Zusammenfassung
Im Zeitraum vom Januar 1994 bis Dezember 1997 wurden 16 Patienten mit ausgedehnten
Weichteilinfekten an der Abteilung für Brandverletzte der Klinik für Wiederherstellungschirurgie,
Universitäts-Spital Zürich, behandelt. Es wird der Fall eines 47-jährigen Patienten
mit einer nekrotisierenden Fasziitis, verursacht durch ein Streptokokken induziertes
Toxisches Schock-Syndrom (STSS), vorgestellt. Die frühestmögliche Diagnose, die Priorität
der chirurgischen Therapie und das Antibiose-Konzept bei der nekrotisierenden Fasziitis
werden diskutiert. Die nekrotisierende Fasziitis ist eine schwere, durch eine Vielzahl
verschiedener Keime verursachte Erkrankung mit einer hohen Mortalität. Ein Anstieg
der Fallzahlen in den letzten Jahren erfordert unsere Aufmerksamkeit.
Abstract
Between 1994 and 1997, sixteen patients suffering from necrotising soft tissue infection
were treated at the burn centre of the Division of Reconstructive Surgery, University
of Zurich. The case of a 47 year old man is presented: He suffered from a necrotising
fasciitis caused by Streptococcal induced Toxic Shock Syndrome (STSS). This example
emphasizes the necessity of early diagnosis, priority of surgical intervention, and
the antibiotic strategy. Necrotising fasciitis is a serious disease, caused by a variety
of bacteria, which shows a high mortality rate, and its frequency was increasing over
the last years.
Schlüsselwörter
Nekrotisierende Weichteilinfekte - nekrotisierende Fasziitis - Streptokokken induziertes
Schock-Syndrom
Key words
Necrotising soft tissue infection - necrotising fasciitis - streptococcal toxic shock
syndrome
Literatur
- 1
Ahrenholz D H.
Necrotizing soft-tissue infections.
Surg Clin North Am.
1988;
1
199-214
- 2
Al-Mazrou A M.
Streptococcal toxic shock-like syndrome: Case report and review of the literature.
Ann Trop Paediatr.
1994;
14
145-148
- 3
Ault M J, Geidermann J, Sokolov R.
Rapid identification of Group A streptococcus as the cause of necrotizing fasciitis.
Ann Emerg Med.
1996;
28
227-230
- 4
Barker F G, Leppard B J, Seal D V.
Streptococcal necrotising fasciitis: Comparison between histological and clinical
features.
J Clin Pathol.
1987;
40
335-341
- 5
Browne B A, Holder E P, Rupnick L.
Nonsteroidal anti-inflammatory drugs and necrotizing fasciitis.
Am J Health Syst Pharm.
1996;
53
256-259
- 6
Chelsom J, Halstensen A H, Haga T, Hoiby E A.
Necrotising fasciitis due to group A streptococci in western Norway: Incidence and
clinical features.
Lancet.
1994;
344
1111-1115
- 7
Cramer S F, Tomkiewicz Z.
Septic pulmonary thrombosis in streptococcal toxic shock syndrome.
Hum Pathol.
1995;
26
1157-1160
- 8
Doctor A, Harper M B, Fleischer G R.
Group A β-hemolytic streptococcal bacteremia: Historical overview, changing incidence,
and recent association with varicella.
Pediatrics.
1995;
96
428-433
- 9
Fisher J R, Conway M J, Takeshita R T, Sandoval M R.
Importance of roentgenographic studies for soft-tissue gas.
JAMA.
1979;
241
803-806
- 10
Gelshorn C J, Piffaretti C, Haldimann B, Martinoli S.
Diarrhoe und Peritonitis bei Sepsis durch Streptococcus beta-haemolyticus Typ A.
Helv Chir Acta.
1994;
60
931-934
- 11
Green R J, Dafoe D C, Raffin T A.
Necrotizing fasciitis.
Chest.
1996;
110
219-229
- 12
Hackett S P, Stevens D L.
Superantigens associated with staphylococcal and streptococcal toxic shock syndrome
are potent inducers of tumor necrosis factor-β synthesis.
J Infect Dis.
1993;
168
232-235
- 13
Kaiser R E, Cerra F B.
Progressive necrotizing surgical infections - a unified approach.
J Trauma.
1981;
5
349-355
- 14
Köhler W.
Epidemiologie und Pathogenese von Streptokokkeninfektionen.
Immun Infekt.
1992;
20
92-98
- 15
Leong W C, Lipman J, Hon H, Brouckaert N T.
Severe soft tissue infections - a diagnostic challenge. The need for early recognition
and aggressive therapy.
S Afr Med J.
1997;
5
648-652
- 16
Lewis R T.
Necrotizing soft-tissue infections.
Infect Clin Dis North Am.
1992;
3
693-703
- 17
Lille S T, Sato T T, Engrav L H, Foy H, Jurkovich G J.
Necrotizing soft tissue infections. Obstacles in diagnosis.
J Am Coll Surg.
1996;
182
7-11
- 18
Meleney F L.
Hemolytic streptococcal gangrene.
Arch Surg.
1924;
9
317-364
- 19
Nadal D, Lauener R P, Braegger C P, Kaufhold A, Simma B, Lütticken R, Seger R A.
T-cell activation and cytokine release in streptococcal toxic shock-like syndrome.
J Pediatr.
1993;
122
727-729
- 20
Norrby-Teglund A, Pauksens K, Norgre M, Holm S E.
Correlation between serum TNF α and IL6 levels and severity of group A streptococcal
infections.
Scand J Infect Dis.
1995;
27
125-130
- 21
Pessa M E, Howard R J.
Necrotizing fasciitis.
Surg Gynecol Obstet.
1985;
161
357-361
- 22
Reda K B, Kapur V, Mollick J A, Lamphear J G, Musser J M, Rich R R.
Molecular characterization and phylogenetic distribution of the streptococcal superantigen
gene (ssa) from Streptococcus pyogenes.
Infect Immun.
1994;
62
1867-1874
- 23
Reichardt W, Müller-Alouf H, Alouf J E, Köhler W.
Erythrogenic toxins A, B and C: Occurrence of the genes and exotoxin formation from
clinical Streptococcus pyogenes strains associated with streptococcal toxic shock-like
syndrome.
FEMS Microbiol Lett.
1992;
79
313-322
- 24
Rouse T M, Malangoni M A, Schulte W J.
Necrotizing fasciitis: A preventable disaster.
J Surgery.
1982;
92
765-770
- 25
Spencer R C.
Invasive streptococci.
Eur J Clin Microbiol Infect Dis.
1995;
14
26-32
- 26
Stamenkovic I, Lew D P.
Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section
biopsy.
N Engl J Med.
1984;
310
1689-1693
- 27
Stone D R, Gorbach S L.
Necrotizing fasciitis. The changing spectrum.
Dermatol Clin.
1997;
15
213-220
- 28
Wang K C, Shih C H.
Necrotizing fasciitis of the extremities.
J Trauma.
1992;
32
179-182
- 29
Wann S R, Yen M Y, Chen Y S.
Streptococcal toxic shock syndrome in southern Taiwan.
J Formos Med Assoc.
1995;
94
172-177
- 30
Ward R G, Walsh M S.
10 years experience in a district general hospital.
Br J Surg.
1991;
78
488-490
- 31
Willis S, Schippers E, Schumpelick V.
Das streptococcal toxic shock-like syndrome als seltenes chirurgisches Krankheitsbild.
Chirurg.
1997;
68
40-44
- 32
Wolf J E, Rabinowitz L G.
Streptococcal toxic shock-like syndrome.
Arch Dermatol.
1995;
131
73-77
- 33
Wood T F, Potter M A, Jonasson O.
Streptococcal toxic shock-like syndrome. The importance of surgical intervention.
Ann Surg.
1993;
217
109-114
Dr. med. Volker Wedler
Klinik für Wiederherstellungschirurgie, Universitäts-Spital Zürich
Rämistraße 100
8091 Zürich
Schweiz
Email: volker.wedler@chi.usz.ch
