坏死性筋膜炎

关键的危险因素包括由于慢性疾病（例如糖尿病、酗酒）所致的免疫抑制、皮肤外伤或溃疡性皮肤病、水痘带状疱疹感染、静脉内用药以及住院治疗。[1]Hoadley DJ, Mark EJ. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 28-2002. A 35-year-old long-term traveler with a rapidly progressive soft-tissue infection. N Engl J Med. 2002 Sep 12;347(11):831-7.[2]Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002 Feb;68(2):109-16.[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[8]Centers for Disease Control and Prevention. Active bacterial core surveillance report. Emerging Infections Program Network: group A streptococcus, 2015. Mar 2017 [internet publication].https://www.cdc.gov/abcs/reports-findings/survreports/gas15.html[6]Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996 Jan 25;334(4):240-5.[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.[27]Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 6th ed. Philadelphia, PA: Elsevier; 2005:1195-1204.[14]Brown EJ. The molecular basis of streptococcal toxic shock syndrome. N Engl J Med. 2004 May 13;350(20):2093-4.[16]Daneman N, Green KA, Low DE, et al. Surveillance for hospital outbreaks of invasive group A streptococcal infections in Ontario, Canada, 1992 to 2000. Ann Intern Med. 2007 Aug 21;147(4):234-41.

蜂窝织炎部位的麻木或剧痛预示坏死性筋膜炎的可能。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35. 伴随坏死性筋膜炎出现的疼痛可能与可见的皮肤变化不成比例。

感染的全身症状。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.

感染的全身症状/体征。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.

感染的全身症状。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.

感染的全身症状。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[5]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.https://academic.oup.com/cid/article/59/2/e10/2895845[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.

蜂窝织炎区域的皮肤的检查可触及捻发音。

蜂窝织炎部位上方的皮肤检查可能发现水疱或大疱。应该注意的是，坏死性筋膜炎患者的表面皮肤可能表现正常，A 族链球菌所致坏死性筋膜炎的表面皮肤变化是一种晚期体征。诸如液体漏出和水肿等细微皮肤变化发生于大疱和发红等明显皮肤变化之前。[Figure caption and citation for the preceding image starts]: 坏死性筋膜炎的晚期体征包括广泛性蜂窝织炎、皮肤硬化、坏死以及出血性大疱形成。来源于：Hasham S, Matteucci P, Stanley PRW, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3 [Citation ends].

对蜂窝织炎区域的皮肤的检查可发现皮肤褪色为灰白色。 应该注意的是，坏死性筋膜炎患者的表面皮肤可能表现正常，A 型链球菌所致的坏死性筋膜炎的表面皮肤变化是延迟的。

对蜂窝织炎区域的皮肤检查可能发现水肿。在蜂窝织炎区域以外可能发现硬化。应该注意的是，坏死性筋膜炎患者的表面皮肤可能表现正常，A 族链球菌所致坏死性筋膜炎的表面皮肤变化是一种晚期体征。诸如液体漏出和水肿等细微的皮肤变化发生于大疱和发红等明显皮肤变化之前。[Figure caption and citation for the preceding image starts]: 坏死性筋膜炎的晚期体征包括广泛性蜂窝织炎、皮肤硬化、坏死以及出血性大疱形成。来源于：Hasham S, Matteucci P, Stanley PRW, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3 [Citation ends].[Figure caption and citation for the preceding image starts]: 一名 2 岁女孩水痘感染后右腹部继发出现坏死性筋膜炎。来源于：de Benedictis FM, Osimani P. Necrotising fasciitis complicating varicella. BMJ Case Rep. 2009;2009:bcr2008141994 [Citation ends].

大约有一半的筋膜炎病例发生于四肢，其余的集中在会阴部、躯干和头颈部。[3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.][4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[7]Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003 Jul;82(4):225-35.A 族链球菌所致坏死性筋膜炎的最常见部位是大腿，发生于四肢特别是手臂的坏死性筋膜炎更可能由 A 族链球菌所致，而非由多重细菌感染所致。近期若有腹部手术史，或者腹股沟部位的坏死性筋膜炎最可能由多重细菌感染导致。