Necrotizing  Fasciitis:  When  A  Harmless  Bug  Turns  Deadly    By:  Bruce  Ruben,  M.D.,  Medical  Director  of  Encompass  HealthCare  and  Wound  Medicine      Before  you  can  delve  into  the  vicious  and  deadly  world  of  necrotizing  fasciitis,  the  ghastly  "flesh-­‐eating  disease"  that's  been  widely  reported  by  the  media,  you  have  to  understand  something  about  the  bacteria  that  causes  it  and  who  is  most  susceptible  to  this  rare  condition.    Causes  of  Necrotizing  Fasciitis  Here,  the  main  culprit  is  a  very  common  bacterium  that  may  be  harmlessly  colonizing  on  your  skin  right  now  called  Group  A  streptococcus  (GAS).  Often,  though,  necrotizing  fasciitis  is  a  combination  of  bacteria  including  klebsiella,  clostridium,  E.  coli,  staphylococcus  aureus,  and  aeromonas  hydrophila.    On  first  reading  that  GAS  is  colonizing  on  your  skin,  one  might  wonder  why  necrotizing  fasciitis  is  so  rare  a  condition.  The  answer  is  that  your  body  has  been  manufacturing  antibodies  since  day  one  to  protect  you  from  any  problem  Group  A  Streptococcus  can  cause.    Essentially,  GAS  is  a  benign  colonizer  that  can  occasionally  cause  mild  skin  infections  such  as  impetigo  or  throat  infections  such  as  strep  and  pharyngitis.  The  bacteria  spread  and  multiply  quickly,  but  with  conservative  antibiotic  therapy,  the  infection  is  resolved  quickly.    However,  when  the  host's  immune  system  is  compromised  and/or  the  strain  of  GAS  (plus  any  of  the  other  bacteria  mentioned  above)  is  particularly  virulent,  more  intensive  medical  intervention  is  required.    In  these  rare  cases,  the  GAS  bacteria  can  travel  to  the  deeper  layers  of  skin  and  subcutaneous  tissues  where  it  spreads  quickly  along  the  fascia,  which  are  the  connective  tissues  that  cover  muscles.  There,  they  release  toxins  that  speed  up  the  rate  of  infection  dramatically,  leaving  dead,  necrotic  tissue  in  their  wake.  That’s  necrotizing  fasciitis,  aka,  the  "flesh-­‐eating  disease."      The  "Flesh-­Eating"  Fallacy  But  "flesh-­‐eating"  is  a  misnomer,  as  the  bacteria  do  not  actually  "eat"  the  tissue,  but  release  toxins  including  streptococcal  pyogenic  exotoxins  that  hyper-­‐accelerate  the  spread  of  the  infection.    Until  recently,  scientists  had  no  idea  what  turned  the  harmless  bug,  GAS,  into  deadly  necrotizing  fasciitis.  But  in  recently  published  research  (January  2014)  conducted  jointly  by  the  Hebrew  University  of  Jerusalem  and  the  National  University  of  

Singapore,  a  new  mechanism  has  been  discovered  that  reveals  how  necrotizing  fasciitis  operates  in  early  stages  of  the  infection.    Researchers  found  that  when  GAS  sticks  to  and  infects  the  host's  cells,  it  delivers  into  these  cells  two  streptolysin  toxins.  These  poisons  impair  the  body's  mechanism  for  quality  control  of  protein  synthesis,  allowing  the  invasive  GAS  to  proliferate  dramatically,  much  faster  than  the  host  can  manufacture  antibodies  to  fight  them.    Treatments  for  Necrotizing  Fasciitis  At  that  point,  the  main  treatments  include  intensive  intravenous  antibiotics  and  surgical  removal  of  infected  tissues.  Still,  even  after  those  modalities  are  promptly  implemented,  bacteria  can  still  succeed  in  proliferating  and  cause  death  in  approximately  25-­‐30  percent  of  patients.    That's  why  necrotizing  fasciitis  is  one  of  the  more  vicious  and  deadly  diseases.  And,  what  makes  it  so  ghastly  are  the  disfiguring  surgical  excisions,  amputations  and  scarring  patients  are  left  with  if  they  survive.    There  is  optimism,  though,  in  the  recently  published  research.  The  team  that  did  the  studies  discovered  that  asparaginase,  a  popular  chemotherapeutic  agent  FDA-­‐approved  for  lymphoblastic  leukemia,  stops  GAS  growth  in  human  blood  and  in  an  animal  model  of  human  bacteremia.  That  may  mean  that  it’s  possible  that  asparaginase  may  also  be  applied  to  treat  GAS  infections  resulting  in  necrotizing  fasciitis.    Hyperbaric  oxygen  therapy  is  also  an  FDA-­‐  and  Medicare-­‐approved  modality  to  combat  the  disease.    In  addition,  a  product  called  NeutroPhase,  a  0.01%  pure  hypochlorous  acid  saline  solution  with  no  bleach  impurities,  has  been  shown  in  extensive  in  vitro  testing  to  kill  bacteria  in  seconds  and  has  the  ability  to  neutralize  toxins  generated  by  GAS.    The  key  to  all  the  possibilities  in  treating  necrotizing  fasciitis  is  early  detection  because  patients  diagnosed  with  the  condition  have  an  ongoing  emergency  that  doesn’t  end  until  all  the  toxins  released  by  the  bacteria  are  gone.    About  the  Author  Dr.  Bruce  Ruben  is  the  Founder  and  Medical  Director  of  Encompass  HealthCare,  located  in  West  Bloomfield,  Michigan.  Encompass  Healthcare  is  an  outpatient  facility  featuring  advanced  wound  care,  IV  antibiotic  therapies,  hyperbaric  oxygen  treatment,  nutritional  assessment,  and  other  treatment  modalities.  Dr.  Ruben  is  board  certified  in  Internal  Medicine,  Infectious  Disease,  and  in  Undersea  and  Hyperbaric  Medicine.  He  is  a  member  of  the  Medical  and  Scientific  Advisory  Committee  and  National  Spinal  Cord  Injury  Association  (NSCIA)  board.