubMed  CAS  Google Scholar 

  11. Elliott DC, Kufera JA, Myers RA (1996) Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 224:672–683

    Article  PubMed  CAS  Google Scholar 

  12. Fisher JR, Conway MJ, Takeshita RT et al (1979) Necrotizing fasciitis. Importance of roentgenographic studies for soft-tissue gas. JAMA 241:803–806

    Article  PubMed  CAS  Google Scholar 

  13. Fugitt JB, Puckett ML, Quigley MM et al (2004) Necrotizing fasciitis. Radiographics 24:1472–1476

    Article  PubMed  Google Scholar 

  14. Hammon M, Herrmann M, Bleiziffer O et al (2011) Role of guanylate binding protein-1 in vascular defects associated with chronic inflammatory diseases. J Cell Mol Med 15:1582–1592

    Article  PubMed  CAS  Google Scholar 

  15. Heitmann C, Pelzer M, Bickert B et al (2001) Surgical concepts and results in necrotizing fasciitis. Chirurg 72:168–173

    Article  PubMed  CAS  Google Scholar 

  16. Herr M, Grabein B, Palm HG et al (2011) Necrotizing fasciitis. 2011 update. Unfallchirurg 114:197–216

    Article  PubMed  CAS  Google Scholar 

  17. Horch RE, Kneser U, Polykandriotis E et al (2012) Tissue engineering and regenerative medicine -where do we stand? J Cell Mol Med 16:1157–1165

    Article  PubMed  CAS  Google Scholar 

  18. Howard RJ, Pessa ME, Brennaman BH et al (1985) Necrotizing soft-tissue infections caused by marine vibrios. Surgery 98:126–130

    PubMed  CAS  Google Scholar 

  19. Howell GM, Rosengart MR (2011) Necrotizing soft tissue infections. Surg Infect (Larchmt) 12:185–190

    Google Scholar 

  20. Kang N, Antonopoulos D, Khanna A (1998) A case of streptococcal myositis (misdiagnosed as hamstring injury). J Accid Emerg Med 15:425–426

    Article  PubMed  CAS  Google Scholar 

  21. Kingston D, Seal DV (1990) Current hypotheses on synergistic microbial gangrene. Br J Surg 77:260–264

    Article  PubMed  CAS  Google Scholar 

  22. Klumpp D, Horch RE, Kneser U et al (2010) Engineering skeletal muscle tissue—new perspectives in vitro and in vivo. J Cell Mol Med 14:2622–2629

    Article  PubMed  Google Scholar 

  23. Koukouras D, Kallidonis P, Panagopoulos C et al (2011) Fournier’s gangrene, a urologic and surgical emergency: presentation of a multi-institutional experience with 45 cases. Urol Int 86:167–172

    Article  PubMed  Google Scholar 

  24. Lamagni TL, Darenberg J, Luca-Harari B et al (2008) Epidemiology of severe Streptococcus pyogenes disease in Europe. J Clin Microbiol 46:2359–2367

    Article  PubMed  Google Scholar 

  25. Leffler M, Derrick KL, Mcnulty A et al (2011) Changes of anabolic processes at the cellular and molecular level in chronic wounds under topical negative pressure can be revealed by transcriptome analysis. J Cell Mol Med 15:1564–1571

    Article  PubMed  CAS  Google Scholar 

  26. Miller LG, Perdreau-Remington F, Rieg G et al (2005) Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 352:1445–1453

    Article  PubMed  CAS  Google Scholar 

  27. Rath SN, Strobel LA, Arkudas A et al (2012) Osteoinduction and survival of osteoblasts and bone-marrow stromal cells in 3D biphasic calcium phosphate scaffolds under static and dynamic culture conditions. J Cell Mol Med (in press)

  28. Sarani B, Strong M, Pascual J et al (2009) Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg 208:279–288

    Article  PubMed  Google Scholar 

  29. Souyri C, Olivier P, Grolleau S et al (2008) Severe necrotizing soft-tissue infections and nonsteroidal anti-inflammatory drugs. Clin Exp Dermatol 33:249–255

    Article  PubMed  CAS  Google Scholar 

  30. Stamenkovic I, Lew PD (1984) Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 310:1689–1693

    Article  PubMed  CAS  Google Scholar 

  31. Taeger CD, Horch RE, Dragu A et al (2012) Perforator flaps. A new era in reconstructive surgery. Chirurg 83:163–171

    Article  PubMed  CAS  Google Scholar 

  32. Tsai YH, Huang TJ, Hsu RW et al (2009) Necrotizing soft-tissue infections and primary sepsis caused by Vibrio vulnificus and Vibrio cholerae non-O1. J Trauma 66:899–905

    Article  PubMed  Google Scholar 

  33. Ustin JS, Malangoni MA (2011) Necrotizing soft-tissue infections. Crit Care Med 39:2156–2162

    Article  PubMed  Google Scholar 

  34. Wienecke H, Lobenhoffer P (2001) Necrotizing soft tissue infections. Chirurg 72:320–335 (quiz 336)

    Article  PubMed  CAS  Google Scholar 

  35. Wilson B (1952) Necrotizing fasciitis. Am Surg 18:416–431

    PubMed  CAS  Google Scholar 

  36. Wong CH, Khin LW, Heng KS et al (2004) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32:1535–1541

    Article  PubMed  Google Scholar 

  37. Wong CH, Wang YS (2005) The diagnosis of necrotizing fasciitis. Curr Opin Infect Dis 18:101–106

    Article  PubMed  Google Scholar 

  38. Yen ZS, Wang HP, Ma HM et al (2002) Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med 9:1448–1451

    Article  PubMed  Google Scholar 

Download references

Interessenskonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Plastisch- und Handchirurgische Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Deutschland

    S. Schnürer, J.P. Beier & R.E. Horch

  2. Chirurgische Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland

    R. Croner

  3. Pathologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland

    R.J. Rieker

Authors
  1. S. Schnürer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J.P. Beier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Croner
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R.J. Rieker
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R.E. Horch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Schnürer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schnürer, S., Beier, J., Croner, R. et al. Pathogenese, Klassifikation und Diagnose der nekrotisierenden Weichteilinfektionen. Chirurg 83, 943–952 (2012). https://doi.org/10.1007/s00104-012-2281-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-012-2281-2

Schlüsselwörter

Keywords

Search

Navigation