NECROTIZING FASCITIS: Reply

Dear Editor,

At the outset I congratulate the surgical team of MH Yol for managing such a dreaded disease at periphery with excellent result. As I have already mentioned in my published letter necrotizing fascitis is caused by mixed aerobic-anaerobic bacteria and begins with a breach in the integrity of a mucous membrane barrier, such as the mucosa of the gastrointestinal or genitourinary tract. The predisposing factors include peripheral vascular disease, diabetes mellitus, surgery, and penetrating injury to the abdomen. In the above-mentioned patient, diabetes mellitus and nutritional deprivation were the predisposing factors. It is a rapidly spreading destructive disease of the fascia, usually attributed to group A Streptococcus pyogenes infection, but can also be caused by anaerobic bacteria, including Peptostreptococcus and Bacteroides species or may occur as part of gas gangrene caused by Clostridium perfringens. This life-threatening condition is diverse in presentation and severity and offers a great challenge to the treating clinician. Early diagnosis may be difficult when pain or unexplained fever is the only presenting manifestation while patients in the later stages of the disease usually undergo septic shock and multiorgan failure. Early and aggressive surgical exploration is essential to save the life of the patient. The patient mentioned in the text was very well managed but if faecal or urinary contamination hinders in the healing process and recovery of the patient, then diversion of faecal and urinary streams may be necessary to prevent contamination. The importance of suspecting an undiagnosed human immunodeficiency virus infection in these patients is already highlighted in my published letter [1].