Written by Laura Davies
In 2022, 29-year-old, Gabriel McKenna-Lieschke attempted to curl 50 kg, which caused his bicep to shear clean off his elbow and left him screaming in agony. Unfortunately, this was nothing compared to what happened next.
After surgery to reattach the muscle, his arm swelled to three times its size and turned bright red. When he awoke from an induced coma three days later, he’d lost his lower arm and the flesh from his shoulder and chest.
Why? During his first operation, he’d contracted necrotising fasciitis, and his arm had been rotting from the inside out.
What is Necrotising Fasciitis?
Necrotising fasciitis is not a skin infection, despite what the grisly photos might look like. It’s something much worse. An infection of the soft tissues that lie deep beneath the skin. This includes the muscles, tendons, ligaments, fat, and fascia, which is the thin casing of connective tissue that surrounds and holds everything in place. Infection here can spread without a trace on the overlying skin. That is until it’s killed enough tissue to be life-threatening, at which point visible symptoms appear, triggering some of the most extensive and gruesome treatments you can imagine.
Occasionally, the media will latch on to a case of the condition as if it’s a new threat to humanity that we should all panic about. However, it’s actually been around for thousands of years. In 500BC, Hippocrates was the first to write up a clinical description, “Many were attacked by the erysipelas all over the body when the exciting cause was a trivial accident . . . flesh, sinews, and bones fell away in large quantities . . . there were many deaths.” Erysipelas being a skin infection causing a bright red, raised and tender rash. It has the potential to cause septicemia but isn’t known for rotting the flesh off people.
He also described one of the patients, Griton of Thasus, who “while still on foot and going about, was seized with a violent pain in the great toe, delirious fevers, swellings, and flesh that was blackened by mortification.” Griton died two days later.
During the late 18th century, descriptions emerged of a new disease that couldn’t be anything but necrotising fasciitis. In one case, a naval surgeon noted an ulcer that devoured one side of a man’s face. In another horrific entry on the HMS Saturn, the physician described the results of one of these ulcers beginning on a man’s penis.
“The symptoms advanced by too hasty strides to be arrested. The glan of the penis soon dropped off; the whole body of the penis passed quickly through inflammation to complete gangrene and mortification. The whole length of the urethra was sloughed away, and also the scrotum, leaving the testes and spermatic vessels barely covered with cellular substance.”
As cases began appearing in hospitals, there was still no name for it, so physicians went with various descriptions like “phagedaenic ulcer”, “gangrenous ulcer”, “malignant ulcer”, “putrid ulcer”, “gangrenous cellulitis”, “necrotizing abscess”, “galloping gangrene”, or “hospital gangrene”, which became the one most commonly used.
Finally, in 1952, the name “necrotising fasciitis” was proposed by American surgeon, B Wilson. “Necrotising” for the death of tissues, “fasci”, for the part of the body affected and “itis”, for the inflammation caused by the infection. Today, necrotising soft tissue infection is gaining traction as it affects more than just the fascia.
What Causes Necrotising Fasciitis?
Necrotising Fasciitis begins when bacteria make it through the skin barrier and penetrate the soft tissues below. This sounds like you’d need a large and obvious wound, but unfortunately, something as small as an insect bite or prick from a rose can be enough.
The condition is often classified by the type and number of bacteria involved.
Type I refers to an infection that’s polymicrobial, which means infection by a number of different kinds of bacteria, with the average being around 4. It’s the most common type, accounting for 70–80% of cases. Bacterial culprits include aerobic organisms such as Enterobacteriaceae and Staphylococcus aureus and anaerobic organisms like Clostridium, Bacteroides, and Peptostreptococcus. These anaerobic bacteria produce gas, which accumulates in soft tissue cavities and is visible on X-rays and CT scans.
Many of these bacteria are incredibly common and found in the upper respiratory tract and on the skin, so it’s pretty normal for them to make it into a small wound or cut. However, if the cut belongs to someone with a compromised immune system, diabetes, obesity, malnutrition, or liver disease, the bacteria can beat the immune response and spread rapidly.
In 2021 a New Zealand woman, Amy Kilgour, popped an ingrown hair near her groin. This introduced the bacteria that caused necrotising fasciitis, 10 surgeries, and the cutting away of more than 10 kilos of flesh. She said, “It was like my insides were dying and liquifying because necrotising fasciitis turns your flesh to sludge,”
Type II is a monomicrobial infection, involving only one type of bacteria, usually group A streptococcus or Staphylococcus aureus.
In 1994, a freak wave of six flesh-eating bacteria cases swept through Gloucestershire in England. Six might not sound like much, but it was higher than normal and enough to cause a media storm. Newspapers ran with headlines like, “Flesh-Eating Bug Ate My Face,” and “It Starts With A Sore Throat, But You Can Die In 24 Hours.” causing everyone with a cold to panic and others to question whether it was safe to remain in the county.
It all turned out to be a bit of a coincidence. Yes, the number of cases was slightly higher than usual, but cultures revealed that almost all of the infections resulted from different bacteria and were unconnected. All except the first two cases, which were fatal. Both of these patients had recently undergone elective surgeries in the same operating theatre. Testing revealed a member of the theatre staff was carrying a large amount of group strep A, the common bacteria responsible for sore throats and carried harmlessly by 15–30% of the population. But, for the two patients on the operating table that day, it was fatal.
Type III is caused by a specific bacteria, Vibrio vulnificus. It’s responsible for the smallest number of cases but is often the most deadly. The bacteria are found in brackish water and can be carried by shellfish. For this reason, type III infections are normally found in coastal communities and are often seen after floods.
Hurricane Harvey claimed two victims by necrotising fasciitis. A 31-year-old man who wounded his arm when repairing several flood-damaged homes and a 77-year-old woman who fell and broke her arm during the flood. A first responder also contracted the disease through an insect bite but survived. Samples taken from the homes revealed Vibrio vulnificus was present.
It’s also possible to contract Type III just through contact with seafood. In 2021, an Indiana man was hospitalised and came very close to having both of his legs amputated after eating raw oysters and in 2018, a woman died in Louisiana after spending the day crabbing in brackish waters at the coast. It’s believed the bacteria entered through scratches on her legs. She fought for 21 days before finally succumbing to the disease.
How Necrotising Fasciitis Kills
Although necrotising fasciitis is often called “the flesh-eating bacteria,” it doesn’t actually eat tissue. Instead, the bacteria secrete endo and exotoxins that cause micro-vascular blood clots, reduced blood flow, and liquefactive necrosis, where the tissue is transformed into a liquid viscous mass. All this happens beneath the surface of the skin, with no visible symptoms to alert victims or for doctors to diagnose.
In 2021, a 45-year-old woman lost half her face after a fall down the stairs left her with a small cut on her eyebrow. She noticed it was more painful than she’d expected but didn’t seek help due to COVID worries and the fact that it didn’t look too bad. However, beneath the surface, the bacteria were destroying her soft tissue at a rate of 2-3 cm an hour. By the time surgeons operated, her jaw and ear were the only parts of the entire left side of her face that could be saved.
If the condition is allowed to progress, the skin’s surface will turn red, then black, and a wound will open. This will grow at an alarming rate as the tissue essentially dissolves. Surprisingly, it’s not blood loss from the enormous, gaping wound that kills, because the toxins restrict the blood flow so effectively. Instead, death comes in the form of septic shock, toxic shock, multi-organ failure, seizure, stroke, or cardiac arrest.
Due to the speed at which necrotising fasciitis can spread, spotting the symptoms early is incredibly important.
The first sign is usually intense pain, swelling or numbness near a wound. However, many victims don’t have a visible cut due to the bacteria entering through an insect bite or small scratch. In these cases, it’s flu-like symptoms such as fever, nausea, vomiting, and headaches that are first to appear.
After a few days, grey or purple blotches will mark the skin, and, if anaerobic bacteria are present, the gas produced can be felt as a crackling sensation. In some cases, large pus-filled blisters will also form. These are filled with a foul-smelling liquid that doctors describe as “dishwater”. Late-stage symptoms include low blood pressure, a lack of urine, a high heart rate, and rapid breathing. Then, the liver, kidneys, and lungs shut down due to toxic shock, and the patient will die.
In 2018, a plane carrying Russian guitarist, Andrey Suchilin, was forced to make an emergency landing due to his body odour. It was so bad that passengers near him were vomiting, and the smell couldn’t even be contained by him locking himself in the toilet cubicle. Once grounded, Suchilin was taken to hospital where they discovered that the smell was his liquidised and rotting flesh, caused by necrotising fasciitis. Doctors tried to save him, but his organs failed and he died a few weeks later.
Left untreated, the mortality rate of necrotising fasciitis is 100%. With treatment this drops to around 30% but the cure is often as horrific as the condition itself.
First, antibiotics will be given to kill the bacteria causing the necrosis but due to the restricted blood flow it’s almost impossible to get these into the wound itself. Therefore the only effective treatment is to cut away all the infected material in a procedure known as debridement.
Huge areas of tissue and sometimes entire muscle groups will need to be removed, if they’re affected. This is rarely fully successful in the first surgery and it’s likely that multiple debridements will need to take place between 12 and 36 hours apart. It’s a race against time as the bacteria spreads toward joints and vital organs. In around 20% of cases, amputations are required to stop the infection making it into the torso.
Survivor, Chris Gordon, describes it like this, “Let me explain what necrotising fasciitis is like. Imagine a fire starting in the middle of a dry forest and the only way to stop it spreading is to keep ahead of it and conduct a controlled burn, and to do this you must remove trees before the fire could use them for fuel. Now imagine that the forest is your skin and the fire is the necrotising fasciitis.”
If surgeons do manage to get ahead of the infection and remove the tissue without killing the patient, a long a painful recovery remains. The wounds are often too large to close and so have to be left open for weeks. This requires them to be packed with wet to dry dressings and in some cases washed frequently with caustic solutions like diluted bleach or iodine.
Some progress has been made with the introduction of vacuum assisted closure devices. This involves packing the wound with foam, fitting an airtight cover and then attaching a suction device. It needs to be left running for hours as it draws blood to the wound and sucks out what survivor and author Peter Watts describes as “clots and globs of gore.”
Once the wound is ready, reconstruction can begin. This usually requires skin grafts as the cavities left behind are often huge. The complexity and success of the grafts is largely dependent on the area affected. Limbs are often the simplest, the torso poses more challenges and the face and scrotum are some of the trickiest.
That’s right, scrotum. Necrotising fasciitis attacks the balls so often that the condition even has its own name, Fournier gangrene. About one in every 62,500 men is affected each year. And it often results in complete debridement of one or both testicles. Remarkably, the bacteria often leaves the testes untouched, but this creates the problem of having something to keep them in. The lucky ones who have held on to over 50% of their scrotal skin can have it stretched to house them. Those who’ve lost more skin have to have their testes sewn into thigh pouches, which is often uncomfortable. Probably a bit of an understatement there.
Treatment often takes so long and damage to the muscles is so extensive that patients have to learn to walk or use their arms again. Depending on the country in which they were treated they can be left in debt, with poor reconstructive options and many become depressed.
In the UK, the NHS offers only basic reconstruction and the woman I mentioned earlier, who lost half her face, had to crowdfund for teeth and a prosthetic eye. In the US there are a number of other crowdfunding campaigns for those who have been left unable to work and suffering due to staggering medical, prosthetic, and physio bills.
In a few cases, like that of Andrew Lane from Essex, England compensation is available. Lane was undergoing a prostrate gland removal when surgeons punctured his bowel and cause necrotising fasciitis causing bacteria to leak internally. He lost his penis and was left with incontinence, a catheter, a colostomy bag, and depression. He received a six-figure payout, although I’m sure many would agree this wasn’t enough.
So how do you avoid contracting one of the most horrific conditions out there? Especially when others have been infected by things as simple as a scratch from a rose bush, a bite from a spider, and there was even one woman in 2022 who contracted it after her sanitary towel twisted in the night and got stuck to her bum.
Essentially, your only line of defence is good wound care. Clean cuts and scratches well, keep them clean and seek medical help if they’re more than a millimetre deep or are gaping. Also avoid flood waters, hot tubs, and brackish water if you have any cuts or wounds.
However, in reality, it’s incredibly rare, affecting around 1.5 people per 100,000 each year. Catching it is just really bad luck.
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