Necrotizing fasciitis: Diagnosis and management of an occult infective focus.

Necrotizing fasciitis is a life-threatening, fulminant disease that is a diagnostic and therapeutic challenge. Presenting with a triad of findings including progressive erythema, severe dermatological edema and severe pain disproportionate to the physical findings, this disease is a surgical emergency. Delayed diagnosis and surgical debridement lead to higher mortality. Early extensive surgical debridement, aggressive antibiotic therapy, invasive monitoring and intensive care management determine the outcome in most cases. In patients who fail to demonstrate clinical improvement, profound sepsis and its sequela -systemic inflammatory response - have frequently been implicated. It is these patients that need to be carefully re-evaluated for 'hidden' foci of infection that may be the real cause of the patient's decline. Once detected, these occult foci can be surgically debrided, resulting in dramatic improvement. Two illustrative cases, one with occult endo- and panophthalmitis and the other with an unusual involvement of deeper muscle planes and the nodal basin, demonstrate this point. This consumptive process gathers momentum at an alarming speed, hence, the treatment must be aggressive and prompt.