title: Necrotizing soft tissue infection of the thigh: consider an abdominal cause.
abstract: BACKGROUND
  Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved.
  
  
  METHODS
  Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance.
  
  
  RESULTS
  Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus.
  
  
  CONCLUSIONS
  High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.
authors.affiliation: Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. h.w.nijhof@lumc.nl
authors.forename: H W
authors.initials: HW
authors.lastname: Nijhof
authors.forename: P
authors.initials: P
authors.lastname: Steenvoorde
authors.forename: B A
authors.initials: BA
authors.lastname: Bonsing
authors.forename: H H
authors.initials: HH
authors.lastname: Hartgrink
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003646:Debridement; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications* / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D011379:Prognosis; D018461:Soft Tissue Infections / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D013848:Thigh / Q000473:pathology*
chemical_list: D000900:Anti-Bacterial Agents