@2024 Afarand., IRAN

---

ISSN: 2383-3483    Journal of Police Medicine 2019;8(1):47-51

Background
Necrotizing Fasciitis (NF) is a rare but life-threatening infection, in which most soft tissues and muscles in the lower limbs are involved.
Previous Studies
… [1]. According to microbiological findings, NF has different types. Type 1 is multi-microbial and is caused by aerobic and anaerobic organisms due to trauma or surgery; type 2 is single-microbial and is commonly caused by group A streptococcus (GAS) and streptococcus aureus without a traumatic history [2]. … [3, 4]. The mortality rate in NF depends primarily on the time of medical and surgical interventions and to what extent the infection affected the subcutaneous tissue, fascia, skin or muscles [5]. Generally, the mortality rate of NF is reported 20-47% [6]. Mortality rate is more in patients with symptoms such as the age over 60 years, chronic heart disease, a heart rate greater than 130 min, systolic blood pressure less than 90 mmHg, creatinine serum level greater than 1.6 mg/dl , liver cirrhosis and necrosis of the skin [7].
Aim(s)
The purpose of this study was to report the incidence of NF in soldiers to develop preventive strategies for injury.
Research type

Research society, place and time
Case 1 A 22-year-old man who suffered from lower limb pain through the military service in the garrison and has had several outpatient visits to the emergency ward and clinic and in each referral he was treated on an outpatient basis is reported. At the last visit, at which he was hospitalized, there were some observations, such as edema, ecchymosis on the left thigh, blisters, severe tenderness with limitation of movement in the limbs. The patient had tachycardia, fever and symptoms of dehydration. In radiology, some air spaces were found in the soft tissue. At the hospital admission, Sodium level was 129 mg/dl, creatinine was 3.9 mg/dl, potassium was 3.5 mEq/l, and urea was reported 178 mg/dl. In the wound culture, the group D streptococcus (GDS) and by staining a gram positive cocci were isolated. The patient was diagnosed with NF and transmitted to the operating room for Fasciotomy. A daily debridement of the wound was performed in the operating room and he simultaneously was treated with antibiotics in the intensive care unit (ICU). Following several debridements, he was transferred to the more equipped health center in the city to continue his healthcare due to the patient's family request. According to follow-ups, the patient has recovered and discharged. Case 2 A 21-year-old man who suffered from lower limb pain during the military service in the garrison is reported. He has had several outpatient visits to the emergency ward and in each referral he was treated on an outpatient basis. At the last visit, he was hospitalized with some observations, including a blister on the left thigh, severe tenderness with limitation of movement in the limbs. The lower limb was inflated and in radiology, and some air spaces were observed in the soft tissue (Fig. 1).The patient suffered from weakness and lethargy, fever, tachycardia, and symptoms of dehydration. In the patient’s record, there was a right femoral bone fracture several years ago. At the admission these test results were obtained: Sodium: 129 mg/dl, creatinine: 1.1 mg/dl, potassium: 3 mEq/l, urea 96 mg/dl, serum glutamic oxaloacetic transaminase (SGOT): 95 units per liter of serum, and serum glutamic-pyruvic transaminase (SGPT): 48 units per liter of serum. Escherichia coli was found in the wound culture. The patient was diagnosed with NF and transmitted to the operating room for debridement. He was simultaneously treated with antibiotics. Following a few days of hospitalization in the ICU and daily debridement of the wound, his right leg was amputated in order to save the patient's life, however the patient died due to septic shock.
Sampling method and number

Used devices&materials
None declared.
Findings by Text
None declared.
Main comparison to the similar studies
None declared.
Suggestions
Commanders should provide an environment where the injuries are prevented and they also should provide the permission to treat and immediate treatment and of injured soldiers.
Limitations
None declared.
Conclusions
… [8, 9, 10]. Early diagnosis and operation are crucial in NF, however due to the normal tissue above the fascia at the beginning of the infection, the diagnosis is postponed, accordingly operation is the only way to the definite diagnose and to distinguish from other diagnoses [9, 11]. The symptoms are varied, including different levels of fever, tachycardia, swelling in the affected area, erythema and tenderness, blister, and necrosis of the skin [12]. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) is one of the scoring systems for differential early diagnosis (Table 1).The maximum score in this system is 13, a score of 6 or more indicates the high possibility of NF, and a score greater than 8 strongly confirms NF. Studies have shown that patients who have received a high score have worse treatment outcomes [13]. … [14]. According to the studies, muscle strain can be observed in soldiers, military personnel, athletes and those with heavy physical activity [15]. In addition, the findings of Jennings et al. research show that most of the muscular injuries of soldiers (80%) occur during a military parade [16], however it should be more considered whether muscular damage alone can cause NF or it can be occurred due to the GAS. NF can be seen in the whole body, but it is more common in the limbs, abdomen and perineum [10]. In two reported cases, the infection was observed in the lower limbs, whereas it has been shown that the lower limbs are more affected in the soldiers in the garrisons due to severe training programs such as military parades [17]. The study by Webber et al. showed that through 2003 to 2006, among invasive GAS infections in three US military training centers, three cases were reported with NF and one case died [18]. … [19-22]. The spread of GAS infection in military centers may be due to the lack of willingness of people to receive medical care, poor cough etiquette and low acceptance of antibiotics [23]. Moreover, to what extent the doctors are informed about the NF, especially its clinical signs and symptoms, is the key to early diagnosis. Immediate treatment, such as surgical debridement and antibiotic therapy, improves the survival and prognosis of patients.
Acknowledgments
None declared.
Conflict of interest
None declared.
Ethical Permissions
None declared.
Funding Sources
None declared.

TABLES and CHARTS

Show attach file