Necrotizing Fasciitis: frozen section biopsy rapidly diagnosed it.

Clinical bottom line (level 4)

  1. Frozen section biopsy of lesions suspicious of necrotizing fasciitis accurately diagnosed necrotizing fasciitis.
Majeski and Majeski: Southern Medical Journal 1997; 90 (11): 1065-1068
Expires November 2004

The study

Setting: acute hospital, USA

43 patients (aged range 36 to 93 years; mean 66, ?% male) cellulitis and possible necrotizing fasciitis (and fever, pus, edema and pain) and no evidence of shock/stress bleeding. Most had other diseases - diabetes mellitus (60%), arteriosclerosis (60%), obesity (44%), malnutrition (33%). 65% "elderly"

?independent unblinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • surgical findings and/or clinical outcome
Diagnostic test: frozen section biopsy (1% lidocaine anaesthesia, 2cm x 1cm elliptical biopsies - skin and deep soft tissue - of suspected necrotizing area and at another area (leading edge of erythema, induration or necrosis), frozen section results within 15 minutes.

The evidence

pre-test probability of necrotizing fasciitis: 28%, (95% CI: 15% to 41%)

diagnostic test necrotizing fasciitis cellulitis LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
frozen section biopsy positive 12 0 inf
(11 to inf) 		100% 0.0
(0.0 to 0.20) 		0%
total 12 31

  • 100% survival reported in this study compared to historical 38% mortality is because of early diagnosis and aggressive surgical management.
  • Two patients with necrotizing fasciitis had crepitus and two had skin anaesthesia.

Comments

  1. Frozen section biopsy took 15 minutes to analyse. In comparison CT or MRI may not useful because of the potential delay in diagnosis.

Citation

  1. Majeski J, and Majeski E: necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. Southern Medical Journal 1997; 90 (11): 1065-1068
Contributor: John Epling and Chris Ball, November 2000
Reviewer:

Clinical Question.
Patient cellulitis and possible necrotizing fasciitis
Intervention or Exposure frozen section biopsy
Outcome diagnosis of necrotizing fasciitis